Abstract
Background:
Functional Neurological Disorders (FNDs) are common, comprising 10% to 30% of the Neurology caseload. Emerging evidence suggests that multidisciplinary rehabilitation is effective in FND, but actual gains in daily functioning are not clear from the current literature.
Aims:
To assess the outcomes of FND patients receiving inpatient rehabilitation in a specialist neurorehabilitation unit.
Methods:
Multidisciplinary (MDT) rehabilitation was provided by a multidisciplinary professional team led by consultants in Physical and Rehabilitation Medicine (PRM). Functional Outcomes such as Functional Independence Measure /Functional Assessment Measure, including motor and cognitive domains, were measured at 3 timepoints (admission, discharge and during post-discharge telephone appointments). Further data on demographics and disease presentation were collected by retrospective chart review.
Results:
Eighteen patients with FND were admitted to the unit over a 2-year period. The median length of stay for patients in the rehabilitation unit was 69 days (47-98 days) and the median post-discharge follow-up was 10 months (3,24 months). All outcome measures demonstrated improvement following rehabilitation. In particular, the median (IQR; FIM) score improved by 30 points (IQR 82-120) between admission and discharge, which exceeds the Minimal Clinically Important Difference (MCID) of 22 reported in the literature, indicating a clinically significant improvement. The improvements post-discharge plateaued but were maintained at follow-up. Qualitative feedback indicated high satisfaction with care in the rehabilitation unit and the improvements in daily functioning achieved.
Conclusion:
FND patients showed clinically significant improvements from inpatient specialist rehabilitation in this cohort. Further multi-site, larger-scale research is needed to determine whether certain types of FND patients have greater improvements than others from inpatient MDT rehabilitation.
Keywords
Introduction
Functional neurological disorders (FND), previously known as hysteria or conversion disorders, encompass a broad range of neurological symptoms such as motor weakness, sensory disturbances, and dissociative/non epileptic seizures. It also includes other symptoms such as cognitive impairment, dizziness, fatigue, bladder and bowel dysfunction and visual disturbance. Despite the very real, subjective symptoms experienced by patients, tests and imaging typically reveal no structural abnormalities. It is believed that these conditions arise from disruptions in normal brain connectivity, thereby affecting neurological function without a grossly visible structural abnormality.
FNDs are common, accounting for approximately 1 in 6 referrals presented to neurology departments with an estimated prevalence of 250 000 to 300 000 people in the USA and 50 to 100 000 people in the UK.1,2 A systematic review indicates that FND is associated with a substantial economic burden, with annual costs per patient ranging from $4964 to $86 722 (2021 US dollars), which exceed those of other neurological disorders (such as epilepsy or multiple sclerosis). 3
Over the past 2 decades, there has been increased awareness of these conditions among clinicians and healthcare professionals, leading to a growing body of research aimed at improving diagnostic approaches and management strategies. Neurologists have focussed on raising awareness of FND, and highlighting the use of positive clinical signs as a diagnostic strategy rather than FND being a diagnosis of exclusion. 4 No imaging or blood biomarker has yet been identified for the condition. Future research directions include validating these positive clinical signs and identifying potential imaging/ blood biomarkers to facilitate early diagnosis and intervention. 5 Similar to many other conditions, early diagnosis and intervention is believed to be associated with better prognosis for these patients. 6
As FNDs are primarily disabling conditions, multidisciplinary rehabilitation approaches that include physicians, physiotherapy, occupational therapy, and psychology are recommended. These interventions help patients understand their condition, identify triggers, and to develop strategies to improve their function and their quality of life.1,7 Research from the fields of psychiatry and psychology has evaluated various psychological interventions, such cognitive-behavioural therapy (CBT), and hypnosis, in improving FND symptoms.8,9 These studies have demonstrated significant symptom improvement following these interventions, irrespective of the timing of their initiation. 10
Despite existing research, further trials and studies are needed to determine the most effective multidisciplinary and interdisciplinary interventions 11 and to evaluate their efficacy and effectiveness, particularly with respect to clinical outcomes and daily functioning for patients.
This study aims to evaluate the daily functioning outcomes of FND patients admitted to a specialist neurorehabilitation unit managed by a multidisciplinary team led by Physical and Rehabilitation Medicine (PRM) consultants.
Methodology
Our neurorehabilitation unit has been developing a set procedure for patient evaluation and treatment. Potentially suitable patients are referred by parent teams in the acute hospital (usually the Neurology or General Medical teams). They are then assessed by a PRM physician, consultant neuropsychologist and/or specialist neuro-rehabilitation physiotherapist (often on 2 or 3 occasions) for their rehabilitation potential. A joint, multidisciplinary decision is typically made regarding suitability for admission. The team has extensive experience of managing these patients, considering factors such as patient physical and psychiatric comorbidity, frailty, other co-existent conditions, patient acceptance of the diagnosis, ability to understand their condition, and patient prior engagement with the therapy teams. Our team continue to develop and refine the selection criteria beyond this service evaluation study. All patients who were referred by Neurology /General medicine team at the time of study were assessed against these factors and were all accepted.
