Gait Improvement Following Cerebrospinal Fluid Tap Test in NPH Patients - Part 2

In the second part of this two-part series, Dr. Shuvro Roy examines the study's findings and their implications for clinical practice moving forward. Show citation: Kim M, Park YH, Song YS, et al. Gait Improvement Following CSF Tap Test in NPH Patients With and Without Striatal Dopaminergic Deficit: A Preliminary Study. Neurol Clin Pract. 2025;15(6):e200549. doi:10.1212/CPJ.0000000000200549

In part one of this two-part series, Dr. Shuvro Roy explains idiopathic normal pressure hydrocephalus (iNPH), its diagnostic challenges, and a study on whether dopamine transporter (DAT) scan results affect gait improvement after a CSF tap test. Show citation: Kim M, Park YH, Song YS, et al. Gait Improvement Following CSF Tap Test in NPH Patients With and Without Striatal Dopaminergic Deficit: A Preliminary Study. Neurol Clin Pract. 2025;15(6):e200549. doi:10.1212/CPJ.0000000000200549

Drs. Mahinda Yogarajah, Benjamin Tolchin, and Jon Stone discuss recommendations for clinicians, patients, and other stakeholders on the management of functional seizures.  Show citation: Tolchin B, Goldstein LH, Reuber M, et al. Management of Functional Seizures Practice Guideline Executive Summary: Report of the AAN Guidelines Subcommittee. Neurology. 2026;106(1):e214466. doi:10.1212/WNL.0000000000214466  Show transcript:  Dr. Mahinda Yogarajah: Welcome to this edition of Neurology Minute. I'm your host for this. My name's Mahinda Yogarajah. I've just finished interviewing Dr. Ben Tolchin and Jon Stone for this week's Neurology® Podcast. For today's Neurology Minute, I'm hoping Ben can tell us the main points of the podcast and the paper discussed in that podcast. Dr. Ben Tolchin: We discussed the AAN guideline on the Management of Functional Seizures. This is the first American Academy of Neurology evidence-based guideline on functional neurologic disorder. It includes a systematic review of the randomized controlled trials relating to the treatment of this disorder, which found that psychological interventions are possibly effective in improving the chance of achieving freedom from functional seizures, in reducing the frequency of functional seizures, in improving quality of life, and in improving anxiety. In addition to the systematic review, there are clinical recommendations based on the systematic review and on related evidence. The recommendations deal with all stages of the diagnosis, management, and treatment of functional seizures and are particularly relevant to neurologists caring for patients with functional seizures. In addition, there are recommendations for future research relating to the diagnosis and management of functional seizures. Dr. Mahinda Yogarajah: Thank you, Ben. For more information, I'd recommend go to the main podcast or go and have a read of the article that's been published in Neurology® on the Management of Functional Seizures Practice Guidelines.

Drs. Greg Cooper, Natalia Rost, and Behnam Sabayan discuss preventive neurology and the need for neurologists to move beyond diagnosis and treatment toward proactive strategies for brain health.  Show citation: Sabayan B, Boden-Albala B, Rost NS. An Ounce of Prevention: The Growing Need for Preventive Neurologists. Neurology. 2025;105(1):e213785. doi:10.1212/WNL.0000000000213785 Show transcript:  Dr. Greg Cooper: Hi, this is Greg Cooper. I just finished interviewing Behnam Sabayan and Natalia Rost for this week's Neurology® Podcast. For today's Neurology Minute, I'm hoping you can tell us the main points of your paper, An Ounce of Prevention, the Growing Need for Preventative Neurologist. Dr. Behnam Sabayan: We are living in a very exciting time for the field of neurology where we are not just getting very good at diagnosis and treatment of neurological condition, but also we are stepping one step back, and that means that we will find the root causes of neurological conditions. We would act as preventive specialists and we would decrease the burden of neurological conditions, not just at the individual level, but also at the population level. And this paper calls for thinking about playing roles at different levels and stages from our offices and our rounds all the way to the community to be brain health advocates and helping other fields and disciplines to reduce the burden of neurological conditions. Dr. Greg Cooper: Well, thank you for that summary and for all of your work on this topic. Please check out this week's podcast to hear the full interview or read the full article published in Neurology®, An Ounce of Prevention: The Growing Need for Preventative Neurologists. Thank you.

