Functional Neurological Disorder (FND)

Functional Neurological Disorder (FND)

Functional Neurological Disorder (FND) is a neurological condition that affects how the brain and nervous system control movement, sensation and other functions.

FND can cause genuine and often disabling symptoms, even when there is no structural damage to the nervous system to explain those symptoms. The way the brain is processing and controlling information can become disrupted, affecting how the body functions.

One way of thinking about FND is to imagine the brain as a satnav. The satnav itself is working, but the way it is processing information and giving instructions can become disrupted. As a result, the body may not respond in the way a person expects, even though the muscles, nerves and other structures may be capable of performing the movement.

FND can affect children, young people and adults. Symptoms can vary considerably between individuals and may fluctuate over time.

At Positive Steps Physiotherapy, we work with children and adults with FND to help improve movement, function, confidence and participation in everyday activities through personalised rehabilitation.

What causes FND?

There is not one single cause of FND.

FND is thought to develop through changes in how the brain processes information and controls movement and other functions. Different factors may contribute to the development or persistence of symptoms, and these can vary from person to person.

Possible contributing factors may include:

• Physical injury or illness

• Pain or other neurological symptoms

• Fatigue and changes in activity levels

• Stressful experiences or changes in circumstances

• Anxiety, low mood or other psychological difficulties

• Increased attention towards symptoms

• Changes in how the brain processes movement, sensation or other information

• A combination of physical, psychological and environmental factors

Importantly, FND is not simply caused by stress or psychological difficulties, and not everyone with FND will have experienced trauma, anxiety or another mental health condition.

FND can develop following an injury or illness, during a period of increased stress or for no clearly identifiable reason. The contributing factors are different for every individual.

Who can develop FND?

FND can affect people of all ages, including children and adults.

It is more commonly diagnosed in women, although FND can affect anyone.

In children and young people, symptoms may occur alongside changes in school attendance, activity levels, family circumstances, relationships or other physical or emotional challenges. These factors may contribute to symptoms for some children, but they are not present in every case.

FND should always be approached as a genuine neurological condition, with the individual's symptoms taken seriously and assessed appropriately.

What are the symptoms of FND?

FND can cause a wide range of symptoms. Not everyone experiences the same symptoms, and symptoms may change in type, severity or frequency over time.

Symptoms can include:

• Weakness in the arms or legs

• Difficulties walking

• Balance problems

• Tremors

• Jerking or spasming movements

• Changes in movement patterns or posture

• Difficulty coordinating movement

• Numbness or altered sensation

• Tingling or unusual sensations

• Pain

• Fatigue

• Dizziness

• Episodes of fainting or altered awareness

• Speech or communication difficulties

• Functional seizures

• Difficulties with memory or concentration

• Visual or hearing symptoms

Symptoms may be persistent for some people, while others may experience symptoms that come and go or change depending on the situation.

FND symptoms can have a significant impact on everyday activities, including walking, getting dressed, attending school or work, exercising, socialising and participating in hobbies.

What are the different types of FND?

FND can present in many different ways. A person may experience one type of symptom or a combination of different symptoms.

Functional movement disorder

Functional movement symptoms affect how a person moves. They may include:

• Functional weakness

• Tremor

• Jerks or spasms

• Functional dystonia

• Changes in walking

• Changes in posture

• Difficulties with coordination

Physiotherapy can be particularly relevant for people whose main FND symptoms affect movement and physical function.

Functional seizures

Functional seizures are episodes that can look similar to epileptic seizures but have a different underlying mechanism.

They are sometimes referred to as functional seizures or dissociative seizures. They are real and involuntary episodes and should be appropriately assessed and diagnosed by healthcare professionals.

Physiotherapy may form part of a wider multidisciplinary rehabilitation programme when physical symptoms are also present.

Functional sensory symptoms

Some people experience changes in sensation, such as numbness, tingling, altered sensation or changes in how the body feels.

These symptoms can occur alongside movement difficulties or other FND symptoms.

Functional cognitive symptoms

Some people with FND experience difficulties with attention, memory, concentration or processing information.

These symptoms may occur alongside physical symptoms and can affect school, work and everyday activities.

Functional speech and swallowing symptoms

FND can also affect speech, voice and swallowing.

People experiencing these symptoms may benefit from assessment and support from a speech and language therapist as part of a multidisciplinary approach.

Persistent postural-perceptual dizziness (PPPD)

Persistent postural-perceptual dizziness (PPPD) is a chronic vestibular condition characterised by dizziness or unsteadiness that can be worse when standing or moving and in visually complex environments.

PPPD can occur alongside FND and may require specific assessment and rehabilitation, including vestibular rehabilitation where appropriate.

Not everyone with FND will experience all of these symptoms, and symptoms can overlap.

How is FND diagnosed?

FND is diagnosed by a healthcare professional using a detailed history and neurological examination.

Importantly, FND is not simply a diagnosis made because other tests are normal.

Instead, clinicians look for positive clinical features that are characteristic of FND. These may demonstrate that a person's symptoms change or behave in ways that are consistent with a functional neurological disorder.

Depending on the symptoms, a healthcare professional may assess:

• Movement and coordination

• Strength

• Sensation

• Walking and balance

• Tremor or other involuntary movements

• How symptoms change during different tasks

• The person's medical history and symptom pattern

MRI scans, blood tests or other investigations may also be used when appropriate to assess for other neurological or medical conditions.

A person can also have FND alongside another neurological or physical condition. Therefore, having an underlying neurological condition does not automatically rule out FND.

