Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, we're highlighting functional neurological disorder. Joining me is Dr. Melanie Stearns. She's a physician specializing in physical medicine and rehabilitation at Northwestern Medicine Marianjoy Rehabilitation Hospital.

Dr. Stearns, thank you so much for joining us today. As we're talking about this topic, how do you determine which patients with FND are appropriate candidates for inpatient rehabilitation? Why don't we start right there?

Melanie Stearns, MD: Sure, yeah. Thank you for having me. So for patients with FND, in order to complete acute inpatient rehab, they really need to be able to tolerate the intensity of therapy that we do. So, we're an inpatient hospital-based rehab program. So, they come, and they stay overnight for a couple of weeks usually. And we do expect them to be able to do about three hours a day, spread out throughout the day. So, it's fairly intensive. It doesn't have to be intense exercise, but they have to be at least able to participate in transfers, working on their activities of daily living, a little bit of strengthening and endurance, like I said, kind of spread throughout the day.

So, they need to be able to tolerate that level of therapy. It can sometimes be a lot for folks with neurological disease. So, they have to be able to do that. And then, they have to have an understanding and acceptance of their diagnosis. So, it can be challenging if they come to rehab and expect further workups to be done. Because once they get here, the focus is really on the rehabilitation and working on their recovery and planning, their discharge to home, and not necessarily going for more MRIs and other testing.

So, I think those are the two big things. They got to be able to buy in to our more intensive rehab program and then kind of accept their diagnosis, assuming that most of this workup has been completed, of course, in acute care. Usually, the flow will be they go to acute care with a problem, and then they come to rehab after.

Melanie Cole, MS: Well, thank you for speaking about patient selection and really what's involved, because it can be pretty intense. Now, as we think of that, what misconceptions, Dr. Stearns, do referring providers commonly have, do they say to you about the role of inpatient rehab for patients with FND?

Melanie Stearns, MD: I don't see too many misconceptions. I do think it's important, again, just to emphasize that they have to participate. Some of these patients have disabling symptoms like severe tremors or different abnormal movement patterns or ataxia or things that might be so disabling that they can't actually complete and participate in a therapy session with a physical therapist.

So, sometimes we'll get referrals, but we look back at how they're doing in acute care with the physical therapist they're seeing in the hospital, and they're not able to really get through it. And if it's that level of severity, then they wouldn't be good candidates. So, I just think it's important to understand that they've got to be able to at least participate and that their symptoms aren't so severe that they can't participate.

Melanie Cole, MS: Can you walk us through a case that demonstrates the role of the physiatrist and interdisciplinary rehabilitation team when they're caring for someone with FND? Tell us about a patient case.

Melanie Stearns, MD: Sure. So, just a few months ago, I had a case of a busy mom of three little kids, and she presented to the acute care hospital with sudden onset weakness of one side of her body. So, she had hemiplegia and tremors. She did have a traumatic history in the past, but this was her first episode of the FND.

So, she was admitted to the hospital and, of course, underwent workup to rule out the scary things. So, we did all of the neuro-axial imaging, extensive testing to make sure that she did not have a stroke or anything. And eventually, we came to the diagnosis of functional neurologic disorder.

She came to us, and she completed about three weeks of inpatient rehabilitation. So, she participated in our hospital-based rehab program where she got three hours a day, worked with physical therapy, occupational therapy, speech therapy, and some of her cognitive and executive functioning skills. And she ended up doing really well, and she slowly improved. So, her weakness actually progressed linearly throughout the hospitalization to the point where when she was discharged, she wasn't requiring any assistive device, and she was functionally able to complete all of her activities of daily living and did really well.

She worked with our psychology team, our nutrition team. She really took advantage of all of the resources that we had at Marianjoy during her recovery. And she was a best-case scenario because sometimes the patients may have further permanent disabling symptoms or ongoing issues. But she really bought into her diagnosis, understood it, and then it was great to see her strength come back, and the tremors subsided, and she was able to complete a full course and then discharge back home.

Melanie Cole, MS: That's a motivated patient, because that's not easy. So, what challenges functionally led to this patient's admission to inpatient rehabilitation at MRH?

Melanie Stearns, MD: So, she had the hemiplegia, which made it difficult for her to ambulate and do her ADLs. She also had pretty extensive tremors that actually affected her arm and leg. So when she would try to get up and ambulate, the shaking, especially in acute care or in early in her stay, was quite profound and was needing to use a walker to stabilize her and different equipment to help her.

And then, because that sort of subsided throughout the course, it improved. But in the beginning, those disabling neurological symptoms, of course, often can be barriers and the reason why they're here is to work through those.

Melanie Cole, MS: Dr. Stearns, you mentioned how she took advantage of all of the resources and really utilized them, and that's really so important when we look at our patients in rehab. So, how did this interdisciplinary care team, including therapy, nursing, psych, which we'll get into in a minute as well, really collaborate to support recovery? Tell me how the team approach works.

Melanie Stearns, MD: Yeah. So, we work together very closely. So, we have our physical therapist, occupational therapist, speech therapist, nursing team, dietitian team, psychology team and our social worker. We have chaplain support. So many volunteering here. There's so many different resources. And we all work together because we communicate frequently, and we meet regularly.

