Functional Neurology 2017
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Transcript of Functional Neurology 2017
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Functional Neurology
What’s it all about?Dr Naomi Warren
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Content Background Clinical presentations Investigations Management Future aims
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Background
Historically: hysteria (the “wandering womb”) conversion disorders dissociative disorders psychogenic medically unexplained non-organic psychosomatic functional
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Functional symptomsCommon… 15% new outpatient neurology 1-10% of inpatient neurology admissions 50% of “status epilepticus” 10% of “first fits” 5% of movement disorders
Patients are just as distressed as patients with disease
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Case 1 16 yr old girl – sporty Ankle injury 2/52 previous 4/52 right weakness leg 3/7 jerking body movements – intermittent o/e – dragging R leg behind her On bed – no movement R leg +ve Hoover’s sign Reflexes normal Episode jerking body – 2 mins
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video
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Case cont…. Explained
Functional Not seizure
Denied stresses initially Parents – due to leave UK stress
Treatment Physio Snowboarding!! www.neurosymptoms.org
Good outcome
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Functional weakness Half sudden onset Often with pain Examination
Look for inconsistencies bed/day to day
Hoovers sign Odd pattern Giving way Dragging leg Ass hemi sensory loss
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Functional gait disorders gait disorders
dragging leg crouching gait tightrope gait without falling
Rhombergs Wibble and wobble but don’t fall down
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Case 2 34 yr old R handed woman FT administrator Sudden onset tremor right hand 4 days
previous Present constantly No previous history
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video
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Functional movement disorders
Can be more difficult to identify
Mostly sudden onset Eg after injury
Tremor Disappears with distraction, entrainment,
variable
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Other mvmt disorders - rarer Dystonia
Fixed, often painful Beware - often organic disease looks unusual
Myoclonus often axial
Tics
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Non-epileptic attacks Aura
Not stereotyped Variable time
Attack Violent Long/multiple Eyes closed No “tonic” phase Fast resp
Post ictal Crying No true confusion
• Not helpfulIncontinenceInjuries
• Some helpTongue biting - lateral
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Investigations? Minimal tests Often need MRI in weakness
Reassure pt/docs ?functional overlay
Explain You think the tests will be normal Incidental findings
Video EEG in seizures
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Management Explanation
Key Psychiatry/ology
To help manage symps CBT
Antidepressants Physio Pain team www.neurosymptoms.
org
Give positive diagnosis
Tell what don’t have Mechanism Emphasise common Reversible “stress/mood makes it
worse” Self help
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PrognosisGood BadAcceptance Strong belief permanentYoung age Long historyShort history Delayed diagnosisLack other symps Anger at diagnosisChange in marital status after diagnosis
Multiple other symps
Anx/depression Pampering carerHelpful family Personality disorder
Financial benefit
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Primary + secondary care aims To understand/believe the condition To provide swift diagnosis To give a consistent message
(limit 2nd opinions) To give appropriate psychological and
physical therapies
Unless self limiting and clearly functional – refer to neurology
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Conclusion Very common problem in neurology Huge cause disability Needs swift investigation and mgmt Careful explanation Appropriate psychological help
Questions?