ARTICLE IN PRESS

The Role of Physiotherapy in the Management

of Functional Neurological Disorder in
Children and Adolescents
Yu-Na Kim, MBBS,* Nicola Gray, BPT,† Anna Jones, BPT (Hons),z
Stephen Scher, PhD, JD,x,║ and Kasia Kozlowska, MBBS, FRANZCP, PhD*,║,{

Children and adolescents with functional neurological (conversion) disorder (FND) present
with symptoms of impaired motor and sensory function. FND involves complex interactions
between the brain, mind, body, and lived experience of the child. The gold standard for treat-
ment is therefore a holistic, biopsychosocial approach with multimodal interventions deliv-
ered by a multidisciplinary team. In this narrative review we examine the role of
physiotherapy in managing FND in children. We searched Embase, Medline, PsycINFO, and
PubMed (back to 2000) for relevant physiotherapy articles and also manually searched their
reference lists. Two review articles and ten observational studies were identified. Data were
extracted concerning the type of study, therapies involved, outcome measures, and comorbid
mental health outcomes. FND symptoms resolved in 85% to 95% of the patients, and about
two-thirds returned to full-time school after completing the multidisciplinary intervention.
Ongoing mental health concerns at follow-up were associated with poorer functional out-
comes. Key themes included the following: use of psychological interventions embedded in
the physiotherapy intervention; integration of play, music, and dance; role of physical exercise
in modulating physiological, neural, and endocrine systems; need for FND-specific outcome
measures; ethical issues pertaining to randomized trials; and need to develop alternate study
methodologies for assessing combined treatments. Clinical vignettes were included to high-
light a range of physiotherapy interventions. In conclusion, the emerging literature suggests
that physiotherapy for children with FND is a useful intervention for improving motor dysfunc-
tion and for addressing other concurrent issues such as physical deconditioning, neuroprotec-
tion, chronic pain, disturbed sleep, anxiety and depression, and resilience building.
Semin Pediatr Neurol 00:100947 © 2021 Elsevier Inc. All rights reserved.

Introduction intersection of neurology and psychiatry. It is characterized

by neurological symptoms involving impaired motor and

F unctional neurological (conversion) disorder (FND) is a

neuropsychiatric (mind-body) disorder that lies at the
sensory function not explained by traditional neurological
conditions.1 In children (including adolescents), motor
symptoms (abnormal movements, dystonia, and motor
From the *Department of Psychological Medicine, The Children’s Hospital weakness or loss of function) are the most common, followed
at Westmead, Westmead, NSW, Australia. by functional seizures, sensory symptoms, and cognitive
y
Department of Physiotherapy, Sydney Children’s Hospital Network, NSW, symptoms. In many children, a combination of symptoms is
z
Australia. common.2,3 All of the following are also common: concur-
Advance Rehab Centre, Artarmon, NSW, Australia.
x rent chronic/complex pain, nonspecific somatic symptoms
Department of Psychiatry, Harvard Medical School and McLean Hospital,
Belmont, MA. (dizziness, fatigue, and breathlessness), and comorbid anxi-
║ ety and depression, along with psychological processes that
University of Sydney Medical School, NSW, Australia.
{
Westmead Institute for Medical Research, Westmead, NSW, Australia. function to amplify symptom severity and promote states of
Address correspondance to Kasia Kozlowska, Department of Psychological ill health.4 Converging evidence from neuroscience research
Medicine, The Children’s Hospital at Westmead, Westmead, NSW,
suggests FND involves dysregulation of the stress system5-9
Australia. E-mail: kkoz6421@uni.sydney.edu.au

https://doi.org/10.1016/j.spen.2021.100947 1
1071-9091/11/© 2021 Elsevier Inc. All rights reserved.
 ARTICLE IN PRESS
2 Y.-N. Kim et al.
and of neural networks mediating motor and sensory func-
tion. Functional neurological symptoms emerge when
stress—physical or emotional—triggers excessive activation
of the brain stress systems (regions processing salience,
arousal, and emotional states), which, in turn, disrupts
motor-, sensory-, and pain-processing regions.10-14 Anteced-
ent stressors are very broad and can involve physical stressors
(eg, an illness, an injury, or a medical procedure), emotional
stressors (eg, bullying, parental conflict, difficulties with
friends, or a traumatic event), or a combination with both.
Because the physical, psychological, and social dimensions of
pediatric FND are so closely intertwined, a holistic, biopsy-
chosocial approach with multimodal interventions delivered
by a multidisciplinary team is the gold standard.15,16 When
motor symptoms, physical deconditioning, comorbid pain,
or comorbid postural orthostatic intolerance (see Text Box 1)
is part of the presentation, physiotherapy is a key component
of the intervention.
Physiotherapy became a key component of pediatric FND
treatment in 1965, when it was found to improve outcomes
in children with functional dystonia.22 By the 1980s—with
the goal of addressing physical impairment by facilitating the
reemergence of normal movement patterns—physiotherapy
had become a standard component of pediatric treatment
programs in the United Kingdom, United States, and
Australia.23,24
In 2015 and 2016, two reviews relied on the same evi-
dence base to examine the effectiveness of physiotherapy
in treating pediatric FND. Fitzgerald and colleagues
(2015) found that the multimodal nature of interventions
made the task of differentiating the effectiveness of indi-
vidual therapies difficult.25 They also noted the heteroge-
neity in the type and severity of FND presentations, the
lack of standardized treatment protocols, the absence of
randomized control trials, and the use of observational/
functional outcome measures (eg, recovery of normal
motor function, or return to school) rather than physio-
therapy-specific outcomes measures. Fitzgerald and col-
leagues concluded that insufficient evidence was available
to determine whether physiotherapy was effective in pedi-
atric FND. In an analysis that substantially diverges from
that of Fitizgerald and colleagues, Domka and colleagues
(2016), while identifying the same difficulties, embraced
the multimodal perspective and the important role that
the physiotherapist played as part of the multidisciplinary
team.15 They highlighted that the physiotherapy interven-
tion needed to be matched to the needs of the individual
child and emphasized the need for an approach “based on
modified behavioral principles” flexibly applied and using
a broad range of possible interventions (which were clearly
described in the review). They concluded that the available
literature showed that the application of multimodal inter-
ventions resulted in the achievement of favorable out-
comes. In this review we expand the scope of the
Fitzgerald and Domka reviews to include all newly pub-
lished studies and to provide, insofar as possible, a clearer
view of the impact of physiotherapy on FND in children.
