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Functional Neurology for GP Event March 2015 - NW
- 1. Functional Neurology What’s it all about? Dr Naomi Warren
- 2. Content Background Clinical presentations Investigations Management Future aims
- 3. Background Historically: hysteria (the “wandering womb”) conversion disorders dissociative disorders psychogenic medically unexplained non-organic psychosomatic functional
- 4. Functional symptoms Common… 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
- 5. Not specific to Neurology... Speciality Symptom Cardiology non-cardiac CP Gastroenterology IBS Respiratory chronic cough Renal/gynae recurrent loin/pelvic pain Surgery chronic abdominal pain Rheumatology fibromyalgia chronic fatigue syndrome
- 6. 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
- 8. Case cont…. Explained Functional Not seizure Denied stresses initially Parents – due to leave UK stress Treatment Physio Snowboarding!! www.neurosymptoms.org Good outcome
- 9. 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
- 10. Functional gait disorders gait disorders dragging leg crouching gait tightrope gait without falling Rhombergs Wibble and wobble but don’t fall down
- 11. Case 2 34 yr old R handed woman FT administrator Sudden onset tremor right hand 4 days previous Present constantly No previous history
- 12. video
- 13. Functional movement disorders Can be more difficult to identify Mostly sudden onset Eg after injury Tremor Disappears with distraction, entrainment, variable
- 14. Other mvmt disorders - rarer Dystonia Fixed, often painful Beware - often organic disease looks unusual Myoclonus often axial Tics
- 15. Non-epileptic attacks Aura Not stereotyped Variable time Attack Violent Long/multiple Violent No “tonic” phase Fast resp Post ictal Crying No true confusion • Not helpful Incontinence Injuries • Some help Tongue biting - lateral
- 16. Other functional presentations Cognitive decline subjective cognitive problems although can usually give a very clear account of themselves Visual loss tunnel vision or blindness with preserved pupil reflexes and optico-kinetic nystagmus Globus Dysphonia
- 17. 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
- 18. Management Explanation Key Psychiatry/ology To help manage symps CBT Antidepressants Physio Pain team www.neurosymptoms. org Give diagnosis Tell what don’t have Mechanism Understanding Emphasise common Reversible “stress/mood makes it worse” Self help Consistency
- 19. Prognosis Good Bad Acceptance Strong belief permanent Young age Long history Short history Delayed diagnosis Lack other symps Anger at diagnosis Change in marital status after diagnosis Multiple other symps Anx/depression Pampering carer Helpful family Personality disorder Financial benefit
- 20. 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
- 21. Conclusion Very common problem in neurology Huge cause disability Needs swift investigation and mgmt Careful explanation Appropriate psychological help Questions?