🎥 Case: Functional Neurological Disorder (FND) and POTS

today I want to share with you a case study of a patient with functional neurological disorder that we treated here in the clinic my name is Dr Nathan Kaiser I'm a chiropractic neurologist and before we get started I should probably go into a little bit of the background about what functional neurological disorders are we commonly abbreviate them fnd for those of you that have some knowledge in this in this area so I think Dr Mark Edwards and John Stone did a really good job articulating what exactly functional neurological disorders are so what they said was fnd describes motor so movement and or sensory feeling symptoms that arise from the voluntary motor or somatosensory nervous system and they're experienced as involuntary so they come from let's wind that back again they arise from the voluntary motor system or the sensory system and they're experienced as involuntary action so involuntary senses involuntary movements and this is really important a lot of times these are looked at like they're rare conditions but what we actually find is they're not particularly rare it's the second most common reason for outpatient neurology consultations after headaches so after headaches fnd is the most common outpatient neurological consultation so pretty important that we talk about it because they're often pretty well misunderstood to be honest with you and part of the reason they're misunderstood really comes from the idea that functional neurological disorders have been conflated or lumped in with other types of issues as well we call them psychogenic disorders or conversion disorders and what that means is those are previous diagnoses that were used to describe um malingering or feigning or or faking symptoms right and to highlight this there's actually a study done and you can see it here that the results of that study showed that both neurologists and psychiatrists when they were surveyed considered a proportion of their feigning as intertwined with or the same thing as fnd so you can see for people that are dealing with functional neurological disorders there's an uphill climb toward a resolution for these because uh quite frankly the toolbox is pretty small so with that kind of background um I think it's important to kind of make a couple statements before we talk about this case so number one um when I look at fnd cases I see a wide variety of them and they are very frequently um different treatment trajectories that we will use with them I don't put myself out there as being any sort of a true expert in this field but with the overlap of of conditions that I treat this happens to be part of the group of people that that seek out care and when we look at the cases very carefully there are some components of them um that make them good candidates for the things that we do so when I show you this case I don't want to show it as this is the treatment for all fnd all hail go do this thing that's not what I'm trying to say what I'm hoping for is that if I share with you a little bit about how we looked at this case and how this story evolved over time that we may be able to shed some light on some ideas for people that are dealing with this for some people that are helping to treat them in practice and maybe just provide some forward momentum in how we think about cases like this so that's really the purpose of sharing this video but I'm going to do it in a case story format because I think it makes it more Rich to try to understand it and feel it so the case that we're going to talk about today I'm going to go back and forth between slides so if I mess it up just bear with me but this is a case of a 17 year old female with a history of painting and she was subsequently diagnosed with uh functional neurological disorder the presentation of her fainting wasn't uh just like a faint to the floor it was associated with a type of a pseudoseizure where we see movement disorder component we see a Tremor portion of this uh they were happening with a relative frequency so as you can see here from her kind of initial history that she provided this happened in several times a day and it kept increasing they did a photic stimulation with an EEG in the hospital which basically we hook people up to an EEG and they do a flashing light and that flashing light helps us to be able to diagnose whether or not there is epileptiform activity in the EEG but when she did that she experienced a ramp up of her symptoms where she was fainting or having these episodes more frequently and they were becoming more prolonged and there was more of a motor component with them so that's that part's important so we'll go back here you can see the types of episodes she would have would have mild kind of jerks um so jerking of jerking off her Limbs and of her head she was having difficulty walking and this is an important one for us she was actually drifting to the side as she walked but she couldn't control it she felt like her body was just carrying her over and when most people look at something like this it's very easy for their mind to go like oh that's not real she was faking it right so it's really hard to be able to um to get a good honest look in a case like this so she was having times where her legs were giving out and then obviously things were worse when she was standing up so moving forward the episodes typically lasted for a couple minutes at a time but they could be anywhere up to a half an hour an hour and usually after it was done she felt a sense of relief what was interesting about that though was that she is non-verbal she's not able to communicate or move but she has a perception that she can still hear and be involved in the time scale of