We give particular attention to what we refer to as
Text Box 1 Orthostatic Intolerance*
Orthostatic intolerance is common in children with FND.
Orthostatic intolerance—also known as postural ortho-
static tachycardia syndrome {POTS)—reflects dysregula-
tion in the autonomic nervous system. The autonomic
nervous system is part of the stress system. “The stress
system comprises a set of overlapping and interrelated hor-
monal, neural (autonomic nervous system), immune-inflam-
matory, and brain systems involved in mediating the brain-
body stress response and underpinning the body’s ability
to regulate itself in response to the stress of life” (p 10).17
“Autonomic dysregulation manifesting as orthostatic intoler-
ance (or POTS) expresses itself via physical symptoms of
dizziness, giddiness, palpitations, lightheadedness, near-
fainting, and fainting on standing up from a reclined or sit-
ting position. It involves too little restorative parasympa-
thetic (vagal) activity (allowing heart rate to increase), too
much sympathetic activity (through which heart rate
increases even more), and no change in blood
pressure18,19. . .Orthostatic intolerance is often accompa-
nied by nausea—or even abdominal pain or vomiting—
reflecting concomitant activation of defensive gut programs
by the defensive parasympathetic system. It is frequently
comorbid with other functional somatic symptoms or syn-
dromes. Because the autonomic nervous system is very
sensitive to stress, orthostatic intolerance is a common
consequence of physical or psychological stress, such as
surgery, a viral illness, gravitational deconditioning (too
much bed rest), puberty (growth spurt or, for girls, the
onset of menstruation), a traumatic event, cumulative
adverse life events, or ongoing distress in the context of
family conflict” (p131-132).17
In children, an increase in heart rate of >40 beats per
minute is consistent with orthostatic intolerance.19 Reg-
ular physical exercise, along with increased fluid intake,
increased salt intake, pressure stockings, and imple-
mentation of slow-breathing strategies that help
increase parasympathetic function and decrease sympa-
thetic function, are core elements of the treatment inter-
vention. In very severe cases medications may also be
used.20,21
*The material is this text box comes from Kozlowska and colleagues,
Functional Somatic Symptoms in Children and Adolescents: A
Stress-System Approach to Assessment and Treatment (2020),17
published under the terms of the Creative Commons Attribution-
NonCommercial-NoDerivatives 4.0 International License (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
psychologically informed physiotherapy (see Results sec-
tion). In addition, and more broadly, we look at our
results on physiotherapy and FND in the context of the lit-
erature on exercise, arousal, physiological regulation,
rhythmic entrainment, and exercise-related mechanisms
promoting neuroprotection.
Methods
A literature search using Embase, Medline, PsycInfo, and
PubMed was conducted on 16 April 2021 with keywords
 ARTICLE IN PRESS
The role of physiotherapy 3

Text Box 2 Keywords Used in Literature Search describing a rehabilitation program. These studies are
Search terms used detailed in Table 1.

Conversion Physiotherapy
Somatoform Physiotherapist
Functional weakness Physiotherapies
Study Designs
Functional overlay Physical therapy All reviewed studies assessed physiotherapy outcomes,
Hysteria Physical therapist using a range of measures (see Table 1), in multimodal
Hysterical Physical therapies treatment programs. In all studies physiotherapy was pro-
Psychogenic Exercise vided alongside psychotherapy with the child, attendance
NOT Cerebral palsy Exercise therapy at school, provision of recreational activities, and, in some
Exercise program cases, occupational therapy, music therapy, or family ther-
Exercise programme apy. One program—which serviced a homogeneous popu-
Exercise regime
lation of children with functional gait abnormality—used a
Exercise regimen
fixed protocol involving a hierarchy of skills (termed Goal
Rehabilitation
Mountain).26 Other programs—which serviced heteroge-
neous populations—drew from a set of key principles for
structuring personalized physiotherapy interventions that
listed in Text Box 2. The search dated back to 2000
matched the clinical needs of each particular child27,35 (see
because the vast proportion of advances in the conceptu-
Text Box 4). The principles themselves, elaborated in Gray
alization and treatment of FND have taken place in the
and colleagues (2020), are based on current best practice in
last two decades. Titles and abstracts were screened using
the field of FND, clinical insights from pediatric practice,
inclusion and exclusion criteria (Text Box 3), and full-
and neuroscience findings. The principles align with adult
text copies were obtained when the abstract satisfied
consensus guidelines36 but, importantly, embrace a more
inclusion criteria or when it was unclear from the abstract
playful approach that is developmentally appropriate in
whether inclusion criteria were satisfied. The data
working with children.35,37
extracted from each relevant article included the type of
study, number of participants, duration and setting, ther-
apies involved, outcome measures, and comorbid mental
health outcomes. The reference lists of all articles were Outcomes
also screened for potential other studies to include. In line with older studies28, outcomes were favorable:
FND symptoms resolved in the majority of children
(
85%-95%)26,27, and approximately two-thirds (67%-
79%) returned to full-time school after completion of the
intervention27,29 (see Table 1). Some children took longer
Results to return to full time school—that is they had a graded
return-to-school program—or they required additional
Studies Selected admissions before they were able to return to school full-
The electronic search yielded 71 citations, with 6 additional time.29 Ongoing mental health concerns (in 19%, 37%,
citations retrieved from searching reference lists. Forty-one and 40% across 3 cohorts) at follow-up (at 12 months,
full-text articles were assessed for eligibility. Of these, 12 18 months, and 4 years respectively) were associated
articles met the inclusion criteria and were included in this with poorer functional outcomes on a Global Assessment
review (see Text Box 3). There was no randomized, con- of Function Scale.27 Importantly, the above studies
trolled study. Included were 1 systematic review, 1 review included children with substantial functional impairment
article, 4 prospective studies (reported in 2 articles), 2 retro- requiring inpatient treatment; that is, these children rep-
spective studies, 1 case study, 3 case studies combined with resented the more complex end of the clinical spectrum.
