Machine learning classification of functional neurological disorder using structural brain MRI features.

BACKGROUND: Brain imaging studies investigating grey matter in functional neurological disorder (FND) have used univariate approaches to report group-level differences compared with healthy controls (HCs). However, these findings have limited translatability because they do not differentiate patients from controls at the individual-level. METHODS: 183 participants were prospectively recruited across three groups: 61 patients with mixed FND (FND-mixed), 61 age-matched and sex-matched HCs and 61 age, sex, depression and anxiety-matched psychiatric controls (PCs). Radial basis function support vector machine classifiers with cross-validation were used to distinguish individuals with FND from HCs and PCs using 134 FreeSurfer-derived grey matter MRI features. RESULTS: Patients with FND-mixed were differentiated from HCs with an accuracy of 0.66 (p=0.005; area under the receiving operating characteristic (AUROC)=0.74); this sample was also distinguished from PCs with an accuracy of 0.60 (p=0.038; AUROC=0.56). When focusing on the functional motor disorder subtype (FND-motor, n=46), a classifier robustly differentiated these patients from HCs (accuracy=0.72; p=0.002; AUROC=0.80). FND-motor could not be distinguished from PCs, and the functional seizures subtype (n=23) could not be classified against either control group. Important regions contributing to statistically significant multivariate classifications included the cingulate gyrus, hippocampal subfields and amygdalar nuclei. Correctly versus incorrectly classified participants did not differ across a range of tested psychometric variables. CONCLUSIONS: These findings underscore the interconnection of brain structure and function in the pathophysiology of FND and demonstrate the feasibility of using structural MRI to classify the disorder. Out-of-sample replication and larger-scale classifier efforts incorporating psychiatric and neurological controls are needed.

Functional neurological disorder is a feminist issue.

Functional neurological disorder (FND) is a common and disabling disorder, often misunderstood by clinicians. Although viewed sceptically by some, FND is a diagnosis that can be made accurately, based on positive clinical signs, with clinical features that have remained stable for over 100 years. Despite some progress in the last decade, people with FND continue to suffer subtle and overt forms of discrimination by clinicians, researchers and the public. There is abundant evidence that disorders perceived as primarily affecting women are neglected in healthcare and medical research, and the course of FND mirrors this neglect. We outline the reasons why FND is a feminist issue, incorporating historical and contemporary clinical, research and social perspectives. We call for parity for FND in medical education, research and clinical service development so that people affected by FND can receive the care they need.

Neuropsychiatric Treatment Approaches for Functional Neurological Disorder: A How to Guide.

There is a growing body of knowledge regarding management of functional neurological disorder (FND). The aim of this article is to guide the clinician through FND clinical management, from delivery of the diagnosis, to creation of a biopsychosocially-informed treatment plan, to troubleshooting common issues that arise throughout longitudinal care. We review the evidence and core principles of both rehabilitative therapies (physical therapy, occupational therapy, and speech and language therapy) and psychological therapies for the treatment of FND, and discuss the benefits of engaging a multidisciplinary and interdisciplinary team. The optimal timing of specific therapeutic interventions is also discussed, emphasizing a patient-centered perspective. Resources for further reading, for both patients and clinicians, are provided throughout. Additional research is needed to further optimize the therapeutic approach to patients with FND, including the need to develop novel treatments for those that do not positively respond to currently available interventions.

Sensory Processing Difficulties and Occupational Therapy Outcomes for Functional Neurological Disorder: A Retrospective Cohort Study.