what's going on in the world they're they're made worse with too much mental activity or too much physical activity and then also we found in her evaluation that simply just being upright um and being in orthostasis also made things harder for her and we'll get into a little bit more depth about what that looks like and then the only thing that helped her feel better was laying down and resting while in the hospital they did give her some IV saline and that gave her uh several hours of relief afterwards which gives us a clue about some of the pathology involved in this case so that's that was actually a helpful little antidote it didn't last a couple hours felt really nice but that's helpful for us in the diagnostic process um what's interesting about that is in that same state she actually uh interacted with a position that was really helpful for her that noticed that um the tachycardia and palpitations that she was experiencing were mostly happening as a consequence of the orthostasis meaning so she could lay down and get relief she could recover but when she stood back up again tachycardia and then symptoms would evolve she could lay down and again try to get to that relief period as long as it didn't go on too long and progress into the loss of consciousness phase so super helpful um very good workup But ultimately they kind of just ran out of tools for what to do on a solution side and then they were recommended to see us so part of the process that we looked at was looking at this is kind of teasing out some of what we saw with these autonomic findings and we confirmed what the other doctor had already noticed um and that was that she had this acceleration let's see if I can show you right here this acceleration of her heart rate that happened when she was in an orthostatic position right here during this yellow part so we see a baseline level of heart rate activity Baseline level of blood pressure activity and we see a drop in blood pressure that's not um on the scale of orthostatic hypotension but it does drop and cause a a requisite uh acceleration of the heart rate meaning say that in easier words so she's having enough of a dip in blood pressure that she has to have a cardiac response so it's not as though her heart rate is just Rogue on its own taken off it's in compensation for the fact that she's not getting adequate blood pressure and we were able to measure that with the Doppler ultrasound of middle cerebral activity in the brain so we were actually able to see that she was um so she was losing some blood flow in her brain which makes a lot of sense for the symptoms that she was having we notice that on the tilt table test she developed some of her symptoms asymmetrically meaning she would develop stereotypes on the right leg she would have posturing overhead to one side she would have fluttering of her eyes in One Direction so these are really helpful in understanding that this isn't uh like a global hypoxia we're actually seeing pathway Genesis where she's losing blood flow in some specific areas so this this was helpful for us moving forward on that I think it's useful also to maybe I didn't videotape this exam so I personally don't have a ton of great visuals for it what I do have is what we looked at with oculography and I do think that this can be helpful so what I'm going to show you first are cicads these cicads are eye movements back and forth side to side but what you'll notice or excuse me these are vertical eye movements my apologies um so she's jumping her eyes to a Target that's up jumping your eyes to a Target that's down and they're randomly spaced throughout that vertical plane and what you're going to notice is the eye movements aren't crisp and sharp like we like to see they're actually slow and delayed and what you'll notice in one point is you'll see her eyes do this little swirl that little swirl is really helpful because it helps us understand some of the integration that's happening between uh areas in cerebellum and the brain stem and the frontal lobe and this pathway that helps our eyes move in that plane so I'm going to show you that real quick here we go and you can see the way her eyes move so you see some graphing up in the up on the top but you're gonna I want you to watch her eyes here and you'll be able to see these movements so you see they're kind of slow going down slow going up they should snap here snap snap see that swirl snap open then her eyes drift with her head movement so now we're starting to get in addition to this along the eye movement she gets some movement of her head so that drift of her eyes over to the side to the left is associated with her head turning to the right so she's actually develops a right head turn and her eyes drift over to the left side so we can see these little subtle indicators that tell us these Pathways in the brain are not working optimally it's good to notice that this test is done seated so she is in a degree of orthostasis not just purely laying down and then another good eye movement test that we were able to pull out is doing the same thing in that vertical plane but now instead of using a sakad sakads are frontally generated in the frontal eye Fields we're going to use a Pursuit which comes from a little bit different mechanism where they're generated based on information our visual system takes in and processes as a reality in the largely in the parietal eye Fields but in in some different Association complexes as well and this is very useful because it helps us see where these two different pathways are going to intermingle to understand what's going on what's Happening here so let's watch this one as well okay so we'll play this here the way this should move let me back up these