descriptions of the rehabilitation programs; and 2 articles In this context, the outcomes for children with less severe

Text Box 3 Inclusion and Exclusion Criteria

Inclusion criteria
- Quantitative and qualitative study designs including
descriptions of clinical care
- Children and adolescents aged 018 years with a
formal diagnosis of functional neurological (conver-
sion) disorder
- Studies involving physiotherapy management
- Studies from 2000
Exclusion criteria
- Adult population
- Children presenting with malingering or factitious disorders
- Studies not involving management that falls within the realm of
physiotherapy
- Studies not providing adequate information about the role of phys-
iotherapy in the management of pediatric FND
- Studies before 2000
 ARTICLE IN PRESS
4 Y.-N. Kim et al.
Table 1 Publications About the Role of Physiotherapy in Pediatric FND Included in This Narrative Review
Study n Description
Multidisciplinary rehabilitation studies (prospective)
Butz et al. 201926 100 Prospective cohort study of pediatric
multidisciplinary rehabilitation
Duration and setting: mean = 10.5 d (range,
2-103 d), inpatient
Outcome measure: WeeFIM
Kozlowska et al. 202027 57 Three prospective cohort studies of multidis- Children with mixed FND (cohort 1), func-
60 ciplinary rehabilitation
25 Duration and setting: 1-3 wk, inpatient
Outcome measures: Global Assessment of
Function, resolution of FND, return to
school, comorbid DSM-5 diagnoses
Also reported: comorbid mental health condi-
tions at presentation and at follow-up;
factors associated with better outcomes
Multidisciplinary rehabilitation studies (retrospective)
Kozlowska et al. 201328 56 Retrospective cohort study of multidisciplin- Children with mixed FND (§ pain) (100 refer-
ary rehabilitation
Duration and setting: 2-3 weeks, inpatient
Outcome measures: resolution of FND,
return to school
Also reported: comorbid mental health condi- home school post discharge
tions at presentation
Key points
All children had motor FND; 94/100 (94%)
completed the program
Treatment included physiotherapy, occupa-
tional therapy, recreational therapy, school-
ing support, and psychotherapy
85% of children reached the maximum Wee-
FIM score at discharge (full recovery sus-
tained at 2 mo)
Return-to-school rates were not reported
Comorbid mental health conditions were not
reported
tional seizures § other FND symptoms
(cohort 2), and mixed FND (cohort 3)
Treatment included physiotherapy, psycho-
therapy (individual and family), attendance
at hospital school, and reintegration to
home school post discharge
FND symptoms resolved in 54/57 (95%),
51/60 (85%), and 22/25 (88%), respectively
45/57 (78.9%), 39/60 (65%), and 14/25
(56%), respectively, returned to full-time
school
At presentation, 41/57 (72%), 38/60 (69%),
and 20/25 (80%), respectively, had mental
health disorders (most commonly, anxiety
and depression)
Children whose existing mental health disor-
ders did not resolve and children who
developed chronic mental health disorders
later (after their FND had resolved)—11/57
(19%), 22/60 (37%), and 10/25 (40%),
respectively—had poorer global functional
outcomes
Early diagnosis of functional seizures (<3
months from onset) in cohort 2 was associ-
ated with better outcomes67
rals for inpatient treatment; 56 admitted)
Treatment included physiotherapy, psycho-
therapy (individual and family), attendance
at hospital school, and reintegration to
FND symptoms resolved in 35/56 (63%),
relapsed occasionally with stress in 10/56
(18%), became chronic in 7/56 (13%), and
were unknown in 4/56 (7%)
47/56 (84%) returned to school (1 transferred
to distance education; 1 dropped out of
school; 3 did not return; and data were
missing for 4)
Anxiety was present in 27/56 (48%), depres-
sion in 8/56 (14%), and mixed anxiety and
depression in 8/56 (14%)

The role of physiotherapy
Table 1 (Continued )
Study n Description
Bolger et al. 201829 30
Case studies
Chudleigh et al. 201330 1 17-year-old girl with right hemiplegic cerebral
Khachane et al. 201931 1 Case study and description of rehabilitation 14-y-old boy with functional dystonia in the
Mesaroli et al. 201932 1 Case study and brief review of physiotherapy 14-y-old boy with motor FND (ataxic gait)
Descriptions of multidisciplinary rehabilitation programs (with physiotherapy as a component)
Calvert and Jureidini 200333
ARTICLE IN PRESS
5
Key points
Comorbid mental health conditions at follow-
up were not reported
Retrospective cohort study of pediatric 25/30 (83%) children had motor FND as part
multidisciplinary rehabilitation of their clinical presentations
Duration and setting: 8.4 § 4.2 days, inpa- Treatment included physiotherapy, occupa-
tient tional therapy, recreational therapy, music
Outcome measures: therapy, and psychological support
WeeFIM, return to school WeeFIM score change of 30 § 11.9 (P <
0.001), maintained at 3 months
20/30 (67%) returned to school within 1
month post discharge; 5/30 (17%) returned
to school later than 1 month post discharge
(1 had subsequent psychiatric admissions
precluding return to school; 4 did not
return; and data were missing for 5)
comorbid mental health conditions were not
reported
Case study and description of rehabilitation
model palsy, plus functional seizures and dystonia
Duration and setting: 2 consecutive, 3-wk Multimodal treatment: daily psychotherapy,
inpatient admissions and 4 mo of weekly daily physiotherapy (attention away from
outpatient therapy foot with dystonia), hospital school, family
Outcome measures: no formal measure; therapy, and pharmacotherapy (botox injec-
frequency of functional seizures (FS) and tion).