The inclusion criteria for this study was a diagnosis of FND made by a Neurologist, and those who are over 18 years old. The exclusion criteria included any patient who was given a new diagnosis of secondary FND while being treated in the rehabilitation unit for other neurological conditions, such as spinal pathology or polyneuropathy. Out of 20 patients, 18 were included, and 2 were excluded.
Following admission to the unit, rehabilitation services were delivered according to each patient’s needs, with a standard protocol where possible. Each patient received 3 hours per day of an intensive rehabilitation programme comprising personalised therapy - physical therapy, occupational therapy, speech and language therapy, neuropsychological intervention and education about their condition. The role of the PRM physicians was to validate the patient’s symptoms and acknowledge their functional impact. This initial step fosters trust and improves engagement in treatment. Following validation, the PRM physician provided further clear explanation of the diagnostic investigations, and emphasises that symptoms arise from functional disruption of neural networks rather than structural pathology. This mechanism-based explanation highlights the potential for reversibility and links the underlying neurophysiology to the patient’s clinical presentation. The physicians then continued to assess the patient’s overall medical and functional status, offering management as necessary and collaborating with other disciplines to support goal-directed rehabilitation planning. Psychological element typically involved: stabilisation and self-management strategies for the patient’s distress; addressing the patient’s understanding of the role of trauma or adverse life events as contributing factors; strategies related to emotion recognition, or a CBT diary. When required, Functional Cognitive Disorder was evaluated by our neuropsychologist. Physical therapy represents a core component of this rehabilitation pathway and focuses on motor retraining and the restoration of automatic movement patterns through strategies such as distraction and attentional redirection, it also includes further education integrated into therapy.
The team accepted patients who accepted the diagnosis and were willing to engage. However, some patients required further explanation of the diagnosis as they were not fully satisfied with the diagnosis. The team continued to work with them to help them understand their condition while validating their concerns and worries. The team also accepts patients with severe disabilities, including those with sphincter dysfunction. Some patients required urological consultation, and the team provides assistance with bladder and bowel management. Patients with pain issues were also accepted, and the management includes education about their conditions, managing their pain through various measures, including physical therapy/acupuncture and medications.
After 2 weeks of multidisciplinary assessment, a goal-planning meeting was held with the team (including representatives from all relevant disciplines), the patient, and their family to develop specific, measurable rehabilitation goals. This was repeated at appropriate intervals (usually 2-4 weeks) to review progress and ultimately plan discharge. Where appropriate, some patients received continued outpatient physiotherapy, occupational therapy or psychological intervention after discharge.
Patient data were extracted from electronic medical records and the UK Research Outcomes Collaborative (ROC) database. This included demographic information, the duration from initial presentation to admission to the rehabilitation unit, length of stay, and key outcome measures on functioning at admission and discharge: Functional Independence Measure/Functional Assessment (FIM/FAM) scores, Rehabilitation Complexity Scale-Extended Version (RCS-E), and extended Activities of Daily Living (ADL). Additional data on identifying triggers for FND, the specific FND subtypes, and any associated symptoms were also collected.
FIM is an 18-item scale covering motor and cognitive domains, each rated on a seven-point scale (1 = total assistance, 7 = complete independence), producing a total score of 18 to 126. The FIM demonstrates high inter-rater reliability and predictive validity across neurological populations,12,13 with reported Minimal Clinically Important Difference (MCID) typically ranging from 12 to 22 points depending on diagnosis. MCID represents the smallest change in a score that patients, clinicians, or caregivers perceive as meaningful in terms of functional improvement. To capture higher-level cognitive, psychosocial, and community-integration skills including extended activities of daily living (extended ADLs, the Functional Assessment Measure (FAM) was administered alongside the FIM. The FAM adds 12 items scored on the same seven-point scale, yielding a combined FIM + FAM range of 30-210. The FAM shows good reliability and enhanced content validity for complex neurorehabilitation. 14 RCS-E is a five-domain measure assessing care, nursing, therapy, medical, and equipment requirements. 15 The RCS-E provides a total score typically ranging from 0 to 15, with higher scores indicating greater rehabilitation complexity.
To assess outcomes after discharge, all patients participated in a telephone follow-up to obtain current functional status (using FIM/FAM and extended ADL scores), patient satisfaction, perceptions of recovery, and information on return to work or education. Data was analysed using Microsoft Excel. The Wilcoxon signed-rank test was used to assess statistical significance when comparing 2 outcomes and the Friedman test when all 3 outcomes were compared.
