[dschwarz]

By PT, I am assuming you mean physical therapy? If so, I’d be more than happy to discuss what that presentation could look like. I’m currently working on a presentation on FND that is focus on physical therapists though it is also relevant to other rehabilitation providers. I’ve done education on pain individually and to groups in professional and post professional physical therapy settings. Let me know if you want to chat!
-David

[dschwarz]

I am not an optometrist, but I have extensively worked with people experiencing post-concussion syndrome symptoms. In other words, my expertise is limited in the area of optics, but I would refer people out if oculomotor activities would not improve their coordination. Sensorimotor disruption is common in post-concussion syndrome, and this can cause strabismus (basically where one or both eyes are pointed outside the area of focus). From my understanding, prisms in eyeglasses bend light so that the person can fixate their eye appropriately. In functional neurological symptoms (such as occurring with post-concussion syndrome), the levels of strabismus are generally minimal (compared to a measurable sustained injury to the brain tissue) but can cause some eye strain and difficulty coordinating movement. Successful oculomotor rehabilitation in these cases hopefully will include a gradual reduction in prisms. So, while they can have a placating effect, that effect is a real effect of the physics of optics and how that interacts with their nervous system. Another thing is that even if someone needs prisms, not everyone can tolerate them from what I hear and some do better without them. I hope that explanation helps. -David

[dschwarz]

Personally, I would market to them for sure as well as any trauma surgeons. I would not worry about giving any caveats. Some people have a faster healing response. Simple amputations can heal pretty quickly with complex trauma along with comorbidities such as diabetes and infection taking a much longer time. All of these people may benefit though. I was more trying to say what is easiest to differentiate. I took a look at the introductions page and see your are a psychologist. When I worked with a lot of people post amputation, I always worked to get them to psychotherapy services to process the trauma/grief more than what I have the time for as a physical therapist (I listen and coach but also have to assess their skin, gait, transfers, and other functional movements as well as education and training, which I work hard at trying to do some of these every session to decrease the likelihood of adverse problems. ). Plus, most PTs do not have the skill or mindset to work with people outside of pathoanatomical issues. It also can take a long time for some of these patients to commit to more treatment so hearing the option early and often in their recovery can be quite helpful. I hope that perspective helps!

[dschwarz]

To be honest, while mirrors can have a beneficial effect, I have not found them to be consistently beneficial. I have a colleague that worked a lot with mirrors related to CRPS, and he found that if the patient was not ready for that level of dissonant experience, the mirror could increase symptoms. In my practice, I have found better success engaging with the phantom limb with similar techniques to PRT vs the visual limb with mirror therapy. It has been easier for me to integrate that practice into their mobility (you cannot carry a mirror everywhere). One difficult aspect is that of healing time (which can be prolonged depending on the reason for the amputation and related to the adherence to wear schedules of their prosthesis if they have it yet) and the formation of neuromas at the residual limb/stump. It can create some difficulty in recognizing the differences between functional and structural symptoms. Chronic phantom limb pain (6-12 months out from the amputation) may be easier to identify as functional with less likelihood of other stuff getting in the way of addressing neural circuit issues.

[dschwarz]

Here is an interesting study that came out. I would say it is not groundbreaking but it is affirming. It is on the observed prevalence of FND in chronic pain clinics: https://pubmed.ncbi.nlm.nih.gov/37227931/

Another study occurred a while back that looked at the high prevalence of autism and autistic traits in FND. When we bring it around full circle, we can see how there is a high rate of abuse/childhood trauma in children with autism especially with a lack of appropriate follow up by adults. The interconnectedness of common context can be such an interesting thing.

[dschwarz]

Thank you Grace!