subjective rating of dystonia At presentation, 6-8 FS/day; at discharge,
4 FS/wk but dystonia not fully resolved; at
11 mo post discharge, further reduced fre-
quency of FS and episodic dystonia only in
times of stress (exact number not docu-
mented)
Comorbid depression and anxiety
model neck, body flexed in C-shape, inability to
Duration and setting: 6 months inpatient walk, and neck spasms
Outcome measure: Psychotherapy, hypnotherapy in physiother-
no formal measure apy, occupational therapy, hospital school,
family therapy, pharmacotherapy
At discharge, his trunk was in upright posi-
tion, and he was able to shower himself,
use the commode chair, and sit in a car for
up to 40 min; 6 wk post discharge, he was
able to walk independently
literature (with an emphasis on adult stud- Treatment with pharmacotherapy for anxiety,
ies) cognitive-behavioral therapy, physiother-
Duration and setting: 8 outpatient sessions apy; also, liaison with regular school
over 3 mo Each treatment session included 1 h of phys-
Outcome measure: Functional Mobility Scale iotherapy and 1 h of psychological therapy
By 3 mo, Functional Mobility Scale score was
18/18 (vs 5/18 on initial assessment); able
to walk independently with normal gait
Description of psychologically informed 14-y-old female with pain in shoulders, cervi-
physical rehabilitation program with a case cal spine, lower back, and loss of motor
study function
Duration and setting: 3 wk, inpatient Treatment with physiotherapy using
“restrained rehabilitation” model
At discharge, returned to full mobility;
 ARTICLE IN PRESS
6 Y.-N. Kim et al.
Table 1 (Continued )
Study n Description
Kozlowska et al. 201234 Description of mind-body, family-based, mul- Physiotherapy, pharmacotherapy, psycho-
timodal rehabilitation program.
Gray et al. 202035 Clinical vignette and therapeutic framework Description of mind-body rehabilitation pro-
with psychologically informed principles of
physiotherapy for understanding and treat-
ing pediatric FND
FS, functional seizures; WeeFIM, Functional Independence Measure for Children.
Text Box 4 Key Principles/Goals
1. Communication that the symptoms are real and
understood
2. A clear, positive diagnosis of FND by a pediatrician, along
with the cessation of medical investigations and the elimi-
nation of uncertainty
3. Education/explanations to enhance the child and family’s
understanding of FND and to generate shared expecta-
tions of regaining physical function and returning to health
and well-being
4. Emphasis on the therapeutic relationship, positive expect-
ations, and open communication
5. A multidisciplinary approach in which physiotherapy plays
an integral role
6. Rehabilitation through goal-directed physiotherapy that
focuses on function, that attends to goals, to what the
child can do, and to well body parts, and that retrains the
child’s movements with diverted attention
7. Addressing maladaptive patterns of behavior (including
thoughts, emotions, states of high arousal, and child- par-
ent interactions) that trigger and maintain symptoms
8. Use of play and playful techniques that are developmen-
tally appropriate.
Adapted from Gray and colleagues, “Psychologically
informed physical therapy for children and adolescents
with functional neurological symptoms: The wellness
approach”. 35 Ó 2020 American Psychiatric Association
Publishing
presentations would presumably be even better. Table 1
summarizes the study characteristics and results.
Discussion of Key Themes
Before presenting some clinical cases illustrating our physio-
therapy intervention, it will be helpful to highlight the key
themes that emerged from our narrative review.
Key points
stopped taking analgesics 2 mo post
discharge
therapy, family therapy, hospital school
gram with “Wellness Approach”Description
of the - physiotherapy assessment
- physical dimension of the physiotherapy
intervention
- psychological dimension of the physio-
therapy intervention
Embedded Psychological Component
An important theme across pediatric studies—and program
descriptions—is the use of psychological interventions
embedded in the physiotherapy intervention.26-28,30-35 Such
psychologically informed physiotherapeutic interventions
typically include many or all of the following dimensions: a
focus on the therapeutic relationship; a focus on building the
child’s sense of enjoyment, mastery, self-confidence, self-
esteem, and other positive feeling-states; careful management
of attention (so attention is focused away from symptoms);
grading the intervention (small goals) so as not to overwhelm
the child; visual depictions of the program goals; the use of
positive reinforcement; and the use of play. See also
Text Box 4 and examples provided in subsection “Clinical
examples of the physiotherapy intervention,” below.
Integration of Play
The second theme pertains to the integration of play—includ-
ing music, song, playful visual metaphors, and other develop-
mentally appropriate activities—within the physiotherapy
intervention.26,31,32,35 Playful activities are, in themselves,
“highly rewarding” (p 421), and they promote physical, emo-
tional, cognitive, and social development.37 Potentially useful in
both individual and group therapy interventions, such activities
build upon a strong therapeutic relationship and require the
therapist to be flexible and creative in integrating play into the
treatment whenever the opportunity presents itself.
The Need for FND-Appropriate Outcome
Measures
The third theme pertains to the use of physiotherapy-specific
outcome measures. Whereas some authors lamented that
pediatric studies rarely used formal physiotherapy
measures25,32—for example, 6-minute walk test—others
noted out that such measures may not be valid and reliable
in FND. They require the child to focus attention directly on
whatever has been dysfunctional. In FND this increased
focus of attention has the consequence of amplifying symp-
toms. In this way, this otherwise standard approach to
 ARTICLE IN PRESS
The role of physiotherapy
measuring the child’s capacity and function is likely to gener-
ate inaccurate results.35 In this context, two studies used
observational measures—for example, the total Functional
Independence Measure for Children (WeeFIM)—that relies
largely on observations of the therapist or nurse during the
intervention. Other studies used global measures of func-
tion—also based on therapist observations—that assessed
the child’s progress by looking at the child’s overall func-
tion.27 Developmentally sensitive, broad-based meas-
ures—such as return to school and return to health—
were included in a number of studies providing informa-
tion about the percentage of children who had regained
normal function and returned to life-as-usual.27,29 A
related finding was that long-term outcomes were related
to persistence of mental health concerns, rather than per-
sistence of the physical symptoms of FND. The implica-
tion is that in tracking children with FND over time,
both physical outcomes and psychological outcomes need
to be taken into account.27
Lack of Randomized, Controlled Trials
The fourth theme pertains to the criticism concerning the
lack of randomized, control trials.25,32 What such critics do
not address, however, are the ethical implications of defer-
ring active treatment by putting children into control groups.