Background and Objectives: Occupational therapy (OT) consensus recommendations and articles outlining a sensory-based OT intervention for functional neurological disorder (FND) have been published. However, limited research has been conducted to examine the efficacy of OT interventions for FND. We performed a retrospective cohort study aimed at independently replicating preliminarily characterized sensory processing difficulties in patients with FND and reporting on clinical outcomes of a sensory-based OT treatment in this population. We hypothesized that (1) a history of functional seizures, anxiety, and/or post-traumatic stress disorder would be associated with increased sensory processing difficulties and (2) the number of OT treatment sessions received would positively relate to clinical improvement. Methods: Medical records were reviewed for 77 consecutive adults with FND who received outpatient, sensory-based OT care. Data from the Adolescent/Adult Sensory Profile characterized self-reported sensory processing patterns across 4 quadrants (low registration, sensory sensitivity, sensory seeking, and sensory avoidance) in this population. Following univariate screenings, multivariate linear regression analyses were performed to identify neuropsychiatric characteristics associated with discrete sensory processing patterns. Clinical improvement was quantified using an estimated, clinician-determined improvement rating ("improved" vs "not improved"), and relationships between clinical participation, baseline neuropsychiatric factors, and outcomes were investigated. Results: Patients with FND reported sensory processing patterns with elevated scores in low registration, sensory sensitivity, and sensation avoidance compared with normative values; differences in sensory processing scores were not observed across FND subtypes (i.e., motor, seizure, and speech variants). In linear regression analyses, lifetime history of an anxiety disorder, history of migraine headaches, current cognitive complaints, and a comorbid major neurologic condition independently predicted individual differences in sensory processing scores. Following a sensory-based OT intervention, 62% of individuals with FND were clinician determined as "improved." In a multivariate logistic regression analysis controlling for baseline characteristics associated with improvement ratings, number of treatment sessions positively correlated with clinical improvement. Discussion: These findings support the presence of sensory processing difficulties in patients with FND and provide Class IV evidence for the efficacy of an outpatient, sensory-based OT intervention in this population. Controlled prospective trials are warranted.

The impact of increasing obesity class on obstetrical outcomes.

OBJECTIVE: Nationally, rates of obesity continue to rise, resulting in increased health concerns for women of reproductive age. Identifying the impact of maternal obesity on obstetrical outcomes is important to enhance patient care. METHODS: We conducted a retrospective cohort study of 6674 women who delivered a singleton infant at ≥ 20 weeks' gestation between December 1, 2007, and March 31, 2010, at The Ottawa Hospital. Maternal pre-pregnancy BMI was used to classify women into normal, overweight, and obese (class I/II/III) categories according to WHO classifications. Obstetrical outcomes among obese women were compared with those of women with normal BMI. Multivariable regression models were used to determine adjusted odds ratios and 95% confidence intervals. RESULTS: Compared with women with normal BMI, obese women had significantly higher rates of preeclampsia, gestational hypertension, and gestational diabetes, and these rates increased with increasing BMI (trend-test P < 0.001). There was a significant increase in rates of induction of labour in the obesity categories, from 25.3% in women with normal BMI to 42.9% in women with class III morbid obesity (aOR 1.67; 95% CI 1.43 to 1.93). Rates of primary Caesarean section rose with increasing BMI and were highest in women with class III morbid obesity (36.2% vs. 22.1% in women with normal BMI) (aOR 1.46; 95% CI 1.23 to 1.73). CONCLUSION: Increasing BMI is associated with increasing rates of preeclampsia, gestational hypertension, and gestational diabetes. There is a significant increase in rates of induction of labour with increasing obesity class, and a significantly increased Caesarean section rate with higher BMI. Obstetrical care providers should counsel obese patients about the risks they face and the importance of weight loss before pregnancy.

Functional Neurological Disorder: Diagnostic Pitfalls and Differential Diagnostic Considerations.

Functional neurologic disorder (FND) is a "rule-in" diagnosis, characterized by positive examination signs or semiological features. Similar to other clinical diagnoses, providers should ideally see robustly present features, including if possible the identification of multiple features consistent with FND for the diagnosis to be made with a high degree of certainty. Diagnostic pitfalls need to be guarded against and vary depending on FND symptom subtype and the specific patient presentation. This perspective article aims to review pitfalls based on an FND symptom subtype, as well as discuss differential diagnostic considerations with respect to both neurologic and psychiatric entities.

Toward a Precision Medicine Approach to the Outpatient Assessment and Treatment of Functional Neurological Disorder.

