Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy

Abstract

Communication problems (eg, dysphonia, dysfluency and language and articulation disorders), swallowing disorders (dysphagia and globus), cough and upper airway symptoms, resulting from functional neurological disorder (FND), are commonly encountered by speech and language professionals. However, there are few descriptions in the literature of the most effective practical management approaches. This consensus document aims to provide recommendations for assessment and intervention that are relevant to both adults and young people. An international panel of speech and language professionals with expertise in FND were approached to take part. Participants responded individually by email to a set of key questions regarding best practice for assessment and interventions. Next, a video conference was held in which participants discussed and debated the answers to these key questions, aiming to achieve consensus on each issue. Drafts of the collated consensus recommendations were circulated until consensus was achieved. FND should be diagnosed on the basis of positive clinical features. Speech and language therapy for FND should address illness beliefs, self-directed attention and abnormal movement patterns through a process of education, symptomatic treatment and cognitive behavioural therapy within a supportive therapeutic environment. We provide specific examples of these strategies for different symptoms. Speech and language professionals have a key role in the management of people with communication and related symptoms of FND. It is intended that these expert recommendations serve as both a practical toolkit and a starting point for further research into evidence-based treatments.

Changing the culture of care for children and adolescents with functional neurological disorder

“…For example, gastroenterologists, respiratory physicians, and otolaryngologists all see patients with functional communication, swallowing, cough, and related disorders. Peer-reviewed literature A concerted effort has been made to publish clinical neurology handbooks [36] , consensus criteria, expert opinion articles, updates on etiology, assessment, and treatment of FND subtypes [23] , [37] , [38] , [39] , [40] , and articles describing the clinical assessment process [41] , [42] . Use of video teaching resources within all levels of education Video teaching resources can be helpful in teaching about patterns of presentation, the neurology examination, and interviewing skills.…”

“…For these children, the somatic narrative potentially includes the following neurophysiological processes and any associated symptoms: activation or dysregulation of the stress system (e.g., upregulation of the autonomic nervous system and increases in cortical arousal) [49] , [54] , [55] , [56] ; changes in homeostatic setpoints (e.g., lowering of pain thresholds and changes in regulation of PCO2 secondary to hyperventilation) [57] , [58] , [59] ; activation of the body’s protective (alarm) systems (e.g., pain and fatigue) that signal a need for protective action [60] , [61] ; and changes in neural networks (see previous subsection). The narrative also includes the positive signs (e.g., entrainment of tremor or incongruity and reversibility of voice or other motor symptoms) that distinguish functional neurological symptoms from other neurological conditions [37] , [38] and that reflect the disruption within and between neural networks controlling emotion processing and motor and sensory processing (see previous subsection). In sum, the somatic narrative provides the pediatrician with valuable information about changes in the child’s body function in response to stress, threat, or danger, whether actual or perceived.…”

“…The speech pathologist has a pivotal role to play in the diagnosis and treatment of functional voice disorders—in particular, when the child presents with functional aphonia (loss of voice), functional dysphonia (most commonly in adolescents with features of inappropriately high-pitched falsetto or unstable voice), anxious concerns about swallowing, choking phobias, or chronic symptoms of “habit,” “tic,” or “barking” cough [38] , [78] , [79] , [80] . A biopsychosocial approach—if possible, in collaboration with the other members of a multidisciplinary team when possible—is important.…”

“…The speech pathologist prioritizes the establishment of a therapeutic relationship and the creation of a therapeutic space in which treatment can take place. The assessment process itself involves a detailed psychosocial history and a formal oromotor/speech assessment (including elicitation of positive signs) [38] , [79] , [80] . In the process, the speech pathologist also creates a safe space for the child.…”

Functional neurological disorder: Engaging patients in treatment

“…Sharing self-help resources, explanatory websites, patient advocacy connections and other written material can further solidify a path forward. See Table 2 [20] , [21] , [22] , [23] , [24] , [25] , [26] Sharing clinical notes with patients where the diagnosis is confirmed is another way to be transparent and continue the educational dialogue.…”