A clear explanation of the diagnosis is an important part of FND treatment and rehabilitation. Understanding why the diagnosis has been made can help a person understand their symptoms and engage with rehabilitation.

Can physiotherapy help with FND?

Yes. Physiotherapy can play an important role in the rehabilitation of people whose FND symptoms affect movement and physical function.

FND physiotherapy is different from treating a traditional musculoskeletal injury. The focus is often on retraining movement, improving function and confidence, reducing unhelpful movement patterns and helping the person return to meaningful activities.

Treatment is collaborative and should be based around the individual's symptoms, goals and priorities. Education, movement retraining and self-management are key elements of physiotherapy for FND.

At Positive Steps, we focus on helping each person understand their symptoms and identify achievable goals that are meaningful to them.

How can physiotherapy help with FND?

Movement retraining

Movement retraining is an important part of physiotherapy for FND.

This may involve practising functional movements such as:

• Walking

• Changing direction

• Getting up from a chair

• Transfers

• Reaching

• Grasping

• Stairs

• Getting down to and up from the floor

Exercises and activities are selected to encourage more effective movement patterns and help the person regain confidence in their ability to move.

The aim is to practise movements that can be transferred into everyday life rather than focusing solely on isolated exercises.

Strength and physical conditioning

Reduced activity can sometimes lead to deconditioning and loss of strength.

Physiotherapy can gradually build strength, endurance and activity levels while considering the person's symptoms and energy levels.

Exercise can be progressed gradually and should be tailored to the individual's current ability and rehabilitation goals.

Balance and coordination

FND can affect balance and coordination.

Physiotherapy may use functional and goal-based activities to challenge balance and coordination in a safe environment.

As confidence improves, activities can be progressed towards situations that are relevant to everyday life.

Walking and mobility

Walking difficulties are common in some forms of FND.

Physiotherapy can work on walking patterns, changes of direction, different walking speeds and navigating everyday environments.

The focus is on helping the person develop more confident and functional movement.

Fatigue management and pacing

Fatigue can be a significant symptom of FND.

Physiotherapy can help someone understand how to balance activity and rest and avoid cycles of doing too much on a good day followed by significant fatigue afterwards.

Strategies may include:

• Pacing activities

• Breaking activities into manageable amounts

• Planning periods of rest

• Gradually increasing activity

• Identifying priorities

• Building activity into everyday routines

Education and understanding FND

Understanding FND is an important part of rehabilitation.

Physiotherapy can help explain how changes in the brain's processing and control of movement can contribute to symptoms.

Understanding the diagnosis and recognising that symptoms are genuine can help build confidence and support engagement with rehabilitation.

The aim is not to suggest that symptoms are imagined or “all in the mind”. FND symptoms are real and can be disabling.

Building confidence and independence

FND can sometimes lead people to avoid activities because they are worried about triggering symptoms or falling.

A gradual return to meaningful activities can help build confidence and independence.

Treatment can be designed around the things that matter most to the individual, whether that is returning to school, work, sport, hobbies, social activities or everyday tasks.

What might FND physiotherapy involve?

Every person with FND is different, so treatment is individualised.

An assessment may look at:

• The person's main symptoms

• How symptoms affect everyday activities

• Walking and mobility

• Balance

• Strength

• Coordination

• Movement patterns

• Fatigue

• Pain

• Confidence with movement

• Current activity levels

• The person's goals

• School, work, home or sporting activities

We then work together to develop a rehabilitation programme based around the individual's priorities.

Where appropriate, we may work alongside other professionals involved in the person's care, such as neurologists, occupational therapists, psychologists, speech and language therapists, GPs and other members of the multidisciplinary team.

FND in children and young people

FND can affect children and young people as well as adults.

For children and young people, symptoms can have a significant impact on school attendance, friendships, hobbies, sport, family life and independence.

Physiotherapy can focus on helping children gradually return to meaningful activities and develop confidence in their movement.

Treatment may involve movement retraining, functional activities, strengthening, balance work, activity management and education.

Where appropriate, we can work with parents, carers, schools and other professionals to help create a consistent approach around the child or young person.

At Positive Steps, we aim to make rehabilitation engaging and relevant to each child's interests and everyday life.

How can Positive Steps help with FND?

At Positive Steps Physiotherapy, we understand that FND can have a significant impact on everyday life.

Our approach is centred around the individual rather than simply focusing on the symptoms. We take time to understand how FND is affecting the person's movement, confidence, activities and participation and then work together to identify meaningful goals.

We use functional, goal-focused activities within sessions to help encourage carryover into everyday life.

Our approach may include:

• Movement retraining

• Functional rehabilitation

• Strength and conditioning

• Balance and coordination activities

• Walking and mobility rehabilitation

• Fatigue management

• Pacing and activity planning

• Education about FND

• Self-management strategies

• Support with returning to meaningful activities

Our aim is to help each individual identify what can be done, build confidence in their movement and work towards the activities that are important to them.

FND can be challenging, but with the right diagnosis, understanding and rehabilitation approach, improvement in symptoms and function is possible. Physiotherapy may form one part of a wider multidisciplinary approach to care.

If you or your child has been diagnosed with FND and would like to find out how physiotherapy could help, please get in touch with the Positive Steps team.

Organisations and resources that can help

FND Action

FND Action provides information, support and advocacy for people affected by Functional Neurological Disorder.

FND Hope

FND Hope provides information and resources for people living with FND and their families.

FND Friends

FND Friends provides information, support and community resources for people affected by FND.

It can also be helpful to discuss FND with your GP, neurologist or other healthcare professional involved in your care.