Functional neurological disorder (FND) is a neuropsychiatric condition. In this field, prospective psychotherapy trials and consensus recommendations for physiotherapy, occupational therapy, and speech language therapy have been published. However, significant clinical complexities remain. "Rule in" signs - while critical for making a positive diagnosis - do not equate to a personalized treatment plan in many instances. Here, we propose that the neuropsychiatric assessment and real-time development of a work-in-progress biopsychosocial clinical formulation aids the development of a patient-centered outpatient treatment plan. This precision medicine approach is based on the literature, expert opinions and our clinical experience working in an interdisciplinary FND service.

Speech and language therapy: A treatment case series of 20 patients with functional speech disorder.

BACKGROUND: While expert consensus recommendations support the use of speech and language therapy (SLT) for patients with functional speech disorder (FND-speech), there are limited published data on clinical outcomes. OBJECTIVE: To retrospectively report the treatment outcomes and clinical characteristics of patients with FND-speech that attended outpatient SLT as part of a multidisciplinary program for functional neurological disorder (FND). METHODS: In this case series, we included adult patients with FND-speech that consecutively participated in outpatient SLT at our institution between October 2014 and September 2021. Baseline demographic and neuropsychiatric characteristics were extracted from the medical records, along with data on FND-speech phenotypes, number of treatment sessions received, and clinician-determined outcomes. Only descriptive statistics were used to report findings. RESULTS: Twenty patients met inclusion criteria; ages ranged from 21-77, with a mean of 51.6±16.2 years. 85% of the cohort presented with mixed FND-speech symptoms. Patients attended a range of 2-37 visits, with an average of 9.2±8.0 visits over 4.4±3.5 months. At the last treatment session, 3 patients were asymptomatic, 15 had improved, and 2 had not improved; 8 individuals that improved received video telehealth interventions. CONCLUSION: This case series lends additional support for outpatient SLT in the assessment and management of individuals with FND-speech, and may help clarify patient and provider treatment expectations. Additional prospective research is needed to investigate baseline predictors of treatment response and further define the optimal frequency, intensity, duration, and clinical setting for SLT delivery in this population.

Developing a Curriculum for Functional Neurological Disorder in Neurology Training: Questions and Answers.

Functional neurologic disorder (FND) is a common condition for which neurology residents often receive little to no formal teaching. Using a question-and-answer format, this article puts forward a case for why an FND curriculum is needed and aims to provide guidance on possible curricular content including medical knowledge, clinical skills, communication, and team-based collaboration. The authors also discuss methods for teaching and evaluating this knowledge and associated clinical skills, linking this to current Accreditation Council for Graduate Medical Education neurology milestones. Finally, the authors consider how to better engage and energize neurology trainees around this underserved yet challenging patient population.

Setting up Functional Neurological Disorder Treatment Services: Questions and Answers.

Functional neurologic disorder (FND) is commonly encountered across outpatient and inpatient medical settings. Given the potential for a high burden of disability in some patients and mounting evidence for the efficacy of FND-specific multidisciplinary treatment services, expanding clinical services for this population is a necessity. In this perspective article, we discuss considerations for creating FND services, including the types of services that exist, how to start, how to identify appropriate referrals, and how to develop and monitor individualized treatment plans. In addition, we discuss how this effort can be done sustainably - balancing patient needs with limited healthcare resources.

Knowledge exchange throughout the dementia care journey by Canadian rural community-based health care practitioners, persons with dementia, and their care partners: an interpretive descriptive study.

