Reclaiming Functional Neurological Disorder for Rehabilitation Medicine

Functional neurological disorder (FND), which includes symptoms like paralysis, tremor and seizures, is one of the commonest conditions in neurological practice. It affects between 50 and 100 000 people in the UK ¹ and is associated with high levels of physical disability and distress. ² It frequently co-occurs with other functional disorders such as fibromyalgia/chronic nociplastic pain, functional gastrointestinal disorders and psychiatric comorbidities such as depression, anxiety and post-traumatic stress disorder. It often leads to wheelchair use or disability aids and loss of employment or education. Why then has rehabilitation medicine not taken more of a leadership role in the management of the disorder?

When one of us began training in neurology in the 1990s, the reason why rehabilitation medicine wasn’t involved was explicit. At that time, ‘conversion disorder’ was a psychiatric disorder for which the only treatment was psychiatric. Rehabilitation units often refused the transfer of a severely physically disabled person with FND from neurological settings, citing concerns that the ward environment would reinforce their disability, that the patient might ‘mimic’ other patients on the ward or be disruptive, or that rehabilitation wouldn’t help. Behind these explicit reasons lay others less spoken: that symptoms were feigned or voluntary, and that rehabilitation teams lacked training or confidence in managing the condition.

Over the last 20 years, a renaissance of interest has positioned FND as a disorder at the interface between neurology and psychiatry. It is long overdue for rehabilitation medicine to also be integrated into that interface. People with FND benefit from a whole-person, biopsychosocial approach, and there is now evidence-based multidisciplinary treatment, including psychological, physical, occupational and speech and language therapy. Dozens of cohort studies now show good outcomes from multidisciplinary rehabilitation, though higher-level evidence is still needed. ³ We need to be sophisticated about how we triage patients, and there is no ‘one size fits all’ approach. In neurology settings, many patients can make significant improvements with education and physiotherapy or occupational therapy alone. Psychological therapy has a central role for many patients, especially those with functional seizures. ⁴ A group of more disabled individuals with more severe psychiatric comorbidities benefit from psychiatrically led rehabilitation. ⁵ Rehabilitation medicine physicians can collaborate with psychiatry and psychology, as they do for many other disorders, such as traumatic brain injury, to provide person-centred and coordinated care.

In the UK, recognition of the number of people with FND and their clinical needs has led to specific pathways in England ⁶ and Scotland. ⁷ A recent NHS England review of Neurological Services identified FND as 1 of 6 core conditions for regional neurological services, and it is also 1 of 7 core conditions in the UK neurology training curriculum. ⁸ Rehabilitation is promoted as the treatment of choice. FND and functional disorders also appear more prominently in the Rehabilitation Medicine curriculum as of 2021. ⁹ Consensus FND-specific recommendations for physiotherapy, ¹⁰ occupational therapy, ¹¹ speech and language therapy ¹² and evidence for psychological therapy, ¹³ as well as online courses specific to rehabilitation, ¹⁴ have created unprecedented access to training for professionals already set up to deliver multidisciplinary care.

There have been many notable studies led by rehabilitation physicians, including in Italy ¹⁵ and the United States, ¹⁶ yet the FND society only had 66 rehabilitation medicine members worldwide as of August 2025, out of 1168 members in total. Overall, one might have expected more leadership or involvement from rehabilitation medicine, given what a good match the speciality is for the condition.

Barriers persist. In many places, older attitudes that FND is ‘not our problem’ remain. A 2021 FND Hope UK survey found that 20% to 25% of services still refused therapy referrals for FND ¹⁷ – extraordinary for such a common cause of physical disability. Services are often concerned about inadequate staffing or training. A small minority of people with FND do have significant psychiatric disorders which will not respond to a standard physical rehabilitation setting or can be challenging for staff. Careful triage by experienced clinicians can help to mitigate that.

Our own experience in rehabilitation teams is that training 1 or 2 key staff members, cascading that knowledge and achieving a few good outcomes, can transform attitudes and confidence. Once health professionals see that dramatic improvement in previously disabled people is possible, and that creativity and therapeutic skill are central to that process, it can be difficult to remember why there has been such historical reluctance to take ownership of this disorder.

Reclaiming FND for rehabilitation medicine does not just have to be about the moral, clinical or evidence-based imperative. A young person who is rehabilitated from lying paralysed in a darkened room to walking and going to university is a tremendously satisfying outcome for everyone involved.