Role and Challenges of Acute Inpatient Rehabilitation in Functional Neurological Disorder: A Case Report

Case Diagnosis: Functional neurological disorder

Case Description or Program Description: A 35-year-old woman with functional neurological disorder (FND), psychogenic non-epileptic seizures (PNES), and generalized body pain was admitted for inpatient rehabilitation. She exhibited right upper extremity (RUE) functional dystonia, bilateral lower extremity (BLE) weakness, and refractory pain in the RUE and BLE described as crampy and burning. During her rehabilitation course, pain significantly interfered with therapy, necessitating escalation of pain management. She experienced PNES episodes characterized by migratory rhythmic myoclonic movements throughout the extremities and trismus, lasting 30–60 minutes. The patient maintained her airway and was responsive. Initial management included IV Ativan, IV Dilaudid, rapid assessments, and oxygen, often treating episodes as epileptic seizures. A rapid response was called during two episodes early in the admission.

Setting: Acute Inpatient Rehabilitation

Assessment/Results: Given patient-reported distress from excessive stimuli, the team transitioned to non-pharmacologic management, including grounding techniques, diaphragmatic breathing, and a low-stimulation environment. Nursing education standardized responses to PNES episodes. Patient-driven coping techniques such as straw breathing, blowing bubbles, lavender aromatherapy, and meditation, were incorporated to her treatment, improving symptom control and reducing unnecessary pharmacologic interventions.

Discussion (relevance): FND is characterized by deficits, in this RUE dystonia, seizure-like movements and BLE plegia, unrelated to neurological disease, with treatment primarily involving physical/occupational therapy and cognitive behavioral therapy. While inpatient rehabilitation offers intensive management, initial unfamiliarity with functional episodes resulted in overuse of benzodiazepines and opioids which further complicated care. This case highlights challenges in managing FND in inpatient settings and underscores the need for standardized protocols.

Conclusions: Education and structured protocols are essential for optimizing care for patients with FND in inpatient rehabilitation. This case highlights the adaptations of the team, initially calling rapid responses and using IV medication for PNES episodes, however with education and patient centered techniques care was transitioned to more appropriate measures and wean off of IV pain medications.