Thread by @ZacharyGrinDPT

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New FND Treatment 🧵

This patient’s FND was triggered by a dog bite to her R thigh. She developed R leg heaviness that progressed to a severe tremor during a soccer game & intermittent head/trunk movements when walking. /1

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Over the past 3 years she had some fluctuating improvement with traditional physical therapy but felt that her progress had plateaued. She was no longer able to work in her physically demanding job or participate in meaningful activities (riding a motorcycle, playing sports). /2

Treatment began with showing her the leg heaviness was actually due to significant muscle tension throughout the leg when walking. Once aware, she began to learn how to fully relax the leg muscles when she felt the heaviness by using her hands on the muscle for feedback. /3

Movement pattern changes with an external focus of attention (hopscotch, skipping, crab walk, braiding, agility ladder stepping, obstacle courses, kicking a soccer ball) were added to access automatic movements that were not “corrupted” by the FND. /4

Dual-tasks: learning to allocate less attention for walking. Using a Bop-It is my fav due to the high attentional demand. Gait may initially worsen but improve as they learn to balance attention allocation to the tasks! Keeping a balloon in the air w/ hands/feet is great too. /5

Behavioral: prevent reinforcement of motor symptom - repetition of a motor task that triggered a motor symptom until the symptom was no longer triggered. If trunk hyperextension was triggered when stepping over an object she would repeat stepping over it until it stopped. /6

Sensory: A weighted vest made it easier for her to relax her leg muscles & made her head/trunk symptoms less frequent when walking. Desensitizing the right leg to vibration allowed her to kick a firm soccer ball without triggering a leg tremor. /7

Autonomic: diaphragmatic breathing with extended exhalation to prevent breath holding during physical activities - ⬇️ sympathetic activity to raise the threshold for triggering motor symptoms. /8

Task variability: This is so important! People with FND may learn a motor skill very well but motor symptoms may easily reoccur by slight modification to the task. Add variability to the interventions so they learn how to adapt their motor responses to meet new task demands. /9

Outcome: After 4-months, she returned to work part-time (will start gradually increasing to full-time), rejoined her soccer league for the upcoming season, and could run without motor symptoms!! 🎉 /10

FND is a complex condition. It demands clinicians be curious, creative, comprehensive, and comfortable with the grey. I hope this thread provides clinicians with some out-of-the-box treatment ideas and provides patients with hope. /11