A New Dawn

24 Sep 2018 0 comments Topic: Acute setting

I work in a Level 1 Neurological Rehabilitation Centre, in a Consultant Neuropsychiatrist-led multi-disciplinary team (MDT).  I attended the Bridges workshop in 2017 and having used it successfully with Stroke and TBI survivors, felt a lot of the Bridges core skills would transfer well with patients suffering Functional Neurological Disorder (FND).

The evidence-base for FND is still growing, but increasing focus is on addressing underlying predisposing, triggering and maintaining factors alongside an MDT approach that relays the message of a positive and potentially reversible diagnosis.  I found that MDT management often featured themes of assertiveness and empowerment and through education and formulation of strategies, aimed to achieve clear, individual goals.  Consequently I felt in a good position to explore Bridges with my patients.

One particular success came with, Dawn; who was diagnosed in 2015 aged 41.  She had suffered worsening symptoms since then, leading to increased dependence on her partner and an inability to continue her employment.  On ‘good days’ she could walk indoors with a frame, but in a position of abnormal posturing of her hips and legs to the right.  In addition, she suffered almost daily with non-epileptic seizures which left her with a pronounced left-sided weakness and dependence on a wheelchair.  She reported being housebound unless taken out by her partner.

Self-management started from first meeting Dawn.  We talked about her history and experiences before arriving at rehabilitation.  This provided a valuable insight into what motivated her, frightened her, what her health beliefs were and what she expected from the rehabilitation process.  She described herself as a “…type A personality.  I want to do everything, all the time, in every means possible”.  Goal setting focused these thoughts in terms of what was important to her, what she wanted to achieve in the longer-term and, more specifically, what she wanted to achieve whilst an inpatient.  Dawn had already considered her ‘steps to achievement’, and with guidance could explore her strengths and difficulties, from which emerged a growing awareness of perceived barriers that may have jeopardised achievement of her goals.

Integrating Bridges was easy but required a subtle shift in my thoughts as well as actions; such as suggesting Dawn sign out and operate the ward door independently.  These actions appeared to empower her, and soon after she suggested meeting me in the gym for each session rather than being collected from the ward.  Now, Dawn attends a public gym independently in addition to our timetabled sessions.  Physiotherapy became more ‘hands-off’, with a focus on Dawn exploring her impairments and using a problem-solving approach to managing them, with education and guidance from us as needed.  For example, in Dawn’s first week I asked her what was stopping her doing “everything, all the time”.  She identified this as being her hip position in standing, so I asked what she thought was needed to help this.  Dawn felt that she needed to adjust her footing first and, once achieved with the help of a mirror, felt that she needed to start moving in this corrected position.  Dawn was encouraged to self-rate her progress rather than rely on therapist feedback, and wrote a reflection each evening from which she felt she could learn better from her sessions.

Over time, Dawn discovered that social anxiety was a powerful maintaining factor of her FND, and worked hard with the MDT to overcome this; largely through increasing her knowledge and understanding of the condition and how it affected her.  Inevitably there have been ups and downs within her rehabilitation, but she felt that using her strategies had enabled her to “hold-off” her seizures, and that they had become less severe with a shorter recovery time after each event.  As a result, Dawn can complete her 2-hour commute home, unaided, unaccompanied and on public transport rather than relying on her partner collecting her.  This relieved stress for both parties.  Reflecting on this, she expressed: “It’s about me.  I can do this.  I don’t need anyone to hold my hand anymore.”

Dawn’s confidence has soared, and she has asked to stay at home for a long weekend: “I need to practice the new strategies I have learnt here, in real life”.  She plans to walk the dog and go shopping with her partner as well as go out for lunch; things she would not have contemplated before.   Dawn has had a lot of therapy previously, and when I asked her how self-management had been different, she replied: “You guided me, you didn’t dictate to me.  You helped me make sense of this mass of goals I had and let me come up with my own ideas and plans.  You came up with ideas and tools to support me with those plans”.

Dawn’s progress has not been exclusive to therapy sessions.  She makes her bed daily, changes her own sheets, clears her own dishes and takes her own medications, encouraging other patients to do the same: “If something’s being done for me, why aren’t I doing it myself?”  Dawn now feels she needs less 1:1 physiotherapy, and will manage her physical skills primarily through gym attendance, Pilates-based exercises, outdoor walking and relaxation.

Dawn has been inspiring to work with, and I would urge any therapists involved with FND to explore self-management with their caseload as part of an MDT approach.

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