[dschwarz]

Unfortunately, I missed yesterday. I look forward to watching the video. Cognitive functional therapy does have some interesting elements that still need teasing out. I see the same thing with acceptance and commitment therapy base models of care in physical therapy and rehabilitation services. One substantial element that is missing it seems is that of positive psychology. I do not think physical therapists are very good at this. I am currently writing up a national survey on physical therapist knowledge, attitudes, beliefs, and behavior related to functional neurological disorders. It has been interesting to see some of the perspectives and the variety of practice. The document that it is based on is unfortunately flawed in my opinion, but it is what the profession has. I believe that the understanding of functional neurological disorders and the treatment of people who have them has a long way to go. There are some good ideas coming out of the UK on functional neurological disorders however the research in general especially the United States is very limited. Fortunately for me this creates a lot of opportunity for my dissertation.

[dschwarz]

I have used Chatgpt to help write some patient materials. The cool thing is that you can specify things like asking it to write at a 6th grade reading level for accessibility.

[dschwarz]

The most basic or simple BPPV is when it is clear from history and it is recent. A young to middle aged adult with a clear posterior canalithiasis BPPV is normally 1 session, maybe 2. This is the most common condition. Lateral canal treatment is tough and an cupulolithiasis treatment becomes much more difficult.

However, I don’t think that is what we are referring to. As otoliths generally dissolve over a few weeks or months and can naturally migrate out of the canal, I believe that we are talking about a sustained central nervous system response…though by that time it is hard to know if an otolith is still present or if it even ever was.

[dschwarz]

Hello all, I am David Schwarz. I work as a physical therapist around Grand Rapids, Michigan in the United States, but I am also licensed as a massage therapist and have an administrative background. Currently, I work in patients’ homes with older adults. I just transitioned from homecare to outpatient in the home for more freedom. I am currently working on my PhD in Physical Therapy at University of Michigan (Flint campus which is where I did my doctorate) and I am focusing my research on Functional Neurological Disorder, primarily on the motor portion for now as it is more palatable for PTs. Some of my other recent work is related to substance use disorders, ACT in PT, cancer pain, physical performance in older adults, and some other smaller stuff here and there.
My initial interest in the pain space was from my experience of starting with weekly migraines that began at about 6ish years old which grew to joint pains and then widespread pain as an adult. Before I was a PT, I worked for 9 years in nursing (“nurse aide” in skilled nursing, assisted living, memory care, UTI research, inpatient psych). I asked my boss at the time (on a co-occurring disorders unit) about what we do to help curb recidivism related to pain. His response was, “we don’t do pain here.” So, I decided that I “do pain” and want to help them. So, I continue to work hard to help people, especially focusing on those people who are on the periphery of healthcare.

[dschwarz]

Whenever I see someone with a BPPV diagnosis, I rarely see it as the only reason (if a reason at all) for the dizziness. When BPPV is clear and the only issue, it is pretty easy to treat nearly every time (1-2 sessions with near if not full resolution)

For example, I had a recent home care patient (female, late 70s) with lateral/horizontal BPPV (cupulolithiasis) but neck pain with relief of dizziness with cervical distraction. However, also had a history of eustachian tube dysfunction, cardiac problems, and deconditioning which could indicate potential orthostatic hypotension, chronic GI problems including frequent diarrhea (every 1-3 hours), and a few other things. However, there was also stress of a daughter with frontotemporal dementia, hoarding behaviors, limited social interactions, aberrant sensitivity to pressure, difficulty sleeping, fear of falling, etc. So I addressed what I could related to the structure (conversion of the crystal to a more advantageous spot and getting it out of the canal). However, we then addressed the fears and pain through recognition of the behaviors that were exacerbating her symptoms such as helping her find better balance and increasing her tolerance to movement (some simple exercise), helping her find good rest (positioning for comfort), calming her system (reducing fear response with movement through visualization and graded motor imagery), and giving her external cues based on the calming imagery (moving like a wave versus telling her how she must move).