In pediatric settings, timely assessment and treatment of chil-
dren is essential in order to prevent chronicity and negative
outcomes. In the majority of children, normalization of
motor patterns occurs early in the treatment intervention,
whereas shifts in other treatment components—progress in
psychotherapy, family therapy, or problems at school—
occur more slowly. In this context, most clinicians would
consider it unethical to put children on waitlists for physio-
therapy; the delays in treatment could compromise the treat-
ment outcome and the child’s chances of returning to full
health and well-being. One option is to utilize natural wait-
lists; for example, to compare patients with a drawn-out ver-
sus efficient diagnosis and referral process, or to compare
patients on outpatient physiotherapy wait-lists. Another
option may be to develop experimental designs similar to
those used in adaptive treatment interventions, also known
as sequential, multiple-assignment, randomized trials.38
Such trials have been used to assess efficacy of (adaptive) inter-
ventions that involve a sequence of decision rules that specify
whether, how, and when a certain treatment is implemented,
leading to individualized sequences of treatment.39-41 Presum-
ably similar experimental designs could be developed to assess
the efficacy of multidisciplinary, multimodal interventions—
the gold standard for pediatric FND—where different combi-
nations of treatment modules are implemented simultaneously
or sequentially, depending on the needs of the child and fam-
ily.38 Using such designs in research, “where all the treatment
options are considered to be potentially effective active inter-
ventions, would eliminate the need to randomize participants
to treatment as usual or other control conditions that are
known to be ineffective”.38
7
Models for, and Effects of, Physiotherapy
The fifth theme pertains to two related issues: the develop-
ment of theoretical models for physiotherapy for FND and
consideration of the unique effects of physiotherapy sepa-
rately from the multimodal intervention.25,32 As noted in the
introduction, clinical studies with children suggest that the
physical, psychological, and social dimensions of pediatric
FND are closely intertwined. Along the same lines, the
emerging picture from neuroscience research is that FND is a
neuropsychiatric (mind-body) condition that involves com-
plex interactions between brain, mind, body, and context—
the lived experience of the child and the family.17,42 In the
neuroscience model, FND involves the activation of brain
regions that underpin salience detection, arousal, pain, and
emotional states, and these regions, in turn—when overac-
tive and overly connected with motor- and sensory-process-
ing regions—function to disrupt motor and sensory.11,17
What this means in practice is that the mind and body ele-
ments of FND are interconnected and that treatment needs
to address both dimensions simultaneously.
The Benefits of Physical Exercise
Because FND has been conceptualized as a disorder of neuro-
physiological dysregulation,17,43 it is reasonable to expect that
physical exercise, with its wide-ranging, modulating impact
on neuroendocrine and other physiological systems,44-51 has
an important role in treating children with FND. In addition
to improving physical function, general health, and well-being,
exercise appears to decrease functional symptoms related to
autonomic dysregulation (eg, postural orthostatic tachycardia
syndrome (POTS), deconditioning (eg, heart rate
variability),44,52,53 increase resilience and stress resistance
54,55
, decrease chronic/complex pain,56 and improve anxiety,
depression, and disturbed sleep,57-59 induce beneficial effects
on the antioxidant system, on neurotrophic factors, and on
the microglia phenotype to promote neuroprotection.60 Chil-
dren receiving physiotherapy for FND potentially benefit in all
of these ways via the exercise inherent in physiotherapy.
Another aspect of movement-based therapies is of particu-
lar importance in treating children with FND: such therapies,
including physiotherapy, can provide an alternative—non-
psychological—means of managing states of distress and
high arousal and of enhancing autonomic and emotional
regulation.44,61 Such combined interventions “work directly
with the body and do not require the child to use language,
to be able to manipulate cognitions, or to have access to
memory or cognitive information about stress or past events”
(pp 295-296).27 They have particular utility with children
who dislike psychological interventions or who struggle to
utilize psychological interventions to manage distress, diffi-
cult emotions, and states of high arousal.
Combining movement with music introduces yet another
element into the therapy.62-66 Emerging evidence suggests
that auditory rhythmic cues can entrain motor responses, and
that temporal rhythmic entrainment—as happens with a piece
of music—can optimize motor planning and execution over
 ARTICLE IN PRESS
8 Y.-N. Kim et al.
the entire movement cycle.66 In this context, the use of music
in physiotherapy for FND may have multiple advantages.
Music can be helpful with regards to the child’s focus of atten-
tion—the attention being on the music—and music may facil-
itate automatic activation of complex motor patterns.
Clinical Examples of the
Physiotherapy Intervention
The clinical vignettes provided below describe a range of
physiotherapy interventions with children and adolescents.
While each intervention is specific to the presentation, needs,
capacities, and interests of the particular child or adolescent,
all the interventions described are based on the principles
described in Text Box 4. The case vignettes of Annabelle,
Sarah, and George are amalgams of similar cases and the case
vignettes of Jai (pseudonym), Delilah (pseudonym), and
Millie (pseudonym) are published with consent.
Annabelle. Annabelle was a 14-year-old adolescent with
functional seizures that sometimes presented with violent
movement of upper and lower limbs and sometimes as faint-
ing episodes. Because the pediatrician’s efforts to communi-
cate the diagnosis had not gone well and because the family
had declined referral to a psychologist, Annabelle’s presenta-
tion became progressively worse. The functional seizures
were now complicated by paralysis and loss of sensation in
the lower limbs, intermittent loss of speech and swallowing,
whole-body pain, and urinary retention. In addition, Anna-
belle was now severely deconditioned due to a prolonged
period of inactivity. She was admitted into the hospital’s
Mind-Body Program (run by the last author, KK) and was
provided with a multidisciplinary intervention, of which
physiotherapy was an important component.34,35
Early in the treatment—when Annabelle was still
experiencing the leg paralysis—the physiotherapy interven-
tion included bed exercises with active assisted range of
motion using limbs that were not paralyzed (eg, if the right
arm was paralyzed, the left arm would assist it through range
of motion). Annabelle completed all these exercises while lis-
tening to music, chatting to the therapist, or being distracted
by techniques that drew her attention away from her symp-
toms (eg, reaching for balloons, which focused her attention
on the balloon, not her leg).