In the final episode of this seven-part series, Dr. Jon Stone and Dr. Gabriela Gilmour wrap up the conversation discussing future directions.  Show citations: Functional Neurological Disorder Society Finkelstein SA, Carson A, Edwards MJ, et al. Setting up Functional Neurological Disorder Treatment Services: Questions and Answers. Neurol Clin. 2023;41(4):729-743. doi:10.1016/j.ncl.2023.04.002  Show transcript:  Dr. Gabriela Gilmour: This is Gabriela Gilmour with the Neurology Minute. Jon Stone and I are back for our final episode of our seven-part series on functional neurological disorder. Today, we will discuss future directions for the field of FND. So Jon, where do you see the field of FND going in terms of diagnosis and treatment? Dr. Jon Stone: So we've seen a tremendous increase in interest in FND, particularly in the last five years since we started the FND Society. I think there's much more awareness of making rule-in diagnoses compared to before. There's much more positivity about treatment and I think people who experience their own patients doing very well with treatment makes them want to see that again. But we've got a long way to go. I think the diagnostic ruling features that we talked about in an earlier episode are still largely clinical. I think we could really benefit from seeing those becoming more laboratory supported, particularly for research, particularly for looking at FND comorbidity and other neurological conditions like MS and Parkinson's. So I think we might see more of that, AI helping us with that maybe, but things like quantifying some of the physical signs that we use. In terms of treatment, I think it's great all the different ideas about treatment that we've had and we know that the rehabilitation therapy for FND benefits from a more FND focused approach. But we have to be honest as well and say that the treatments, there's still large numbers of patients who are not improving. And so we do need to think about other ways to help people. People are interested in treatments, modalities such as using virtual reality, people looking at medications such as psychedelics or things like that. We've got to be careful with that obviously in peoples where their brains don't work properly. But I think we can do better than we are and people are exploring those options interestingly. Dr. Gabriela Gilmour: Yeah. And I think on the note of treatment, as we've sort of spoken through this podcast series, we've talked about places or environments where there's already services set up for patients. And so I think another major goal for the future for the FND Society is to build more services and have more expertise and knowledge across the world. What would you tell neurologists to do or how would you support them if they don't have other health professionals to help in their local environment? Dr. Jon Stone: Well, I'm aware that that's probably what most neurologists feel like. That they can recognize FND, but they don't have people to refer to or therapists who know about FND. So I certainly share that frustration. What I would say has happened locally here in Edinburgh, and also I see this in other centers as well. If you just start referring patients, helping to send patients to your colleagues who want to have therapy, educating your colleagues, then the people around you can develop that expertise that's needed. You don't necessarily need a whole new team. If you're an enthusiastic neurologist interested in FND, be careful about doing it just on your own because I think there's a lot of good you can do, but it'd be quite easy to burn out there without some help. So I think it's a slow process of gathering together interested health professionals. Ideally, of course, you want to have a psychologist to do therapy, a psychiatrist for more detailed assessments of complex patients, physio, OT, speech and language therapy. Once you get that, what I find is that then locally, they will start to teach each other because this is work that most people in rehabilitation actually enjoy when they know how to do it. They like seeing people with FND. They like the fact that this is a disorder that will often be static for many years or a long time anyway, and where therapy can actually change that trajectory. So just sort of hang in there. There are articles you can read about more details about how to set up services and think about that as well. Dr. Gabriela Gilmour: Well, thank you so much, Jon, for joining me for this series. This is our final episode of the Neurology Minute series on Functional Neurological Disorder. And thank you to all of our listeners. Dr. Jon Stone: Thank you very much, Gabriela.  

In part six of this seven-part series on FND, Dr. Jon Stone and Dr. Gabriela Gilmour discuss the prognosis of functional neurologic disorders.  Show citation:  Gelauff J, Stone J. Prognosis of functional neurologic disorders. Handb Clin Neurol. 2016;139:523-541. doi:10.1016/B978-0-12-801772-2.00043-6  Show transcript:  Dr. Jon Stone: This is Jon Stone with the Neurology Minute. Gabriela Gilmour and I are back to continue with part six of our seven-part series on FND. Today we're going to talk about prognosis. What's the outlook for people with FND? It's obviously a question that patients and relatives desperate to know the answer. Gabriela, what do you say to your patients with FND when they say, "What's going to happen to me? Dr. Gabriela Gilmour: That's a difficult question because the prognosis is variable and I'll talk in a moment about what we know about prognosis from the literature. But I think when patients ask me what's going to happen, I try to instill hope because we do know that this is a condition that can improve and it can improve, especially when patients have access to rehabilitation programs or psychotherapy or other treatment plans. So I try to emphasize that piece and emphasize hope when I'm talking about that with my patients. But if we sort of take a step back and we look at what is the overall prognosis from what we know in the literature with FND, fundamentally, FND for many is a chronic and often relapsing condition. As I mentioned, it can certainly improve with rehabilitation. A challenge is that most of our published studies on the prognosis of FND really come from a time when we knew a lot less about the condition and we had fewer treatment options. So these studies are somewhat difficult to apply today, but in these studies, we see that at least without treatment, most patients are the same or worse at follow-up. However, now we're starting to develop more rehabilitation programs and we have more evidence that shows that people certainly improve with rehabilitation and with therapy. There are some factors that I try to emphasize to patients as being good prognostic factors when I'm talking with them. These may be things like younger age, a shorter duration between symptom onset and diagnosis and patient agreement with the diagnosis or the perception of having control over their illness. When these types of things are present, I try to highlight them to, again, help build that hope for recovery. The one thing that I would also add maybe a bit of a different question, but I think is important to mention is that we as neurologists still have a lot to provide to our patients, even those who may not see much recovery in their symptoms and live with chronic illness. It's really important to consider that regular check-ins. In these check-ins, we can monitor for changing perpetuating factors. We can facilitate social services, mobility aids that help overall quality of life. We can still offer a lot to our patients. The other piece that I would mention too is that our patients are at risk of iatrogenic harm. So there is definitely a role for the neurologist to look at, are there medications that might not be indicated that are causing harm? Are there other things that we can communicate clearly with other care providers to make sure that we reduce that risk for our patients? Dr. Jon Stone: So it's about balancing some realism, but also making sure the patient doesn't lose hope. A good outcome isn't always necessarily that symptoms gone away. It might be similar to other chronic neurological conditions that we look after where we're okay with an outcome where the patient still has symptoms if they understand their condition and can learn to live with it better. We'll be back for our final Neurology Minute episode on FND with myself and Gabriela Gilmour talking about future directions in FND. Thanks for listening.