The service evaluation study was approved by the Trust’s clinical audit department (ID number 24-973C). As it was a service evaluation rather than research, formal ethics committee approval was not required. This was also confirmed using the Medical Research Council’s decision support tool. Informed consent to participate was obtained from all participants.
Results
Out of 20 patients, 18 patients were included in the study, the other 2 were excluded because FND was not the primary diagnosis at admission to the rehabilitation unit. The majority of patients were female and engaged in paid employment at the time of diagnosis (Table 1). Patients demonstrated multiple triggers for the onset of FND, the most common being psychological, followed by either a medical or surgical event or pain. All patients had prolonged admissions in the acute hospital prior to admission to our neurorehabilitation unit. All 18 patients (100%) presented with motor impairments, 10 (55.5.%) presented with additional sensory impairments and 4 of them (22.22%) presented with a functional seizure. After discharge, 66% required continued outpatient physiotherapy, 88% occupational therapy and 33% psychological therapies.
Patient Demographics.
Overall, at discharge, all improvements (FIM, FIM-M, FIM-C, FIM + FAM, ADL, RCS-E) in functioning were significant (particularly considerable improvement in motor functioning) At follow-up, all improvements were significant except the cognitive domains (FIM-C), which were not significant (P-value .10; Table 2).
Comparison of Outcomes at Admission, Discharge and Follow-Up.
Abbreviations: E-ADL, extended activities of daily living score; FIM, functional independence measure; FIM-C, functional independence measure cognitive domain; FIM-M, functional independence measure motor domain; FIM + FAM, combined functional independence measure and the functional assessment measure; FIM + FAM-C, cognitive domain of the combined measure; FIM + FAM-M, motor domain of the combined measure; RCS-E, rehabilitation complexity score-extended version.
Three-quarters of patients were discharged back to their own homes (Table 3). Patient satisfaction with their care was high, with 15 of 18 (83%) patients reporting they were satisfied or very satisfied.
Post-Discharge Outcomes (3-24 months).
After a median of 10 months follow-up (3-24 months), these improvements plateaued but had mostly been maintained (Figure 1). However, the majority of patients remained functionally impaired, with fewer than 20% having returned to work. Patient perception of their recovery was variable, with approximately 45% reporting >50% improvement and 55% reporting <50% improvement. Three patients experienced relapses after discharge but were not admitted again to the neurorehabilitation unit; they were discharged from acute wards and continued their rehabilitation through outpatient/community services (Table 3).
Change over time in each of the 4 scoring systems.
Discussion
Our study found that multidisciplinary inpatient rehabilitation led to significant improvements in daily functioning among patients with FND. As there is currently no established FIM Minimum Clinically Significant Difference (MCID) value for FND, we used the MCID reported for stroke populations (22 points for FIM score) as a reference benchmark. 16 Our cohort demonstrated a 35-point improvement in the FIM score, which substantially exceeds the threshold. This quantitative improvement was consistent with the qualitative feedback from patients, who reported meaningful gains in their functional abilities. Nearly half (45%) of patients perceived their health to improve by over 50%. These improvements in daily functioning were maintained at post-discharge follow-up with a median of 10 months. The high patient satisfaction scores suggest that inpatient rehabilitation wards provide a supportive environment to support patients’ recovery.
Our findings are consistent with previous work suggesting that optimising inpatient rehabilitation pathways for patients with FND can expedite and improve management, potentially leading to better outcomes. A study from the USA 17 examining the effect of a specific inpatient pathway demonstrated improvement in patients’ functional outcomes measures using Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI). Their pathway included clear admission criteria, emphasising the importance of an accurate diagnostic process, patient acceptance of the diagnosis and readiness for rehabilitation. The rehabilitation process was planned for 2 weeks, followed by discharge planning. The study also underscored the value of educating the rehabilitation team about FND management to avoid unnecessary dilemmas within the teams, and to support both patients and staff.
Research on FND is increasing, especially within the neurology, psychology, and physical rehabilitation fields. 18 Most studies advocate for a multidisciplinary rehabilitation with an interdisciplinary approach as the optimal strategy for managing these complex conditions.4,7,18,19 Anecdotal evidence indicates that despite existing evidence base, persistent negative beliefs exist about FND patients, often labelling them as difficult to manage and highly demanding. A lack of knowledge and sometimes patient doubts regarding the diagnosis frequently contribute to a poor experience for both patients and clinicians.
