Reflective article on plenary session by Dr Elizabeth Mallam entitled Funtional Neurological Disorder. This article was submitted as a condition of the author receiving a bursary place at PMG2024.

(Photo of Dr Elizabeth Mallam - courtesy of Richard Millar)

I was extremely grateful to be offered a bursary place by the Posture and Mobility Group committee to attend the 2024 conference. Attending the conference was a thoroughly enjoyable experience and provided me with invaluable learning experiences to inform my ongoing clinical practice.

I found the talk titled “Functional Neurological Disorder (FND)” by Dr Elizabeth Mallam (Consultant Neurologist from North Bristol NHS Trust) to be particularly interesting and insightful. I have therefore chosen to use this talk as inspiration for my reflective piece, structured using the Gibbs reflective cycle (Gibbs, 1988).

Dr Mallam expertly described the challenges that patients with FND experience in order to receive a diagnosis, including the ever-present stigmas surrounding FND which are present within healthcare systems. She highlighted the importance of a multi-disciplinary approach to the management of FND, with specific focus on the importance of education. It was particularly interesting to hear her thoughts around the decision-making process in relation to wheelchair prescription/eligibility. She made the comparison of a person unaffected by FND being able to complete a very long walk if required, however that they may then be too tired to enjoy/engage in their day after this due to fatigue. She then applied this metaphor to a person with FND, advising that although they may manage a journey outdoors without use of a wheelchair, that they may then be too tired to engage in the activity which they set out to complete.

I found this particularly thought-provoking as I often struggle with the decision-making process around wheelchair provision and triage for clients with FND. Often clients with FND are discussed during a multidisciplinary team (MDT) clinical case discussion within my wheelchair service. This  is a good starting point to ensure best practice care. However, having spoken to colleagues, I understand that many clinicians also experience the same challenges around wheelchair provision for this patient group. There also seems to be variability between clinicians in terms of decision making around eligibility for wheelchair provision and the equipment prescribed.

I often refer back to the evidence base when faced with these types of situations. A paper which I have referred to previously, and is also mentioned in Dr Mallam’s talk is “Physiotherapy for functional motor disorders: a consensus recommendation” (Nielson et al., 2014). For the most part, the evidence base relating to FND management and rehabilitation advises against use of mobility aids, promoting early weight bearing to improve function and symptoms. Using this to guide, eligibility for wheelchairs is challenging as there are both pros and cons to wheelchair provision in this patient group. However, this consensus article does acknowledge that mobility aids are not always contra-indicated.

Both this article and the discussions within Dr Mallam’s talk prompted me to reflect on my decision-making process around triage and wheelchair provision for these clients. Although taking a purist rehabilitation approach is ideal in isolation, looking more holistically and at the wider social picture is also as important. Access to a wheelchair for a person with FND may allow for greater participation in social activities, increased independence, improved mood and improved fatigue management. This may then allow someone to engage in more consistent rehabilitation, which in turn can result in improved function and rehabilitation gains. It is now well established that factors such as mental health issues can perpetuate and also trigger symptoms, and these factors can be a significant barrier to rehabilitation progress (Bennett et al., 2021). Therefore, it is important to consider how these can be addressed alongside rehabilitation. Early liaison with members of the multidisciplinary team (MDT) such as occupational therapists involved in fatigue management and neuropsychologists will help to inform decision making and ensure that appropriate equipment is issued, when clinically indicated.

I feel that Dr Mallam’s presentation and my review of the evidence base prompted necessary reflection on my clinical reasoning and approach to equipment provision within the FND patient group. I need to ensure that I am completing a thorough review of the client’s history and liaising with appropriate members of the MDT to make an informed decision around wheelchair eligibility and prescription. Through doing this, I can ensure that I am completing a comprehensive assessment of factors which may be causing symptoms and therefore taking a more holistic approach to patient management.

References:

Gibbs, G. (1988). Learning by doing: a Guide to Teaching and Learning Methods. Oxford: Further Education Unit.

Nielsen, G., Stone, J., Matthews, A., Brown, M., Sparkes, C., Farmer, R., Masterton, L., Duncan, L., Winters, A., Daniell, L., Lumsden, C., Carson, A., David, A.S. and Edwards, M. (2014). Physiotherapy for functional motor disorders: a consensus recommendation. Journal of Neurology, Neurosurgery & Psychiatry, [online] 86(10), pp.1113–1119. doi:https://doi.org/10.1136/jnnp-2014-309255.

Bennett, K., Diamond, C., Hoeritzauer, I., Gardiner, P., McWhirter, L., Carson, A. and Stone, J. (2021). A practical review of functional neurological disorder (FND) for the general physician. Clinical Medicine, [online] 21(1), pp.28–36. doi:https://doi.org/10.7861/clinmed.2020-0987.