Later in treatment—once Annabelle had regained some
power in her legs—she participated in games in the
hydrotherapy pool (attention being focused on the game)
and some yoga mat work with attention directed towards
breathing (in and out of the lungs, counting the timed
inspiration and expiration) with relaxing music in the
background and lighthearted discussion throughout the
session. Annabelle also practiced transfers from a wheel-
chair to a bed or into a chair—just in case her symptoms
continued to fluctuate—and she needed these skills when
discharged home. Annabelle then progressed to training
to stand, which involved throwing and catching or shoot-
ing balls into a hoop.
Over a three-week inpatient intervention, Annabelle
regained normal sensation in her legs and the capacity to
walk, and she learned to perceive the warning signs of her
functional seizures and to implement strategies to avert
them.67 She slowly regained her strength and independence.
She continued outpatient physiotherapy coupled with indi-
vidual psychotherapy, some family sessions, and reintegra-
tion to her home school.
Jai. Jai was a 14-year-old boy who presented with a fixed
dystonia of the neck (to the left) and weakness and loss of
coordination in both legs. He had been previously active and
had participated in competitive sports. The physiotherapy
intervention included boxing because of Jai’s special interest
in it. When Jai was wheelchair dependent, he used gloves
and boxing pads in a supported seated position. The physio-
therapists focused on using the unaffected body parts to gen-
erate the benefits of exercise and had the opportunity to
praise Jai for his efforts and improvements. When he had
recovered some strength in his legs and was working on
standing, the sessions progressed to boxing in supported
standing (between parallel bars) and then to independent
standing encouraging boxing style foot work patterns (light
feet, alternate stepping on the spot). This boxing intervention
helped to restore Jai’s motor function and also helped to
maintain his motivation and compliance with the Mind-Body
Program during his long illness. See Khachane and colleagues
[2019] for a full description of the multidisciplinary
intervention).31
Sarah. Sarah was a 9-year-old girl who presented with
functional tics, functional dysphonia (whispered phonation),
and an inability to weight-bear through her left foot. Sarah
had previously been an active child who participated in
many group activities. The physiotherapy intervention
focused on the collaborative task—shared by Sarah and the
physiotherapist—of making up dance routines designed
around what Sarah was physically able to perform. Sarah
enjoyed composing the dance routines, for herself and the
physiotherapist to learn and perform together. The physio-
therapist contributed ideas to ensure that Sarah continued to
challenge herself and extend her motor retraining. This inter-
vention also included music and other equipment, including
Hula-Hoops or balls to add further distraction and complex-
ity. Over time, the dance routines progressed to challenge
and extend Sarah’s physical limitations in the safe space pro-
vided in physiotherapy sessions.
George. George was a 12-year-old boy presenting with
lower limb weakness (he was in a wheelchair), whole-
body pain, and persistent fatigue. George was interested,
and advanced, in physics. He responded well to a scien-
tific explanation of FND (see Models for, and effects of,
physiotherapy, above). His physiotherapy sessions (includ-
ing working on supported standing, walking with hand
hold assist and progressing to walking independently)
involved scientific conversations, periodic table quizzes,
making up music playlists that he could use in future ses-
sions, and conversations about his future career options—
all of which functioned to keep George’s attention dis-
tracted from his symptoms.
 ARTICLE IN PRESS
The role of physiotherapy
Delilah. Delilah was an 18-year-old young woman with a
five-year history of FND. She had been a high achiever in
both sports and academics. At the age of 13 years, Delilah
had presented with dizziness and general malaise, which pro-
gressed to deep-rooted fatigue, and postural orthostatic
tachycardia syndrome (POTS). These symptoms were
accompanied by extreme dystonic foot posturing and claw-
ing of the toes, an uncoordinated gait (astasia abasia), loss of
bilateral lower limb sensation, and violent automatic kicking
movements if someone else attempted to touch Delilah’s feet.
It had taken two months and visits to multiple specialists for
Delilah to receive a positive diagnosis of FND (and POTS)
and to begin treatment. Despite intense treatment efforts—
multiple inpatient admissions with a tertiary care multidisci-
plinary team—Delilah’s FND did not respond to treatment.
Physiotherapy was particularly challenging to implement
because Delilah was unable to reach a standing position with-
out a hoist because of the in-turned posture of her feet, the
extreme lack of coordination in her legs, and her propensity
to faint (a symptom of POTS). In consequence, during the
first four years of her treatment—after it became clear that
Delilah’s illness had taken a chronic course—the aim of
physiotherapy was to ensure that Delilah would be ready to
engage in the next step of her physiotherapy intervention
(see below), once her some of the above-described barriers-
to-treatment had settled. During this difficult period the
goals of physiotherapy included:
 Maintaining autonomic system function and capacity
to be in an upright position without fainting (daily
home-based tilt table sessions)
 Maintaining general physical strength and conditioning
(twice-weekly outpatient physiotherapy coupled with a
school gym program)
 Prevention of a fixed dystonia (regular casting, inter-
mittent manipulation under anesthetic, and use of spe-
cially made orthoses)
 Maintaining hope: repeated positive suggestions were
made, that, with ongoing work, nothing precluded
Delilah from regaining normal or at least substantially
improved motor function in the future
Key breakthroughs included the following: resolution of
the POTS with medication and Delilah’s perseverance with
the tilt table; a resolution, following the second botulinum
toxin treatment, of her feet’s aversion to touch (though the
dystonia was unaffected); and a decrease in the severity of
the dystonia following a trial of guanfacine. The effect of bot-
ulinum toxin on sensory processing, though not widely
known, has been documented in the literature.68 Guanfacine
is a selective alpha-2A adrenergic agonist that helps to down-
regulate (switch off) the brain stress systems and to decrease
arousal, with the theoretical possibility that the disruption of
motor-processing regions would, in turn, decrease (see
description of neurobiology of FND in the introduction). At
this point in her treatment (just prior to transitioning; see
below), Delilah was able to stand without fainting; her feet
9
could be touched thereby facilitating the use of orthoses; and
the dystonia in her toes was much reduced.
