Dr. Lehn is a neurologist from Princess Alexandria Hospital in Brisbane, and he is a movement disorder specialist with focus in movement disorders. Today's episode, we're going to have some updates in the area of functional movement disorders. Despite the recognition by the neurology community about these disorders, it is common that many neurologists find complex to understand the condition itself and to treat it. But lucky we have experts that have developed expertise and also insights about how to diagnose them and treat them.
Now thank you again for coming, Dr. Alexander Lehn.
View transcript
[00:01:19] Dr. Alexander Lehn:
So, one of the really exciting areas in recent years is exactly that, that we understand much more about how the human brain works and with that how functional neurological symptoms develop. And that interplay I find really interesting to the more we learn about brain functioning, the more we learn about underlying processes leading to the development of functional symptoms.
And the concept of predictive coding is something that really has transformed our understanding with that. You might know we often use the analogy of hardware and software disturbances when we explain functional neurological disorders for people who are not used to that. The analogy is that in functional neurological disorders, the brain hardware, so the kind of cable work in the brain is typically still intact, but the brain software is glitching. So really what we mean with that is the way the brain communicates within itself or with the body or with outside world is glitching and on a superficial level that makes a lot of sense for people and is very helpful as well.
But I guess what people need to understand, the brain is not like a computer in a traditional sense, as in some sensory information goes into this central processing unit that we call our brain and then kind of gets digested and processed, and then we spit out a program.
The way the brain actually works is, it's a predictive machine, and our brain constantly tries to predict how our bodies work, what happens in our body, what happens in the outside world around us, and what happens with interactions between our brain and our body and the outside world. And that way of predicting is really what glitches in functional neurological disorders, and understanding that helps us a lot more to realize why certain symptoms develop the way they do, and hopefully will help us as well to manage those symptoms better in the future.
[00:03:08] Dr. Hugo Morales:
We're under this understanding of the pathophysiology using this concept of predictive coding.
Is it something that in a clinical basis, we can identify? Meaning is it any risk factors that patients may have that within that understanding of predictive coding?
[00:03:25] Dr. Alexander Lehn:
Yeah, so certainly risk factors as well.
And also I think particularly, for it's imminently important for clinicians, the importance of helping a patient to understand the diagnosis. Because if the prediction is wrong, if the expectation for you as a patient or sufferer of a functional neurological disorder is, for example, of no recovery or nothing else that can be done, it's really hard to shift those symptoms.
So you need to be able to shift this goalpost of prediction into another area. by helping a patient to understand the actual diagnosis and the underlying processes to then enable recovery for patients. So it has direct impact in, in patient's care.
[00:04:06] Dr. Hugo Morales:
With this new information that we have, based on sort of the pathophysiological underpinnings of this disorder, is this something that has helped the broader neurological community to see how we diagnose them earlier, or how we perceive the condition and treat the condition?
[00:04:27] Dr. Alexander Lehn:
Yeah, really more like, I guess, so the predictive coding is not directly relevant, I guess, in the diagnostic process, but certainly in the treatment process. And it puts really more pressure on us neurologists who typically are the ones who diagnose a disorder. to get that first part, that front end of treatment right.
And the front end of treatment is explanation of the diagnosis. I see a lot of interest amongst therapists, physiotherapists, psychologists, and other therapists. The neurologists, I think it's fair to say, have been hesitant often to have these discussions with patients because it's often awkward and takes a lot of time.
And I guess that's it. truth be told, we haven't been told how to do those kind of things. And I think it really emphasizes that importance of that, that first step to get that right for patients.
[00:05:12] Dr. Hugo Morales:
And how the society itself has amalgamated efforts to actually understand how can we better treat these patients without any study groups?
[00:05:23] Dr. Alexander Lehn:
So the functional movement disorder study group has been ever growing in the last year. And it's really nice to see that, I guess, reflects that increasing interest in the community as well. I think we have 168 members now. So as part of the MDS in the functional movement disorder study group. And it's a really keen bunch of people and a lovely bunch of people to, to work with.