INTRODUCTION: Accessing, assessing, exchanging, and applying dementia care information can be challenging in rural communities for healthcare practitioners (HCPs), persons with dementia (PWD), and their care partners. The overall purpose of this research was to enable HCPs, care partners, and PWD to use dementia care information more effectively by examining their information needs, how these change over time, and how they access, assess, and apply the knowledge. METHODS: A qualitative interpretive descriptive approach was used. A convenience sample was initially recruited through study collaborators in Southwestern Ontario, followed by purposive sampling. Nine rural dementia care networks consisting of PWD (n = 5), care partners (n = 14), and HCPs (n = 14) were recruited and 80 interviews were conducted at three time points. Transcripts were coded using Lubrosky's thematic analysis. RESULTS: Six stages of the dementia care journey were identified: (1) recognizing the symptoms; (2) receiving a diagnosis; (3) loss of independence; (4) initiating and using home care and respite services; (5) long-term care (LTC) placement; and (6) decisions related to end-of-life care. Rural care partners identified the need for different types of knowledge during each of these critical decision points of the dementia care journey. They accessed information from family members, friends, local organizations, and dementia internet sites. Persons with dementia tended not to identify the need for dementia care information. The HCPs accessed dementia care information from their own organization, other organizations, and internet sites. Care partners and HCPs assessed the trustworthiness of the information based on whether the source was a well-known agency or their own organization. Barriers to knowledge exchange included: lack of rural community-based services for dementia care; care partners reluctant to seek help and had limited energy; and lack of integration of dementia-related services and supports. Facilitators of knowledge exchange included: rural care partners with healthcare experience who were actively seeking information; development of trusting relationships between HCPs, care partners, and PWD; and formal mechanisms for exchanging information within and across rural community-based organizations. METHODS: This research illustrates the stages of the dementia care journey, and the types of information typically needed, accessed, assessed, and applied at each stage. Healthcare practitioners can use these findings to support rural care partners in navigating their dementia care journey. Support is needed as care partners often do not have the time, energy, skills, or knowledge to seek out dementia care information independently. In addition, PWD typically do not recognize the need for this knowledge, leaving care partners potentially isolated in this journey. Developing formal linkages within and across rural organizations will facilitate knowledge exchange and the delivery of cost-effective, quality dementia care. However, additional rural community-based resources are urgently needed to implement these recommendations. This may require a redistribution of resources from acute care to rural community care.

Sensory Processing Difficulties in Patients with Functional Neurological Disorder: Occupational Therapy Management Strategies and Two Cases.

Functional neurological disorder (FND) is a condition at the intersection of neurology and psychiatry, with some patients experiencing sensory hypersensitivities and other sensory processing difficulties. It has been postulated that poor integration and modulation of sensory information with cognitive, affective and behavioral processes may play a role in the pathophysiology of FND. In this article, we first succinctly review the role for occupational therapy (OT) in the multidisciplinary therapeutic approach to managing patients with FND. After highlighting previously published data identifying sensory processing difficulties in patients with FND, we subsequently outline the components of the sensory-based outpatient OT program for FND at the Massachusetts General Hospital. Here, we detail how occupational therapists assess and treat sensory modulation difficulties with the aid of resources like the Adolescent/Adult Sensory Profile (AASP), The Canadian Occupational Performance Measure (COPM), and the Sensory-Motor Preference Checklist. We then report on 2 clinical cases representative of the sensory modulation difficulties endorsed by some patients with FND, illustrating how developing an individualized, sensory-based treatment plan can help improve functional neurological symptoms and overall participation in activities of daily living. Prospective, controlled research is needed to further operationalize OT-based sensory modulation interventions, as well as define the tolerability and efficacy of this intervention for pediatric and adult populations with FND.

The Ottawa and Kingston (OaK) Birth Cohort: development and achievements.

OBJECTIVE: The Ottawa and Kingston (OaK) Birth Cohort collected data on maternal and infant genetic and epidemiologic variables in order to (1) explore the association between folate supplementation or thrombophilias and adverse, placenta-mediated pregnancy outcomes; (2) create a biobank of maternal and infant biological and genetic samples; and (3) stimulate future research using this cohort data. METHODS: A prospective cohort design was used to collect mother and infant data. Women were recruited at 12 to 20 weeks' gestation, during prenatal care visits at The Ottawa Hospital and Kingston General Hospital from October 2002 to April 2009. Data on maternal and infant demographics, maternal health, obstetrical history, and pregnancy outcomes were collected. Testing was done for biological/serological markers associated with adverse pregnancy outcomes. Maternal and cord blood samples were biobanked. RESULTS: A total of 8085 mothers were recruited to the OaK Birth Cohort. Analysis of the cohort data showed that taking multivitamin supplements containing folic acid was associated with a reduced risk of preeclampsia (aOR 0.37; 95% CI 0.18 to 0.75). The majority of participants agreed to have their genetic/biological samples biobanked (samples collected for n = 7241 mothers, n = 2175 infants) and to be re-contacted regarding future research opportunities. CONCLUSION: Birth cohorts are a useful tool in determining associations between risk factors and adverse maternal and fetal outcomes, and can serve as a repository of data for future research. Creating strong research partnerships helped enhance financial resources and increase participant recruitment potential. Epidemiological and biobanked data and samples from the OaK Birth Cohort are available for use by other investigators.

