FND & Functional Movement Disorder: How PT Helps

Medically reviewed by Dr. Richard Holsman, PT, DPT, NCS, Board-Certified Neurologic Clinical Specialist

Physical therapist walking and talking beside a smiling middle-aged woman in a bright therapy gym as she practices relaxed, natural walking

Your leg gives way, your hand shakes, or your walking suddenly changes. You have scans and blood work, and they come back normal. Then a neurologist tells you it is functional neurological disorder. If you have been left wondering whether anyone believes you, start here: the symptoms are real, the diagnosis is a real one, and there is a rehab approach built for it.

This article follows the published consensus recommendations for physiotherapy in functional motor disorder (Nielsen et al., Journal of Neurology, Neurosurgery & Psychiatry, 2015) and recent neurology reviews. Recommendations are paraphrased for patients. It is general education, not a diagnosis.

What Is Functional Neurological Disorder?

Functional neurological disorder (FND) is a problem with how the brain sends and receives signals, rather than damage to the brain or nerves themselves. A common way to explain it: the hardware is intact, but the software is not running properly. The result is genuine symptoms that the person is not producing on purpose (Hallett et al., Lancet Neurology 2022).

FND comes in several forms, and many people have more than one (Hallett et al., Lancet Neurology 2022):

Functional movement disorder (FMD): tremor, jerks, spasms, abnormal postures (functional dystonia) or a changed way of walking
Functional weakness: weakness or heaviness in an arm or leg, sometimes on one side, much like a stroke
Functional (dissociative) seizures: episodes that look like epileptic seizures but have a different cause
Persistent postural-perceptual dizziness (PPPD) and functional cognitive symptoms, such as everyday memory and concentration trouble

Fatigue, pain, poor sleep and trouble concentrating often come along with it. FND can start after a physical trigger, such as an injury, an illness or a migraine, and stress may or may not play a part. Current diagnostic criteria no longer require a psychological cause to be found (Espay et al., JAMA Neurology 2018).

How Common Is It?

FND is not rare. In a study of 3,781 new patients at Scottish neurology clinics, symptoms that were functional or psychological made up 16% of diagnoses, the second most common group after headache (Stone et al., 2010). Estimates of new cases run about 4 to 12 per 100,000 people each year, and 60 to 75% of patients are women (Espay et al., JAMA Neurology 2018). It affects people of every age, including teenagers and older adults.

How Is FND Diagnosed?

FND is not a diagnosis of “everything else came back normal.” A neurologist makes it based on positive signs: specific findings on examination that show the nervous system can still work normally, even if it does not work normally all the time (Aybek & Perez, BMJ 2022). Examples include:

Hoover’s sign: a leg that is weak when you push it down on purpose becomes strong when you lift the other leg
Tremor entrainment: a shaking hand changes its rhythm to match the beat when you tap with the other hand
Walking that looks very different from walking patterns seen in stroke, Parkinson’s disease or other conditions

In published studies, many of these signs are highly specific, which means they are rarely seen in people with other neurological diseases (Aybek & Perez, BMJ 2022). Once the diagnosis is made, it is very rarely changed later. Long-term follow-up studies have found the original diagnosis was wrong in about 4% of cases or fewer (Espay et al., JAMA Neurology 2018). FND can also occur alongside other conditions such as migraine, epilepsy or multiple sclerosis, so your neurologist will still look for and treat those.

Clinicians can read how these signs are tested, and what the research says about their accuracy, on our FND and functional movement disorder signs page.

Can Physical Therapy Help FND?

Yes. Neurology reviews describe physical and occupational therapy as treatments of choice for functional motor symptoms such as weakness, tremor and walking problems (Aybek & Perez, BMJ 2022). Physical therapy for FND is different from standard strengthening, though. Muscles and nerves are usually fine; the goal is to help the brain get back to running movement automatically.

A 2015 consensus of FND experts set out how therapists should approach it (Nielsen et al. consensus, 2015):

Education first. Your therapist explains FND in plain language and makes sure you understand the diagnosis. Believing the diagnosis makes rehab work better.
Show that normal movement is possible. Your therapist may show you, using your own positive signs, that your body can move normally when your attention is elsewhere. This is not a trick; it is evidence that recovery is possible.
Retrain movement with attention diverted. Paying close attention to a movement often makes functional symptoms worse. Therapy uses rhythm, music, walking at different speeds, walking backward or sideways, and tasks that shift your focus so automatic movement can come back.
Focus on everyday function, such as standing, walking, using your hands and getting back to your activities, rather than isolated exercises.
Use aids carefully. Walkers, wheelchairs, splints and braces can keep abnormal patterns going. They are used only when truly needed, and casts or splints for functional dystonia are generally avoided.
Build a self-management plan so you know what to do if symptoms flare.