Other vestibular diagnoses are limited in their use though I think they may be more common such as Persistent Postural Perceptual Disorder (PPPD) and Mal de Debarquement. Unfortunately, well-meaning PTs do not want to break from the BPPV model because they can explain it more easily. The problem is that a functional neurological condition such as PPPD does respond to an Epley maneuver, but it likely only harms the patient as it gives a false hope with the mechanistic/structural explanation. In that sense, I would say it may not truly be a placebo but rather digging the patient down into their condition…in other words iatrogenic harm. The problem that I have found is that no matter how much you try to show a patient or even tell them that their PT was not really helpful before, the amount of time, effort, and money they put into that person does not allow for them to change their mind. A way I have reframed the benefit of the movement is that it is an exposure to a movement that is novel and it gives the opportunity for their system to build confidence, which can be done with plenty of other movements too…and then we work towards breaking free from that model of BPPV and only return to it if the signs and symptoms are clear.

I could go on about this because I normally do, but I will summarize: Dizziness can always be a functional neurological symptom, and I believe the science supports that an element of it is nearly every time as distress is common.

[dschwarz]

Egocentricity is difficult to overcome. I am much more careful about this now compared to my earlier days in practice, but I can still get wrapped up in myself when time is a factor. I believe that these patients (and I guess all patients) need both our time and attention to feel validated. For example, I see doctors with a residency program partly to be able to be a helpful element to their training (and also because I couldn’t get a referral to a psychiatrist after mine quit outpatient practice…healthcare is such a mess at times). I started with another resident this last month and decided to read the notes as he seemed distracted and rushed in the appointment. He wrote one bit of information that made me feel like he doesn’t understand me: he wrote that I was working part time and left that job to start my PhD. The reality is that I not only am still working and have been doing my PhD even while part time, but I am now full time. Does this really matter? Probably not, but it feels like it does matter because of how meaningful being able to work full time is for me. The reason why I tell this story is that we never know what is meaningful to or patients or what will lead to their loss of a sense of validation and understanding. The funny thing is that the context of feeling like he was rushed and lacked attention led to the lack of understanding/invalidation interpretation of the error in history taking. This is part of why I generally spend substantially longer amounts of time in my initial evaluations compared to others in my profession. I do my best to set my clock aside and just listen, taking the necessary time. It would be great if we could all do that and have space to meet our patients needs without compromising our own needs.

[dschwarz]

I am excited that I was able to reorganize my schedule to be able to make the meeting on Wednesday.

Some of the publication related to misdiagnosis of mind-body disorders such as Functional Neurological Disorders (FND)/conversion disorder as issues stemming from structural problems are interesting. (For context, I am a DPT/physio in the US working on my PhD) I had a patient who I could not convince the doctor to have better assessment performed on her. She had two strokes in a 4-5 years period with the first one triggering significant depression which improved in the 6-8 months prior to the seconds stroke, and the second stroke having episodes of dizziness that became problematic 2-3 months after the stroke. She became fearful and stopped walking due to the dizziness and falling. She had a particular movement pattern that appear with symptoms that included reduced reaction to environmental stimuli and rotating her head to one side. I was able to help her understand better the recongition of kinesiophobia related to dizziness/fatigue/pain and her symptoms initially resolved within a couple of days so we could progress improving her confidence with movement. At times throughout care these symptoms would return and I tried to get the doctors office to stop telling her it is all because of her stroke. Unfortunately, I was unsuccessful at that (I would like to think that I am typically successful with educating the physicians I have worked with, but pobody’s nerfect, right?). I have the way I learned for educating physicians and other healthcare professional on mind-body, FND/conversion, whole person problems, but are there any favorite ways that you all have?

The way I learned/taught myself: Typically, I describe the symptoms and the current assumed aetiology. I then describe what I see with movement and function and describe how these are not consistent with the current problem (or what parts are consistent and what are not). Then I describe the current context of stressors and some of the conversations I have had with the patient. Finally, suggesting that the condition appearred to be of a functional nature and describing how I came to that conclusion through testing such as cognitive initiation of sensory provcation (motor imagery, memory, imagined context changes), Hoover’s sign, hip abductor test, modulation of attention, etc. After all of that, I asking what questions, comments, or concerns they have.

Thanks!
David J Schwarz

[Author]

Posts