Multidisciplinary rehabilitation for functional neurological disorder using psychobehavioral approaches in acute inpatient setting: A case report

Abstract

The role of acute inpatient rehabilitation is pivotal in the treatment of functional neurological disorders, offering a multidisciplinary approach to a condition often challenging to diagnose and manage. This case report discusses a 44-year-old right-handed male with complex past medical histories of Bell’s palsy, cholesteatomas, hearing impairment, coronary artery disease, cavernoma, hypertriglyceridemia, glaucoma, hypertension, hyperlipidemia, parotitis, psoriasis, seizure, and tremors transferred to our rehabilitation service with presented functional neurological disorder symptoms. The patient’s treatment emphasized an acute comprehensive rehabilitative intervention with psychobehavioral approaches, focusing on both physical symptoms and psychological aspects of the condition. This case illustrates the effectiveness of acute rehabilitative care in functional neurological disorders, highlighting the significance of early intervention and a holistic treatment approach in improving prognosis and overall quality of life for patients with functional neurological disorders.

Introduction

Functional neurological disorder (FND) or conversion disorder is a neurological condition that is caused by aberrant brain networks that affect neurological functioning.^1–7 It accounts for one of the most common reasons for visits to neurology clinics. ⁸ The complexity of FND poses a significant diagnostic challenge because of its heterogeneous neurological manifestations, including muscular weakness, spasms, twitches, paralysis, abnormal movement, altered sensation, and seizure-like episodes, which often resemble other emergent conditions like cerebrovascular accidents or coincide with a patient’s existing medical conditions.^2–4

Historically, FND was an exclusionary diagnosis based on all neurological tests, with identifying underlying psychological factors.^6,7 However, recognizing the complex interplay between psychological and neurological determinants, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition has introduced revised inclusionary criteria that de-emphasize the necessity of psychological stressors as a prerequisite for diagnosis.^1,5–7 Despite the exclusion of other organic etiologies, patients frequently experience persistent and debilitating symptoms that remain inadequately addressed. Given its substantial economic burden and the significant use of healthcare resources, there is a pressing need for the development and implementation of evidence-based treatment strategies.^6,9

Effective management of FND, particularly during acute exacerbations, lies in a multidisciplinary approach that extends beyond initial medical stabilization to encompass acute inpatient rehabilitation. ¹⁰ Given the variable and polysymptomatic nature of FND, a comprehensive assessment addressing physical, psychological, and social dimensions is essential for developing an optimal, individualized treatment plan.^4–6 Therefore, acute rehabilitation plays a crucial role in improving symptom severity and enhancing the overall quality of life for patients with FND.^11–15 Moreover, early recognition and targeted intervention in the rehabilitation setting have been shown to significantly improve prognosis, with intensive, early acute inpatient rehabilitation programs yielding superior outcomes compared to subacute rehabilitation settings in post-acute hospital care.^16,17

The present case illustrates a patient with a complex medical history who initially presented to the acute care hospital with symptoms consistent with, yet previously undiagnosed as, FND. During the subsequent acute rehabilitation course, successful treatment was achieved upon discharge through the integration of psychobehavioral therapeutic interventions and a multidisciplinary approach. This report aims to exhibit our rehabilitative treatment model, addressing the diagnostic complexities and management of patients with severe motor disorders due to nonorganic causes, and highlighting the critical role of an acute rehabilitative treatment approach in achieving successful clinical outcomes.

Case presentation

The 44-year-old right-handed male whose occupation was an engineering construction worker with a stated past medical history of Bell’s palsy with right facial droop due to unknown etiology, bilateral mastoidectomy due to cholesteatomas and status post (s/p) bilateral bone anchored hearing aid placement, coronary artery disease s/p percutaneous coronary intervention, recently diagnosed cavernoma, familial hypertriglyceridemia complicated by chronic pancreatitis, glaucoma s/p glaucoma surgery, hypertension, hyperlipidemia, parotitis, psoriasis, seizure, and tremors.

Initial presentation

The patient initially presented to the emergency department (ED) with multiple complaints, including acutely worsening right-sided facial droop and tremors greater than his stated baseline, stuttering speech, blinking, double vision, brain fog, neck pain, and right-sided weakness. The patient stated his presenting symptoms started 6 months ago with no recalled trigger. His main complaints during the time included: (1) Right medial thigh and calf neuropathic pain and weakness limited by the pain, (2) right monocular diplopia with tinnitus, (3) severe neck pain and tension-like headache, (4) right facial droop worsening from his baseline, and (5) severe cognition impairment, including memory decline and difficulty with executive functioning, during the time. Prior to hospitalization, the patient was seen by multiple medical specialists, including an outpatient cardiologist, neurologist, pain interventionist, and pulmonologist, where each respective workup was unrevealing of any organic causes.