At 18 years of age and on completion of school, Delilah
was transitioned to adult physiotherapy services because she
was still disabled by her FND symptoms. She still required
bilateral ankle foot orthoses, however, had commenced a
graded program to reduce time spent wearing them to gradu-
ally reduce reliance on their support for normal foot posture.
She could walk with crutches, but only for short distances.
For anything more than that, she was dependent on her
wheelchair. As Delilah’s locomotion improved the physio-
therapist introduced a variety of exercise approaches that
included dance choreography (with music, following TikTok
routines) and athletic challenges (eg, skipping rope).
Through familiar tasks such as skipping rope, the physiother-
apist aimed to access preexisting, “known” movement pat-
terns. The expectation was that these tasks would enable the
“automatic” activation of key muscle groups (eg, the calf
complex for antigravity plantarflexion) that Delilah could not
activate via conscious control (eg, being asked to raise her
heels). Likewise, with the TikTok dance routines, Delilah
was deeply engaged in the complexity of the choreography
and in timing her movements to the music. She was able,
with practice, to perform complex and dynamic movement
routines smoothly. If, instead, she had been asked to perform
single tasks requiring similar strength and dexterity, she
would have been unable to perform them with the same pro-
ficiency. By utilizing Delilah’s engagement in the music, the
“whole task” focus of learning the dance choreography, and
the fun element in this activity the therapist was able to facili-
tate Delilah’s ability to activate more intuitive, automatic
movement patterns.
The final breakthrough came when Delilah was 20 years of
age. Through a series of events, Delilah came to understand
that her FND had emerged in the context of ongoing stress.
Delilah explained that as a child, she had been unaware of
the stressors in her life. It was only in retrospect, when she
experienced life without those stressors, that she had realized
their intensity and their impact on her health and well-being.
She also reported that the multidisciplinary team’s therapeu-
tic holding69—“being there for me”—over the first five years
of her illness, coupled with the team’s belief in her and the
possibility of recovery, had been a source of comfort,
strength, and hope.
Millie. Millie was a 16-year-old adolescent with a four-
year history of functional somatic symptoms. At 12 years of
age, Millie had presented with increasing fatigue of unknown
cause that caused her to progressively withdraw from activi-
ties and family interactions. Three years later, Millie became
unable to manage even family outings, and she complained
of headaches and of stiffness and joint pains in legs and back.
Subsequently, she developed full-body shaking when stand-
ing, a sense of “brain fog” and difficulties in concentrating,
and intermittent slurred speech. She became increasingly
reliant on use of a wheelchair. A neurology review yielded a
diagnosis of FND and comorbid POTS. Millie had the follow-
ing goals for the physiotherapy component of her treatment:
to reduce reliance on her wheelchair (which she used at all
 ARTICLE IN PRESS
10
times outside of the home); to be able to safely shower while
standing; and to be able to walk with friends. The physio-
therapy intervention focused on building movement and
postural control through increasingly challenging postures.
Initially, the physiotherapist used distraction (altered focus
of attention) and elements of playful movement to guide
Millie into and through unstable sitting and kneeling posi-
tions. Over time, these positions progressed to variations that
included crawling and other forms of movement. As time
went on, the physiotherapist used distraction or dual tasking
to introduce varied complex movements and to facilitate
stepping and walking. Examples of these tasks include use of
floor ladder and ball tasks concurrently or running drills
such as passing a baton in a relay style race and running
while bouncing a ball. After a two-month period (going from
3 times weekly to weekly physiotherapy sessions), Millie no
longer required a wheelchair for school, and she was walking
with much improved posture and patterning, and with mini-
mal tremoring. By four months, Millie’s motor symptoms
had fully remitted. Normal participation in sports was slowly
reintroduced, and Millie’s physiotherapy was incrementally
discontinued.
Key Learning Points Pertaining to
Psychologically Informed
Physiotherapy Embedded in the
Vignettes
In this section we provide a brief commentary to highlight
key issues and themes illustrated by the vignettes. Additional
resources are described in Text Box 5.
A Therapeutic Relationship That Supports the
Child’s Psychological Well-Being
Establishing a therapeutic relationship with the child—
and creating a safe space for the child in therapy—was of
primary importance for the physiotherapists in all the
vignettes. “The therapeutic relationship involves trust,
mutual respect, and a sense of hope, and it lays the foun-
dation for a collaborative approach in which the child
and therapist work together as a team” (p 390).35 In the
therapeutic space, children feel comfortable, feel heard
and believed, and are able to express themselves freely
without judgment. The physiotherapist aims to build
each child’s confidence in the rehabilitation process—in
the therapist and in the therapist’s capacity to help the
child, and in the child’s own capacity to engage in the
physiotherapy process—leading the child to trust his or
her own body, and enabling recovery to take place.
Session “mood” can range from light-hearted and fun, to
demanding and frustrating, to emotive of fear, loss, and over-
whelm, to delight, joy, and pride. A good therapeutic rela-
tionship allows physiotherapists to harness these moments
to educate, to support, to provide strategies, and to celebrate
Y.-N. Kim et al.
Text Box 5. Additional resources.
The key elements of psychologically informed physiotherapy
have previously been articulated by Gray and colleagues
(2020) in an article entitled “Psychologically Informed Physi-
cal Therapy for Children and Adolescents with Functional
Neurological Symptoms: The Wellness Approach”.35 The
principles of assessment and treatment—including the
establishment of a multidisciplinary team—have been care-
fully described by Kozlowska and colleagues (2020) in
Chapter 13 of an open access book entitled, Functional
Somatic Symptoms in Children and Adolescents: The
Stress-System Approach to Assessment and Treatment.17
And the important capacity of clinicians working in psycho-
logical services to take on a case-management role—
because of their training in biopsychological formulation and
their familiarly with implementing interventions on multiple
(biopsychosocial) system levels—has been elaborated in a
recent article by Kozlowska and colleagues (2021) entitled,
“Changing the Culture of Care for Children and Adolescents
with Functional Neurological Disorder”.4 There are also
many good resources that discuss the importance of a posi-
tive diagnosis of FND and the important role the neurologist,
pediatrician or other doctor.17,70-72 And finally, Vassilopou-
los and colleagues (Vassilopoulos et al is now (in press))
discuss the various levels of treatment—termed the
stepped-care—in a review pertaining to assessment and
treatment of children with FND.38
with that child, thereby furthering the rapport and trust that
is vital in effective rehabilitation.