Occupational therapy follows similar principles for daily tasks, work and self-care, with taught strategies to manage symptoms (Nicholson et al., 2020).

What Does the Research Show?

In a 2017 pilot randomized trial of specialist physiotherapy built on these principles, 72% of patients rated their symptoms as improved six months later, compared with 18% of those who had standard care (Nielsen et al., 2017). The larger Physio4FMD trial in England and Scotland, published in 2024, found that specialist physiotherapy was not better than usual care on its main measure of physical function at 12 months. More patients in the specialist group rated their motor symptoms as improved, and no serious side effects were linked to treatment (Physio4FMD, Lancet Neurology 2024). Put simply: rehab helps many people, results vary, and research is still working out which parts of treatment matter most.

Recovery is more likely with an early diagnosis and a clear understanding of the condition. A longer time before diagnosis is linked with poorer outcomes (Espay et al., JAMA Neurology 2018). Many people also benefit from a team approach that includes their neurologist and, for some, psychological therapy for symptoms such as anxiety, low mood or trauma.

Practical Tips for Day-to-Day Life

Learn about FND. The free patient guide at neurosymptoms.org, written by neurologist Jon Stone, and the FND Society are good places to start.
Stay active in small, regular doses. Long rest can lead to deconditioning. Pace yourself, and avoid big “boom and bust” swings in activity.
Notice when symptoms ease. Many people find symptoms improve when they are absorbed in something else, such as talking, music or a familiar task. That is a clue therapy can build on.
Look after sleep, pain and mood. They all affect how the brain controls movement.

When to Call Your Doctor or 911

A diagnosis of FND does not mean every new symptom is functional. Have new or different symptoms checked.

Call your neurologist for new symptoms, a clear change in your usual symptoms, or episodes that look different from before.
Call 911 for sudden face drooping, arm or leg weakness, or trouble speaking (possible stroke signs); a seizure lasting more than five minutes or one seizure after another; a fall with a head injury; or trouble breathing.

FND Rehab at Holsman

Our team includes two board-certified neurologic clinical specialists (NCS): our founder, Dr. Richard Holsman, PT, DPT, NCS, and Dr. Mandakini Desai, PT, DPT, NCS, clinic supervisor at our Maplewood and South Orange clinics. We build FND rehab on the published consensus approach and work with your neurologist. Occupational therapy can help with daily tasks, work and self-care.

You can schedule physical therapy, occupational therapy and speech therapy directly. Some insurance plans require a referral for coverage; our staff will verify your benefits for free. See our insurance page. If getting to a clinic is hard, ask about in-home therapy in Northern New Jersey; in New York, in-home care is provided by our sister practice, Home Therapy PT. Call 1-855-465-7626, contact us, or find a clinic near you. For related reading, see physical therapy for multiple sclerosis and physical therapy for Parkinson’s disease.

Frequently Asked Questions

Is functional neurological disorder real?

Yes. FND is a recognized neurological condition in which the brain has trouble sending and receiving signals, even though there is no structural damage. The symptoms are genuine and are not made up or produced on purpose.

What is the difference between FND and functional movement disorder?

Functional neurological disorder is the umbrella term. Functional movement disorder (FMD) is one type of FND and includes functional tremor, jerks, spasms, abnormal postures and walking problems. Other types include functional weakness, functional (dissociative) seizures and persistent postural-perceptual dizziness.

How is FND diagnosed?

A neurologist diagnoses FND based on positive signs on examination, such as Hoover’s sign for leg weakness or tremor entrainment, that show the nervous system can still work normally. It is not simply a diagnosis made because tests were normal.

Can physical therapy help functional neurological disorder?

For many people, yes. Expert consensus recommendations (Nielsen et al., 2015) describe physiotherapy built on education, showing that normal movement is possible, retraining movement with attention diverted, and a self-management plan. In a 2017 pilot trial, 72% of patients rated their symptoms improved at six months versus 18% with standard care. A larger 2024 trial (Physio4FMD) found no difference on its main physical function measure, though more patients in the specialist group rated their motor symptoms as improved.

Should I use a walker or a brace if I have FND?

Only if your therapist and doctor agree you need one for safety. Consensus recommendations advise avoiding mobility aids, splints and braces where possible, because they can keep abnormal movement patterns going. Casts and splints for functional dystonia are generally avoided.

Do I need a referral for physical therapy for FND?

You can schedule physical therapy, occupational therapy and speech therapy directly. Some insurance plans require a referral for coverage; our staff will verify your benefits for free.

Sources

This article is for general education and isn't a substitute for an evaluation by a licensed clinician.

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Functional Neurological Disorder (FND) and Functional Movement Disorder: How Physical Therapy Helps