What is functional neurological disorder and how might it affect employees? Hokman Wong breaks down everything occupational health teams need to know about this condition and the adjustments employees might benefit from.
Functional neurological disorder (FND) is a condition where there is a disorder of the function of the nervous system and how the brain and body send/receives signals. An analogy is a computer where the hardware is fine, but due to software problems programs do not work.
FND is the second most common reason for a neurological outpatient visit after headache or migraine.
FND is not a condition where we are able to identify structural damage. Historically, our inability to objectively measure FND has resulted in it being misunderstood and poorly accepted. This situation is changing due to advances in research. Doctors are now taking FND seriously. Public awareness is on the rise, with the first Parliamentary FND awareness day which took place on 8 February 2023.
Despite being a recognised medical condition, FND remains poorly understood by wider health services and NHS treatment is woefully inadequate. FND patients commonly feel helpless and rejected. It’s therefore important employers and HR professionals are aware of FND, the ways it can impact an employee and the best way to support these individuals.
Cause and symptoms of FND
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Medical science knows far less about how neuropathways combine to function than we know about computer software. At present we do not know the exact cause of FND, but we do know it usually has multiple causes, which can consist of biological, psychological and social factors. Pre-disposing factors make patients more susceptible and precipitating factors may trigger or exacerbate symptoms. Perpetuating factors prolong symptoms which may reinforce and entrench over time.
The nervous system controls every aspect of our being. FND symptoms are wide-ranging; it can affect multiple body systems and reflect a lack of control over these systems. The motor system may be affected with abnormal movements such as tremor, increased tone or weakness. The sensory system may be affected with numbness, pins and needles, or areas of increased pain. There may be cognitive symptoms such as confusion, fatigue, poor concentration and memory.
FND symptoms are real and are not “all in the head”. FND patients do not have voluntary control of their symptoms, and the condition is known to cause events that can be mistaken for seizures and stroke, with 9% of admissions to hyperacute stroke units having FND.
Treatment and prognosis
Ideally, treatment should be multidisciplinary and holistic (biological-psychological-social). The disciplines involved will depend on the symptoms, but generally include neuropsychiatric, neurology, physiotherapy, occupational therapy, and neuropsychology.
Rehabilitation can be expected to be undertaken for up to 12 months in the community or as an outpatient, or a combination of inpatient and community rehabilitation.
FND commonly lasts longer than 12 months and so may be considered long-term. Impairments can affect normal day-to-day activities. The disability provisions of the Equality Act 2010 may apply.
The NHS has very few treatment centres for FND, which are generally based in major cities and are associated with academic neurosciences centres (e.g. St George’s University of London Atkinson Morley Regional Neuroscience Centre). Such units have lengthy waiting lists, generally between 1-2 years for inpatient rehabilitation.
Long-term prognosis in FND is difficult to predict. It is generally considered to be a condition that may be improved with adequate treatment. I have worked with a leading FND expert and from their experience they put the figure at around 60-80%; however outcomes are highly variable and complete and enduring resolution is less common (less than 10%) and relapses are common (around 50% within a year).
FND commonly lasts longer than 12 months and so may be considered long-term. Impairments can affect normal day-to-day activities. The disability provisions of the Equality Act 2010 may apply, requiring an employer to make reasonable adjustments.
How may FND affect an employee?
FND symptoms are wide-ranging and each patient is unique. From my experience of working for clients with FND, I have come across symptoms such as: leg weakness resulting in difficulty walking, hand tremor, fatigue, poor concentration, aversion to loud noises, headache, emotional lability, photophobia, difficulty planning and making decisions. Save for one client, FND prevented them from working. The one client who was able to work was self-employed; their capacity to work was greatly reduced, and they had to take frequent time off in between work.
If an employee with FND is assessed as fit to return to work then an employer may need to consider adjustments.
Patients with FND are prone to relapses. Unmanaged psychological pressure and workplace stress may trigger a relapse. It is impossible to quantify this risk. Temporary adjustments such those listed below may be used to manage the risk of relapse.
- Increased managerial support through regular meetings to address views on operational circumstances and needs, monitor return to work, provide effective communication, and proactively respond to difficulties. This may help to reduce stress of returning to work.
- Gradual and gentle phased return to normal working hours, allowing the employee to work at their own pace. They should also be allowed sufficient time to catch up with administrative work.
- Allowing the employee to start with less psychologically/cognitively challenging work.
- A review of the risk assessment for workplace stress to identify and manage modifiable stressors.
- A referral to an employee assistance programme, if available.
- Regular review of temporary adjustments.
- Regular occupational health assessments.
Whether a temporary adjustment is reasonable will depend on operational requirements, expectations, limits and restrictions.
By giving them the right support and advising on adjustments, occupational health professionals and can help employees with FND remain in, or return to, work.