And there's several projects we're working on at the moment. There's two, I think, particularly interesting projects and important projects. Tim Nicholson is leading one project about identifying and developing better outcome measures for studies, because that's been a huge issue in the field of functional neurological disorders: how do you actually measure outcomes for trials? Because by their very nature they're vague, they're variable, symptoms change, symptoms come and go. So it's hard to capture these kind of things. So really important to develop better outcome measures for that and it's great that Tim Nicholson is leading The team to kind of develop that better in the future, which I think will be really important for future trials.
And the other important project that the team is working on in collaboration with the Functional Neurological Disorders Society is that by John Stone and Jeffrey Starb to develop new definitions of the diagnosis of FND, new definitions of actually how to diagnose new classifications for that.
And I think pushing that into the next century and reflecting our improved understanding that we have developed in, in recent years would be really important going forward as well.
[00:06:52] Dr. Hugo Morales:
Now, I would say many years ago, we wouldn't think a main differential diagnosis, a neurological presentation would be functional movement disorder or functional neurological disorder. How has that changed over time and how now we incorporate more into the differential diagnosis?
[00:07:10] Dr. Alexander Lehn:
Truth be told for all of us who work clinically, that's what we see, isn't it? We see functional neurological disorders every day. We see the symptoms every day and what encourages me in recent years as well is how that has now been more accepted and understood in Mainstream in our wider movement disorder society. And I remember a few years ago when you went to talks about Differential diagnoses of let's say tremors, usually functional tremors were never on the list. Which is kind of weird because it's so common and we see those those things so commonly. And it's lovely to see being, for example, at the meeting this year where most talks when they talk about differential diagnoses have functional neurological disorders on that list. It's discussed in an appropriate way without guilty giggles in, in the in the auditorium.
And I think it's really nice to see that change in all of us, accepting it as a real and genuine disorder.
[00:08:04] Dr. Hugo Morales:
Are there any new clinical trials of treatment for functional neurological disorders?
[00:08:09] Dr. Alexander Lehn:
They are. And I guess that comes back to the difficulty of measuring outcome criteria.
There's one, the physio for FMD trial was just published early this year, led by Glenn Nielsen. Massive phase three trial, beautifully done trial for specialist physiotherapy for treatment of functional movement disorders. But the primary outcome measure was actually not met. And that was really interesting again for us. Like sad of course, and frustrating. But interesting to see that we need to do better with how we measure outcomes.
So the primary outcome was the physical function part of the SF36, which was not met. But many of the secondary outcomes were met and it just showed us again that it's hard to measure those outcomes. It's something we need to do better because in order to show progress, we need to Get smarter with how we measure those things in the future.
[00:09:00] Dr. Hugo Morales: Also I want to get your insights of anyone who wants to provide services for functional neurological disorders. What are the crucial elements to have in your clinic to build that?
[00:09:14] Dr. Alexander Lehn:
I think it takes much less than people think, and people often far too nervous around that. And Really what I would say just get the basics right.
It's good old school clinical Neurology. It's take a good history, examine well, and be able to trust your history and examination findings and make your diagnosis based on that. And then Just be honest to patients, be sincere, listen to patients. All these things I guess we went to med school for to, to learn and we kind of then in our hectic lives nowadays forgot a bit again. And we often tend to get weird when we see patients with functional symptoms, which then understandably makes patients a bit weird about that as well.
So I think if we just get those basics right, they will go a long way for all of us and all of our patients.
[00:09:59] Dr. Hugo Morales:
That wraps up today's episode of the MDS podcast. A big thank you to Dr. Lehn for sharing his valuable insights and update in functional movement disorders.
Stay tuned for our next episode and we'll continue exploring the latest advancements in movement disorders. Until then, stay curious and keep learning.