Occupational therapy
Occupational therapists can help patients identify and exercise normal movement and gradually integrate it into their daily activities.
For all motor symptoms, the use of distraction techniques and video recording (with the patient's consent) is useful. Video recordings are useful as they provide important feedback for both the patient and the occupational therapist. Videos can show the variability, frequency and duration of symptoms, highlight successes and serve as a reference point for further treatment.
Tips for working with patients with motor subtype FND
(Nicholson et al., 2019)
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Encourage the patient to perform tasks that promote normal, automatic movement, good posture and even weight bearing (e.g. alternating standing and sitting).
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Promoting optimal posture at rest and during daily activities (Taking into account the 24-hour management approach).
Promoting an even distribution of weight when sitting, standing and walking, to normalise movement patterns and muscle activity.
Gradual escalation of functional activities.
Avoiding postures that promote prolonged end-of-span joint position (e.g. full hip, knee and ankle flexion).
Using strategies that reduce muscle overactivity.
Applying relaxation strategies.
Consideration and management of associated symptoms, such as pain.
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Add alternative, voluntary "rhythms" on top of the existing tremor and gradually slow down all movements until complete rest.
If the patient has unilateral tremor, use the unaffected limb to dictate a new rhyme (e.g. tapping, opening/closing the palm), leading to complete rest. You can help yourself with music.
Try to help control tremor during rest, and only later switch to controlling tremor during activity.
Teach the patient relaxation techniques that will relax the muscles and prevent cocontraction. Cocontraction is not an effective strategy for tremor suppression and will not be effective in the long term.
Start with gross motor skills, as they do not require as much concentration as fine motor skills (e.g. handwriting training; use markers and a board with large print).
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Applying general relaxation techniques.
Using grounding techniques (coming back to the present moment by focusing on sounds, smells, etc.).
Addressing motor and cognitive triggers of twitching (e.g. breath holding, frustration, anxiety).
Encouraging people to learn activities that require slower movement, such as yoga. This will help to regain control of movement and shift attention away from the symptoms.
Cognitive symptoms
Occupational therapists can encourage and guide the patient to:
Visual symptoms
It is crucial to help the patient understand the diagnosis and to communicate with them in a very sensitive and empathetic way. Praise and encourage incidents where patients have used visual information without being aware of it (e.g. avoiding obstacles) as this will reinforce positive behaviour.
Occupational therapists also use various strategies to prevent patients from avoiding activities and becoming too dependent on others. They also play an important role in managing and alleviating secondary symptoms such as light sensitivity and agoraphobia. They also help to prevent unhelpful behaviours such as constant closing of the eyes.
Functional seizures
Help patients to feel safe and not afraid of getting hurt if an attack occurs, while avoiding constant reassurance and physical restraints. Ask the patient about triggers or warning signs before a seizure starts and work together to develop strategies to prevent a seizure when they are identified. Sensory grounding techniques aimed at maintaining attention on the present moment are very useful to prevent dissociation. The patient can be guided to focus his/her attention on colours, textures or sounds in the environment, cognitively engaged through various word games, or engaged with sensory-based distractors (e.g. rubber bands, bracelets, etc.).
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Nicholson, C., Edwards, M. J., Carson, A. J., Gardiner, P., Golder, D., Hayward, K., ... and Stone, J. (2020). Occupational therapy consensus recommendations for functional neurological disorder. Journal of Neurology, Neurosurgery & Psychiatry, 91(10), 1037-1045.
Gardiner, P., MacGregor, L., Carson, A., and Stone, J. (2018). Occupational therapy for functional neurological disorders: a scoping review and agenda for research. CNS spectrums, 23(3), 205-212.
Ranford, J., Perez, D. L., and MacLean, J. (2018). Additional occupational therapy considerations for functional neurological disorders: a potential role for sensory processing. CNS Spectrums, 23(3), 194-195.