Journal of Neurology, Neurosurgery, and Psychiatry | 2021
Expanding the therapeutic toolkit in functional neurological disorder: consensus recommendations for speech and language therapy
Abstract
Our ability to communicate with one another is precious. For individuals diagnosed with functional neurological disorder (FND)—a prevalent, costly and potentially disabling condition at the intersection of neurology and psychiatry— patients can present with speech and swallowing difficulties in isolation or as part of a mixed symptom complex. Baker and colleagues have deftly addressed a previously unmet need in the field by organising a multidisciplinary, international expert panel (including 18 speech and language professionals) to detail consensus recommendations for the management of functional communication, swallowing, cough and related conditions. Convergent with published consensus recommendations for physiotherapy and occupational therapy in FND, 4 this article expands the therapeutic toolkit for the management of functional neurological symptoms. After first providing a guide for how to assess and explain the FND diagnosis by leveraging the biopsychosocial model and emphasising positive clinical signs, general and symptomspecific management strategies for a range of functional speech, voice and swallowing presentations are outlined. The importance of the initial consultation by the speech and language professional is emphasised, highlighting that early rapport building to aid a positive patient experience is crucial. While treatment duration varies across patients, general therapeutic principles include (among other techniques) the identification of symptomatic behaviours, introducing strategies to facilitate automatic movements, and extending instances of therapeutic success towards more relevant and meaningful activities. Rehabilitative and psychotherapeutic strategies are encouraged to be used in one treatment package, including helping the patient notice and challenge unhelpful thought patterns. Within specific symptom presentations, practical ‘how to’ tables guide the reader in learning the intricacies of treatments for functional voice, dysfluency/stuttering and articulation disorders. Notably, the authors took an inclusive approach by considering a broad range of therapeutic interventions that cuts across definitions for FND and functional somatic symptoms. These consensus recommendations for functional communication, swallowing, cough and related conditions set the stage nicely for largescale clinical trials aimed at rigorously testing the efficacy of the proposed strategies, as well as understanding clinical and neurobiological factors linked to individual differences in clinical outcomes. Similar to largerscale efforts underway to rigorously examine the utility of physiotherapy for functional motor symptoms, it can be anticipated that this article will pave the way for clinical trials involving speech and language therapists. Given the heterogeneity of symptom presentations across individuals with FND, and that a given patient may present with one set of symptoms initially and subsequently develop distinct functional neurological symptoms over the natural history of their condition, it is also likely that the speech and language treatments outlined in these recommendations will need to be studied both in isolation and in combination with other emerging evidencebased FND treatment modalities. In the future, the highly collaborative international FND community could test the potential efficacy of pairing patients to specific treatments based on both clinical phenotype and biopsychosocial formulations. The future is bright for clinical and research efforts in FND and related conditions, and these consensus recommendations are a welcomed and important step forward.