Diagnostic workups

Code stroke was initiated in the ED. Subsequent CT imaging at ED revealed no acute pathological finding and the patient was admitted to inpatient service. Video electroencephalogram was negative for any seizure activity. MRI demonstrated a known 4 mm cavernoma but was otherwise unrevealing. Bilateral lower extremity duplex ultrasound was negative for any blood flow abnormalities. Lumbar puncture showed normal intracranial pressure and physiologic cerebrospinal fluid. Serological test real-time quaking-induced conversion and 14-3-3 testing protein measurement were negative for potential neurodegenerative disorders. No definitive diagnosis was given at the referring hospital. The patient was later accepted into our acute rehabilitation service after 3 weeks of acute hospital course.

Acute inpatient rehabilitation course

Upon arrival, the patient was alert and oriented but exhibited distress about his continued deficits and neurological symptoms. He reported continuing right lower extremity pain with newly onset dystonia of the right hand and chorea of the bilateral upper and lower extremities. The patient also stated he had word-finding difficulties, short-term memory impairment, diplopia, blurry vision, muscle twitches, and severe muscular spasticity while ambulating.

A physical exam revealed grossly intact cranial nerves except for right-sided facial asymmetry. His hearing was seemingly intact despite the removal of his hearing aid. His right lower extremity was paretic. There was reduced right-sided sensation compared to the left on his hand and distal lower extremity. Right-sided dysmetria was noticed on the finger-to-nose test. ¹⁸ Spasticity and rigidity were present in all extremities. However, the patient’s physical presentation was distractible. For example, facial drooping and muscle spasms were absent when not examined directly. Table 1 details the physical exam results at admission.

Table 1.

Physical exam.

Parameter	Result at admission	Result at discharge
Cranial nerves exam 2–12	Grossly intact except right-sided facial asymmetry (V–VII)	Intact
Sensation	Diminished sensation on right side	Improved sensation
Finger-to-nose dysmetria	Present	Absent
Strength exam	LUE, LLE 5/5; RUE 4/5, RLE 2/5	LUE, LLE 5/5; RUE 5/5, RLE 4+/5
Upper motor neuron sign	Positive left extremity Babinsky sign	Absent
Muscle spasticity	All extremities	Absent except some rigidity of left hands

LUE: left upper extremity; LLE: left lower extremity; RUE: right upper extremity; RLE: right lower extremity.

Physical medicine and rehabilitation management

The primary goal of our physical medicine and rehabilitation (PM&R) team was to manage the patient’s medical conditions to ensure his participation in the daily 3-h intensive therapy sessions, as well as coordinate with other allied health care professionals on goal setting, progression, and discharge plan for the patient. Prior to arrival, the patient was not on any specific spasticity and neuropathic pain management. Pregabalin was prescribed at night for the patient’s neuropathic pain and tizanidine three times a day for his muscle spasm. Clonazepam was also added for the patient’s overall anxiety and muscle spasms but was later discontinued due to excessive daytime sedation.

In addition to the medical management, the PM&R team also met with the patient at least once a day to build rapport between the primary care team and the patient. Through effective communication, we were able to identify maladaptive cognitions and behaviors, while also giving us the opportunity to educate and help address concerns surrounding the patient’s clinical condition. During daily rounds, we kept the patient informed about updated therapy progress, discharge plans, and other relevant new diagnostic findings. The physiatrist also led the interdisciplinary meetings multiple times throughout the patient’s stay with his physical therapist (PT), occupational therapist (OT), speech–language pathologist (SLP), social workers, nurses, and psychologist. Specific goals were established for an overall rehabilitative plan for the patient, as well as addressing other relevant medical updates with the team. The preestablished goals for the patient upon discharge were: (1) Achieving an independent to supervising level of performing activities of daily living (ADLs), self-transferring capacity, and ambulation. (2) Strengthening both upper and lower body strengths with special emphasis on the paretic side. (3) Improving both dynamic and static balance for fall prevention. (4) Improving the patient’s overall cognitive levels, including short-term memory recall and problem-solving abilities.

Physical and occupation therapy

PT and OT were carried out every day with the patient. The initial evaluation from the PT/OT team revealed that the patient required moderate to minimal assistance for most of the major functional parameters (Table 2). The patient also exhibited significant right-sided weakness that severely impaired his task-completion ability for ADLs. The patient’s overall balance was also poor, putting him at a high risk of falling.

Table 2.

Physical and occupational therapy.