should the eyes should go up and down smoothly in a coordinated way no jumping nice and smooth as they're tracking that Target up and down so you can see here when you watch her eyes one they're a little jumpy and they're jumpy side to side which if you're following a Target that's going straight up and down there's no reason for your eyes to move side to side and do the swirls that you see there at the top and at the bottom okay so these are really really helpful for us in that diagnostic process so what we did from here we'll just kind of share that part so we know there's an orthostatic component to it we see these errors in the eye movements we see that she has a drift when she walked she has we didn't talk about it but with the Maddox Rod test we see that there is the positioning of her eyes is skewed so that they don't actually at 20 feet away they don't actually aim at the same spot they aim at slightly different places and this tells us a little bit about how her brain is directing that Symphony of eye movement coordinating posture coordinating delivering blood to her brain so what we did and again as we talk about the treatment part caveat here is um this is just what we did in this case it's not an invitation to try this on everybody you see or to try it on yourself it's an invitation to understand how I thought about a case Okay so don't run and do this at home what we did was we noticed the place in her orthostasis where things start to fail we start at the very Baseline laying flat zero degrees and we worked on subtle head movements side to side or opposite of the plane where where she has the the hyperkinetic movement and we just worked on having her do this simple gaze fixation turning her head only about three degrees in either direction and I did it passively so the key for that is that if I do it for her if I turn her head slightly and control the rotation of her spine with my hands while she looks at a Target she is not generating the movement she's getting feedback about the movement from her body we talked about in the very first slide how there's a mismatch between what we see what we experience as voluntary versus the outputs from the motor system or the inputs from the sensory system so we are commandeering the sensory system in this case we're taking it over and as we do that she's able to generate these smoother movements we could then bring her up incrementally watching for the stereotypes in her legs watching for the Acuity in her eyes and making sure she didn't fall into a convergent spasm so we did that slowly over the course of days and we were able to find that she could then sit up and move and walk without drifting to the side we found that she had longer time periods between episodes and it was she was able to tolerate movement with her eyes and of a moving environment better and better and better sequentially so an example of that if we slide back to looking at the tests that we did a couple days in we repeated this test so you can see here this is the repeat two so this is the third time we check this test and you can compare the eye movement here tracking up and down so again we're looking for Smooth Up and Down eye movement okay so here you can see it's not perfectly smooth yet but you don't see any of the horizontal deviations that we saw before and we don't see any of the swirling so even though this isn't perfect home run yet we can already see that these objective signs that we're looking at are starting to transfer into her experience of her subjective reality which is awesome so we continued that until we were able to get her to an upright position and being able to actively turn her own head we transition that to then doing some exercises in our our whole body rotation device where we actually have her in a chair goggles on similar to the ones that you're looking at here so I can see your eyes fixated on a Target and we just have her rotating back and forth like this so it's a little bit harder than me doing it but it's still passively her body getting a stimulus of this movement in her body getting that stimulus allowed her to attenuate or to calm down the hyperkinetic myoclonus that she was experiencing which is beautiful so we did this over the course of a couple weeks and then we transferred it to tools that she could use at home so that she could get out of the wheelchair be able to go to school to be able to sit through class and all of the movement and class and being able to walk to class without getting you know triggered by all of the sensory information and then ultimately be able to pursue higher order education and and some of the extracurricular things that she does with that so it's a it's a beautiful Story one that I'm I'm super proud of her and her family for being able to execute it but it's one that I share because there are a couple key points and that we could find these levels of orthostasis or the fact that her symptoms are brought out by the by positioning where she does her brain doesn't understand how to get blood into the head which further exacerbates or makes worse some of the firing rates that she experiences with the syndrome so she has these symptoms but the pathway that is responsible for them when you take blood away from it it's going to do worse and that's what we see here so by allowing blood flow to exist in that pathway and then slowly exercising that pathway she was able to get some purchase she was able to get some momentum in being able to rehabilitate that and take part in that process and solve it herself which is pretty beautiful so um enough of me rambling I hope it helps please leave comments and and questions and hopefully um taking this little bit of time help somebody thank you guys