Clarity About Roles and Responsibilities, and
the Need For Good Communication Within
the Multidisciplinary Team
Clarity of roles within the multidisciplinary team is another
important element of successful treatment. In each vignette
the physiotherapist’s primary role was to engage the child in
psychologically informed physiotherapy. Other elements of
the treatment intervention—psychotherapy with the child,
work with the family, pharmacotherapy when needed, and
intervention with the school—were the responsibility of
other team members working in psychological services or in
the medical context. And those other team members would
specifically seek out the physiotherapist’s input if questions
arose, for example, in relation to mobility and physical safety
on a child’s return to school.
In the inpatient setting, ongoing clarification of evolving
roles, responsibilities, and clinical challenges occurs as part of
the ongoing communication during the already established
team meetings. Such meetings involve all members of the mul-
tidisciplinary team, including education staff. In outpatient set-
tings, such meetings may need to specially organized.
In the vignette of Annabelle, because of the close commu-
nication between the psychologist and physiotherapist, the
physiotherapist knew exactly what strategies Annabelle was
expected to practice for the management of her functional
seizures. Likewise, in the vignette of Delilah, close
 ARTICLE IN PRESS
The role of physiotherapy
communication between the physiotherapist and the physi-
cal education instructors in her school gym, allowed Delilah
to maintain a carefully crafted physiotherapy program that
addressed a variety of needs, over a period of many years.
Knowing Who is Steering the Ship
Multidisciplinary teams function best when a clinician or a
clinical team holds responsibility for the overall management
of the case—when there is someone who steers the ship.
With the exception of Millie, all the children in the vignettes
were managed by a psychological medicine team who, while
the child was in the hospital, took responsibility for manag-
ing the case in collaboration with the full multidisciplinary
team. In the case of Delilah this team continued to manage
the case—including collaboration and communication
between multiple professionals—until transition to adult
services because no pediatric services were available in the
community to oversee the broad array of Delilah’s medical
needs.
Physiotherapy For FND Differs From
Standard Approaches
All the vignettes highlight that physiotherapy for FND is not
the same as standard musculoskeletal, or even neurological,
approaches. Physiotherapy with children with FND involves
careful management of attention away from symptoms and
utilizes playful approaches—games, dance, music and so
on—that aim to activate complex movements automatically.
The important role of music was highlighted in the vignettes
of Sarah, Delilah, and Millie. The use of music as a form of
“temporal rhythmic entrainment” (p1)66 to activate complex
movement patterns, may be of particular utility in the treat-
ment of pediatric FND.
Physiotherapists Who Treat Children With
FND Need to be Able to Manage Functional
Seizures or Symptoms of Orthostatic
Intolerance
Physiotherapists who see children with FND become quite
skilled at helping the child manage functional seizures. The
therapist will typically endeavor to identify any warning
symptoms with the child (and family). The physiotherapist
will then implement a safety plan. The child is encouraged to
get into a safe position and to practice grounding strategies
with the aim of either preventing onset or reducing its sever-
ity and duration. Grounding strategies might include mind-
fulness tasks, cognitive tasks in isolation or in combination
with sensory or motor tasks. Along the same lines, when a
child identifies the warning signs of orthostatic intolerance,
the child is encouraged to sit down, let the episode pass—to
allow the autonomic system to settle—and to then stand up
in a much slower way, so as to continue the session.
11
Making Sure That the Child Has Received a
Positive Diagnosis
Finally, the vignettes of Delilah and Millie highlight the
important role of the pediatrician in providing a positive
functional diagnosis so that the appropriate treatment can
be provided expeditiously.17,70-72 When treatment is
prompt—even in the face of significant functional
impairment—outcomes are excellent (see outcome sec-
tion). When treatment is delayed because a positive diag-
nosis and explanation have not been provided, the child
may be taken to see many different doctors, resulting in
iatrogenic harm and what we have previously termed the
spiral to chronic illness (see Chapter 2 in Kozlowska and
colleagues 2020 for a detailed discussion). From a neuro-
science perspective, the deferment of treatment—because
a diagnosis had not been provided—is likely to increase
the likelihood of aberrant neural network patterns becom-
ing entrenched and therefore more difficult to rectify. On
occasions, when a positive diagnosis has not been pro-
vided, the physiotherapist may need to speak with the
child’s pediatrician (or family doctor) to make sure that
the situation is rectified, and that the child is being pro-
vided with all elements of the biopsychosocial interven-
tion as needed.
Conclusions
In this narrative review we have provided an update about
the role of physiotherapy in managing pediatric FND. A
growing body of evidence indicates that physiotherapy—
alongside psychological, family, school, and other interven-
tions, as required—is an important component in the treat-
ment of children with FND. While randomized, controlled
trials provide the strongest type of research evidence, treat-
ment using the biopsychosocial (systems) approach is the
gold standard for treating pediatric FND, and investigators
will therefore need to develop research methodologies that
assess the efficacy of physiotherapy as part of broader, multi-
modal treatment interventions.
More broadly, in this narrative review we provide an
overview of the key principles that guide physiotherapy
interventions, along with clinical vignettes that highlight
these principles at work, for children with FND. These
principles and the methods used in the vignettes can be
applied across the full range of clinical presentations. In
addition, we have argued that physiotherapy for children
with FND is a useful intervention that, in addition to
improving motor dysfunction, helps to address physical
deconditioning, loss of neurophysiological regulation,
shift of the immune system to a pro-inflammatory state,
chronic/complex pain, disturbed sleep, symptoms of anxi-
ety and depression, and the building of resilience. And
finally, we have highlighted the important role of
music—potentially as a form of rhythmic entrain-
ment66—to promote restoration of normal motor function
in physiotherapy with children with FND.
 ARTICLE IN PRESS
12 Y.-N. Kim et al.

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