Given that FND patients often present with multiple functional deficits, the biopsychosocial model has emerged as the most suitable framework to address their needs, Within neurorehabilitation, the WHO ICF biopsychosocial model provides a structured framework for understanding disability as the result of dynamic interactions between neurological impairment, individual psychological factors, and the surrounding social and environmental context, thereby guiding holistic assessment and intervention planning.19,20 Rehabilitation physicians are particularly well-positioned to assess, support, educate and lead the management of FND patients. Ongoing investigations continue to explore the most effective strategies for patient care, including physiotherapy and psychological interventions.21,22
Several factors appear to influence patient prognosis, including understanding and acceptance of the diagnosis and engagement with therapy disciplines. In our study, 3 patients experienced FND symptoms flare-ups after discharge. Notably all 3 had not fully participated in psychological interventions during the admission and after discharge and 1 patient showed limited physical improvement due to denial of the diagnosis and reluctance to engage with rehabilitation. In contrast, the best outcomes were observed among those who fully understood their diagnosis, actively engaged with all the disciplines, and effectively utilised the techniques taught by the therapy teams. These findings suggest that understanding the diagnosis and the ability to fully engage in rehabilitation may be predictors of positive outcomes. It’s also worth mentioning that patients’ full engagement with rehab can be affected by various factors such as uncontrolled pain, fatigue, and mental health issues.
Other factors affecting prognosis are still under investigation. One study indicated that younger age and early diagnosis correlate with positive outcomes, whereas long symptom duration and motor/non-epileptic FND are negative predictors. However, methodological issues due to small sample sizes and differences in outcome measures in this study limit our conclusions and point to a need for further research. 6
Our study has some strengths and weaknesses. It is a “real-world” study of consecutive patients in a general specialist neurorehabilitation unit, using routinely collected, validated functional outcome measures collected at admission and discharge. Although our team has significant experience in the management of FND, the unit does not purely specialise in FND; it is a generalist neurorehabilitation unit. At any one time, no more than 2 of the 32 patients (6%) at the unit have FND. The remainder have the usual variety of patients that would be found on any such unit, such as patients with traumatic brain injury, intracranial haemorrhage, polytrauma, Guillain-Barré Syndrome, spinal cord injury and critical illness neuropathy. Although FND admissions may eventually benefit from dedicated pathways, this study demonstrates that current inpatient neurorehabilitation settings can support patients with FND and yield positive outcomes. The prospectively collected follow-up data also reassuringly show that the observed functional changes were maintained, contrary to the belief that improvements do not sustain after discharge.
The weaknesses of our study include the retrospective nature of some data, particularly the comorbidities, presenting symptoms and information about the psychiatric illnesses and psychological background, which may greatly impact the outcomes, were not systematically collected. The duration of follow-up also varied significantly, although the chosen minimum time point of 3 months allowed us to assess whether outcomes were maintained for at least that period. Patients were also carefully selected for admission, thereby introducing a significant element of selection bias in the study, and the outcomes of those omitted or not referred to us were not collected. The criteria for admission are experience-based and include the factors discussed in the methodology section but are ultimately subjective rather than objective. Beyond the study period, the team continues to develop and formalise the selection processes. Literature suggests that patient acceptance of their condition and willingness to engage with all multidisciplinary team are key predictors of treatment success, so this reflects pragmatic, “real-world” practice which any other unit would use.
A further limitation is the absence of disorder-specific outcome measures for functional motor symptoms, such as the Functional Movement Disorders Rating Scale (FMDRS). While global tools like the FIM/FAM provide valuable information about overall disability and day-to-day functioning, they lack the specificity needed to quantify changes in functional motor phenomena, reducing the precision with which symptom-level improvements can be assessed. Also, improvements in non-motor symptoms, such as seizures and sensory issues, were not systematically assessed at discharge and follow up.
Further research is needed to identify optimal pathways and rehabilitation programmes, including intensity and duration, as well as patient selection and predictors of the best outcomes. Further research could also analyse the effect of rehabilitation programmes that included novel interventions like transcranial brain stimulation and virtual reality which have some emerging evidence23,24
Conclusion
This study demonstrates that good outcomes can be achieved for patients with FND treated in specialist neurorehabilitation units staffed by a team experienced in managing FND. This opens a new service pathway to improve outcomes for this underserved patient group. Further research is needed to identify the patient factors that determine outcomes and the most effective type, intensity, and duration of inpatient rehabilitation programme for these patients. Answering these research questions will inform our understanding of the cost-effectiveness of these programmes for FND.
Footnotes
Ethical Considerations
The service evaluation study was approved by the Trust’s clinical audit department (ID number 24-973C). As it was a service evaluation rather than research, formal ethics committee approval was not required. This was also confirmed using the Medical Research Council’s decision support tool.
Author Contribution
The authors jointly contributed to the development and final approval of the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.