So, that's part of what's unique about acute inpatient rehab is the physician, myself, meets with the team, with everyone, the therapists, psychologists, social workers, and we talk about the barriers. We talk about how the patient's doing and how we can get them home safely. So, we meet, we talk, we call each other, we see each other in the hallway. I'll be rounding on the patients and talk to the therapists while they're in therapy. So, it's a very collaborative hands-on approach. I'm seeing these patients every day. And so, it really helps to kind of be all on the same page about how we're going to get them home safely. So, lots of communication and discussions as she moved forward.

Melanie Cole, MS: And now, let's touch on psychology, what role that plays during an inpatient rehabilitation stay for patients with FND? Because, obviously, this can be devastating, these kinds of neurologic disorders. Speak a little bit about how psychology really helped this patient.

Melanie Stearns, MD: So, psychology is very important, especially because stressors can often trigger functional neurologic disorder, especially patients that have a history of traumatic experiences in the past. There's actually a very strong correlation between this history of prior trauma and the development of FND. And so, psychology is really important for stress management to process a lot of the trauma and stress. And this patient saw our psychology team here. Because the course of acute rehab is only a couple of weeks, it's important that they have longer-term psychology and often psychiatry established. And this patient actually did have a preexisting psychologist that they also actually participated in sessions with while they were here virtually, which was helpful as that psychologist knew the patient well. So, they were able to latch on to some resources they had, as well as speak to our psychologist and have sessions here. So, it was really great for her to be able to utilize different psychologists and to help and process everything.

Melanie Cole, MS: It's very comprehensive. And when we think of the rehabilitation strategies or interventions, what do you feel were the most effective in helping this patient regain her function?

Melanie Stearns, MD: What I noticed with this patient and many patients is a lot of positive reinforcement. So, small improvements: Make a really big deal out of them and it seems to then help accelerate the next improvement. And they really take positive feedback very well. And it's a great strategy, is focusing on, like, "Oh, wow, your tremor is a little bit better today. This is so great. I think you're going to be able to do more." And just really using that, the positivity and encouragement is extremely helpful, is what I've noticed. And so if all the members on the team, which we all are very on the same page about that for these patients, it can really help because we're all being positive and encouraging.

Melanie Cole, MS: So as motivated as she was, were there some setbacks? Were there some barriers, challenges that arose, and how did you address those?

Melanie Stearns, MD: So, this patient had a pretty smooth course like I described. But I will say, in others, sometimes patients do not get significantly better. And unfortunately, the disease can be quite disabling if they aren't making good improvements. And so, how are they addressed? Then, we're focusing more on caregiving and equipment needs and how are we going to help them function the best they can at home? Are they going to need a wheelchair? Are they going to need a power wheelchair? Will they need bathroom equipment? So, those patients that may struggle and may have a slower recovery or ongoing disabling symptoms, the shift becomes more about home preparedness than making that full strength recovery.

Melanie Cole, MS: Well, what functional gains did she achieve? And tell us what the discharge plan included for her.

Melanie Stearns, MD: So, she became mostly independent after about two or three weeks here. So, she was able to go home without her walker. She might have used one for longer distances to start, but she was able to ambulate well. Her tremors subsided, her weakness improved, so she returned home without an assistive device. We did make sure that she had all of her therapy set up outpatient. So once they finish acute rehab, they go home, and then they go to outpatient physical, occupational therapy, psychology. We made sure that that was all set up and that she had a really good support as she was going back home to her stressful environment with three little kids and things can be triggered again.

So, she did continue to do her outpatient therapies and improve. But luckily, her weakness really improved dramatically, so she didn't go home needing a lot of physical assist, which is always the goal, and she was independent with her basic self-care tasks,

Melanie Cole, MS: That's excellent. That's a very, very hopeful patient story, Dr. Stern. So as we get ready to wrap up, what key lessons from this case would you want other physiatrists to take back to their own practice?

Melanie Stearns, MD: I think many physiatrists are aware of this too, is just that they do have the potential to really improve and to consider acute rehab if their symptoms come on suddenly. Sometimes it can be hard to bring in patients from the community to acute rehab, because insurance often won't cover it if they don't have an acute issue or acute medical issue of acute workup for neurologic things.

So, I think it's important just to remember that acute might be a good option for them, or to consider if they aren't able to get into acute and they are presenting with these symptoms, there are often day rehab programs where it's more of an intensive outpatient therapy program that might be beneficial for them. NM has several locations for that, and that they can do not exactly the same intensity as inpatient, but they can still get therapy several hours a week and that these patients often do well with that increased attention, increased therapy sessions. They often do well with some of those programs. So, considering outpatient intensive rehab programs, if they're able, again, to tolerate it. It could be an option if they don't qualify for the inpatient program from being admitted to a hospital.

Melanie Cole, MS: Thank you so much, Dr. Stearns, for joining us today and telling us about this patient's story. It was so comprehensive. Thank you again. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/rehabilitation to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.