Functional neurological disorder in the emergency department.

We provide a narrative review of functional neurological disorder (FND, or conversion disorder) for the emergency department (ED). Diagnosis of FND has shifted from a "rule-out" disorder to one now based on the recognition of positive clinical signs, allowing the ED physician to make a suspected or likely diagnosis of FND. PubMed, Google Scholar, academic books, and a hand search through review article references were used to conduct a literature review. We review clinical features and diagnostic pitfalls for the most common functional neurologic presentations to the ED, including functional limb weakness, functional (nonepileptic) seizures, and functional movement disorders. We provide practical advice for discussing FND as a possible diagnosis and suggestions for initial steps in workup and management plans.

Breastfeeding intention and early post-partum practices among overweight and obese women in Ontario: a selective population-based cohort study.

OBJECTIVE: To explore the relationship between overweight and obesity and breastfeeding behaviors, a cohort study was conducted among 22,131 women who delivered in Ontario hospitals between April 1 2008 and March 31 2010. METHODS: Data regarding maternal characteristics, maternal body mass index (BMI), infant characteristics, and breastfeeding practices were obtained through the Better Outcomes Registry & Network birth records Database. Multivariate linear regression analysis was used to determine the rates of three outcome measures - intention to breastfeed, exclusive breastfeeding in hospital, and exclusive breastfeeding upon discharge from hospital - between non-obese, overweight and obese patients. RESULTS: While overweight mothers have similar intentions to breastfeed compared to non-overweight mothers (OR 1.03 (0.87-1.21), obese mothers were less likely to intend to breastfeed (OR 0.84 (0.70-0.99). Overweight and obese mothers were less likely to exclusively breastfeed in hospital compared to non-overweight mothers (aOR 0.67 (0.60-0.75) and 0.67 (0.60-0.75), respectively), and overweight and obese mothers were less likely to exclusively breastfeed on discharge (aOR 0.68 (0.61-0.76) and 0.68 (0.61-0.76), respectively). CONCLUSIONS: This study highlights that while overweight and obese women may benefit more from exclusive breastfeeding compared to non-overweight women, they are less likely to exclusively breastfeed in the immediate post-partum period.

Dementia Care Knowledge Sharing within a First Nations Community.

This article discusses the First Nations sample of a larger study on dementia care decisions and knowledge sharing.The purpose is to enhance understanding of the process of knowledge sharing among health care practitioners(HCPs), care partners, and persons with dementia (PWDs) within a rural First Nations community. A constructivist grounded theory methodology was used. Nineteen interviews were conducted at three points in time with two dementia care networks that included two PWDs, three care partners, and two HCPs. A sharing dementia care knowledge model was conceived, with the PWDs and their care partners at the centre. Knowledge sharing in the model was represented by three broad themes: (1) developing trusting relationships, (2) accessing and adapting the information, and (3) applying the information. Culturally sensitive approaches were essential to developing trusting relationships. Once developed, knowledge sharing through accessing, adapting, and applying the information was possible.

Formal dementia care among first nations in southwestern Ontario.

This article explores how dementia care is provided to First Nations communities in southwestern Ontario. Data were collected through in-depth interviews with health care providers and analysed using a constructivist grounded-theory methodology. Two interrelated frameworks for understanding dementia care were identified: a care delivery framework and a knowledge framework. The care delivery framework identified care goals, care elements being provided, care barriers, and strategies and solutions to deliver care and overcome barriers. The knowledge framework defined four groups of knowledge stakeholders: persons with dementia, informal care providers, formal care providers, and the First Nations community. It identified the knowledge each stakeholder held or needed and processes of sharing - or failing to share - knowledge in dementia care. Several barriers, many created by a lack of knowledge, negatively impacted dementia care. However, health care professionals had effective strategies for providing care, designed to overcome barriers and which encompassed elements of knowledge sharing.