Parameter	Result at admission	Result at discharge
Transfer
Sit to stand	Minimal assist a	Independence
Stand to sit	Minimal assist	Independence
Bed/chair-to-chair transfer	Minimal assist	Independence
Mobility/ambulation
Assisted advice	Rolling walker	Cane
Walk 10 feet (level)	Moderate assist b	Independence
Walk 50 feet (level)	Moderate assist	Independence
Walk 150 feet (level)	Not attempted	Independence
Walk on uneven surface	Not attempted	Independence
Gait pattern	Ataxic, leaning, unsteady, and decreased foot clearance	Ataxic but steady with decreased foot clearance
Curb	Not attempted	Independence
Stairs	Not attempted	Independence using one rail to climb 12 stairs with 6 inches height
Occupational capacity
Eating assistance	Setup/clean up assist	Independence
Eating deficit	Setup	None
Oral hygiene	Setup/clean up assist	Independence
Grooming assistance	Touching assists with verbal cues	Independence
Grooming deficit	Setup, steadying	None
Shower/bathing assistance	Moderate assist	Touching assist
Showering deficit	Setup, steadying due to right-sided weakness	Setup
Upper-body dressing assistance	Touching assist	Independence
Upper-body dressing deficit	Setup, steadying	None
Lower body dressing assistance	Moderate assist	Independence
Lower body dressing deficit	Setup, steadying	None
Putting on/off footwear	Moderate assist	Independence
Footwear deficit	Setup, steadying	None
Toileting hygiene	Touch assist	Supervision
Toileting deficit	Setup, steadying, grab bar use	Safety concern

^aSeventy-five percent patient’s effort.

^bFifty percent of patient’s effort.

Recognizing the patient’s unique presentation, a key focus during interdisciplinary meetings was to raise awareness about the potential psychiatric and psychological underpinnings of the symptoms. To facilitate the therapeutic process, psychobehavioral approaches were incorporated into daily training. Specific and structured therapeutic exercises that targeted multiple physical and functional impairments were carried out. During each session, numerous psychobehavioral approaches were used by the therapy team. An operant conditioning model was used to reinforce direct attention toward executing functional tasks, while simultaneously discouraging fixation on specific impaired movements. A scaffolding approach provided a carefully graded progression of tasks designed to build both confidence and skill. Specific prompts and verbal cues were delivered to offer real-time feedback, guiding the patient to initiate and perform tasks independently and thereby address maladaptive motor patterns. In addition, the therapy team provided targeted education to address concerns regarding the patient’s physical condition while regularly providing encouragement and highlighting progressions that were being made.

Speech and cognitive therapy

Speech therapy sessions were provided daily for the patient’s cognitive deficit. At admission, the patient exhibited short-term memory impairment, with his recall and word sequencing of four words and above being only at a 60%–70% level. He also had a language fluency deficit. His initial Montreal Cognitive Assessment score was 22/30 (Table 3). ¹⁹ The speech therapy’s goal was to enhance cognitive communication functioning, and memory training, and improve his comprehension and expression abilities. Reinforcement strategies were used to retrain the patient’s cognitive functioning. Guided recovery was implemented to provide hints or questions rather than direct instructions, encouraging the patient to engage in active problem-solving and cognitive recall. Therapists also incorporated stress-management techniques and challenged unhelpful thought processes that deterred fixation on debilitations and provided healthier coping mechanisms.

Table 3.

Speech therapy.

Parameter	Result at admission	Result at discharge
Speech and language assessment	Limited verbal output and difficulty forming sentences	Communicate needs and participate in conversations with minimal assistance
Cognitive evaluation	Short-term memory and problem-solving abilities deficits	Significant improvement; follow multi-step commands and engage in complex decision-making
Voice and articulation	Weak with poor articulation, impacting intelligibility	Improved, with articulation clear and speech easily understandable
Fluency	Stuttering with frequent repetitions	Enhanced, with occasional mild dysfluencies

Psychotherapy

While in the acute inpatient rehabilitation unit, psychology was consulted by the primary team for evaluation, after the patient expressed significant emotional distress and depressive thoughts, but no suicidal ideations. The patient was reluctant to participate in the psychiatric consultation and refused any psychological interventions. He did, however, endorse a history of post-traumatic stress disorder due to events stemming from his childhood but refused to disclose any details. Furthermore, he exhibited severe anxiety and sleep problems attributed to the uncertain etiology of his current symptoms. The patient repeatedly expressed urgency in seeing a movement disorder specialist and requested an earlier discharge so that he can do so. With further investigation of the social history, the patient appeared to have good social support and financial stability. Besides potential FND, adjustment disorder with mixed anxiety and depressed mood was considered by psychology.

Discharge outcome

After 8 days of intensive inpatient rehabilitation, the patient demonstrated significant functional improvement and met the preestablished goals set by the interdisciplinary team. His neurological symptoms, including neuropathic pain and spasticity, were significantly alleviated by medical management. He appeared less stressed and anxious upon discharge. However, follow-ups were lost after the patient’s discharge. Tables 1 to 3 list the detailed discharge physical exams and therapy evaluations for the patient.

Discussion

Traditional models have emphasized psychotherapeutic interventions as the primary means of treatment; however, with growing awareness of the high heterogeneity of symptoms, current treatment models now highlight the necessity of an integrated multifactorial approach to cater to the individual needs of each patient.^4,5,10 However, treatment success is based on first establishing a definitive diagnosis and communicating it effectively to ensure that patients fully understand and come to acceptance with this condition. ⁵ This enhances adherence to treatment plans and improves outcomes. ⁵ Although the patient’s presentation aligned with classic FND profiles, a definitive diagnosis was not confirmed by any specialist, underscoring the diagnostic ambiguity in the acute phase—most cases are diagnosed in secondary care. ¹ This diagnostic uncertainty presented a unique challenge for our team and likely contributed to the patient’s persistent anxiety, symptom fixation, insistence on further diagnostic workup, and reluctance to receive essential psychiatric and psychological interventions.

To navigate these challenges, we prioritized building strong rapport by empowering the patient through the validation and normalization of their concerns. ²⁰ We aimed to foster an effective dialogue, which allowed us to integrate elements of cognitive behavioral therapy by including motivational interviewing into daily interactions to encourage self-reflection and to improve compliance with the rehabilitation program. Furthermore, this aided us in identifying maladaptive cognitions (e.g. belief that “I still feel pain in my right leg so it must be weak”) and behaviors (e.g. avoiding attempting weight-bearing on that leg), which we relayed to the rest of the treatment team to be cohesively addressed. ²¹ In addition, incorporating operant conditioning, guided recovery, and scaffolding techniques from cognitive behavioral therapy into daily therapeutic sessions facilitated strengthening self-directed attention to healthy functional movements, while discouraging poor patterns of movement that would otherwise be reinforced by avoidance behavior. ²² These approaches aided in maintaining the patient’s engagement with the rehabilitation program, aligning with a strategic psychobehavioral framework that emphasizes relearning, requisition, shaping, and reinforcement.^14,15 Moreover, rehabilitative programs emphasizing PT/OT and SLP were more culturally accepted than direct psychological intervention. ¹¹ This shift from direct psychological confrontation to a psychobehavioral caring model ensured the patient’s successful progression in therapy. It was also important for our medical team to refrain from the use of any unnecessary medications that may have posed barriers to engagement in therapy (e.g. benzodiazepines).

Another critical aspect of our success stemmed from providing education to each team member to enhance understanding of the disorder and its unique treatment requirements. Regular interdisciplinary meetings enabled real-time progress updates and strategic adjustments, facilitating a highly individualized and intensive treatment plan while also mitigating environmental and social factors that could hinder recovery. ¹⁷ These strategies maintained the patient’s engagement with the rehabilitation program while aligning with a psychobehavioral framework emphasizing relearning, adaptation, and reinforcement.^14,15,22

Inpatient programs have demonstrated efficacy in treating FND and offer distinct advantages by offering integration of multidisciplinary care within the acute setting.^23–25 This cohesive, interdisciplinary approach enabled tailored rehabilitation that addressed both physical impairments and psychosocial aspects of the patient’s condition. However, our success was contingent upon the patient’s compliance with our rehabilitation program, which was successfully fostered by the development of strong rapport with our medical team as well as the patient’s understanding of his condition. Lastly, it was critical for treatment team members of each discipline—including PT, OT, SLP, nursing, social work, and psychology—to become familiar with not just the disorder, but the unique needs of the individual, when developing a treatment plan of their respective expertise. This rehabilitation model allowed the proper deliverance and receptiveness of effective treatment.

Overall, this case demonstrated a successful acute inpatient rehabilitation model for a patient with classic FND symptoms. We propose that this model be considered for broader application in the acute rehabilitation of patients with FND. In addition, the limited number of studies and reports on this scenario indicates a need for a treatment consensus by the corresponding authorities.

Conclusion

The present case report shows the critical role of acute inpatient rehabilitation in the management of FND, highlighting the importance of a comprehensive and multidisciplinary approach. Our management demonstrates that integrating physical, occupational, and speech therapies alongside psychobehavioral interventions can significantly enhance outcomes in complex cases where neurological and psychiatric symptoms are multifaceted. The successful management of this patient reinforces the need for flexible, patient-centered rehabilitation strategies that adapt to individual preferences and psychological profiles. This case contributes to the clinical practice supporting early and multidisciplinary rehabilitative care in improving the functional prognosis of patients with FND.