In part five of this seven-part series on FND, Dr. Jon Stone and Dr. Gabriela Gilmour discuss treatment options.  Show citation:  Gilmour, G.S., Nielsen, G., Teodoro, T. et al. Management of functional neurological disorder. J Neurol 267, 2164–2172 (2020). https://doi.org/10.1007/s00415-020-09772-w  Gilmour GS, Langer LK, Bhatt H, MacGillivray L, Lidstone SC. Factors Influencing Triage to Rehabilitation in Functional Movement Disorder. Mov Disord Clin Pract. 2024;11(5):515-525. doi:10.1002/mdc3.14007  Stone J, Carson A. Multidisciplinary Treatment for Functional Movement Disorder. Continuum (Minneap Minn). 2025;31(4):1182-1196. doi:10.1212/cont.0000000000001606 Tolchin B, Goldstein LH, Reuber M, et al. Management of Functional Seizures Practice Guideline Executive Summary: Report of the AAN Guidelines Subcommittee. Neurology. 2026;106(1):e214466. doi:10.1212/WNL.0000000000214466  Show transcript:  Dr. Jon Stone: Hello, this is Jon Stone with the Neurology Minute. Gabriela Gilmour and I are back to continue with part five of our seven-part series on FND. Today we'll be discussing treatment. Gabriela, talk us through what the rehabilitation or therapy approaches exist for FND now. Dr. Gabriela Gilmour: I would start actually even before jumping into rehabilitation and therapy to again emphasize something that we talked about in the last episode, which is that rehabilitation very much starts at our first visits with our patients when we examine for positive signs and show these to our patients and explain what they mean. So education about FND is really a fundamental treatment step, and I think we as neurologists have so much to offer to our patients in these visits. Next, when we're thinking about rehabilitation for FND, this often includes some combination of physical rehabilitation and psychological therapy and really should be individualized to each patient. So multidisciplinary or integrated therapy approaches are the gold standard and treatment strategies with these are really guided by our evolving understanding of the mechanisms of FND. So for example, this means using strategies like distraction, motor visualization, relaxation and mindfulness to target that underlying mechanism of FND. And then we use psychological therapies to also address perpetuating factors. So as we have discussed in this series, patients often experience many symptoms. So we also want to think about those other symptoms in our treatment plan, whether that be chronic pain or sleep disturbance or treating comorbid psychiatric or neurological illness. When we think about the subtypes of FND, there is some research into specific strategies for each. So psychotherapy, in particular, cognitive behavioral therapy is the focus for functional dissociative seizures with strategies aimed at attack prevention. Whereas for functional movement disorder, motor retraining physiotherapy has the most evidence. One big thing that I want to emphasize though is that rehabilitation for FND really relies on patient self-management and patient engagement. So I often explain to my patients that I can't retrain their brain, but I can help support them in this process and doing this for themselves. Dr. Jon Stone: So when you meet a patient with FND, how do you decide whether therapy is going to be helpful for them? I think people often have a tendency to say, "Oh, it's FND right off you go to psychotherapy or physiotherapy," but is that always the right option? How should we try and help our patients to decide if it's the right time for them to do these treatments? Dr. Gabriela Gilmour: Yeah, I think that that's something that's really maybe not unique, but something that's really important to FND and to treatment planning and FND. When we're supporting our patients as they embark on a treatment pathway, we really want to set them up for success. And so this really does rely on a robust triage process. So unlike other neurological conditions where you have X disease, therefore, why is the treatment? For FND, we've got a host of different types of treatments, and we want to individualize that and we want to time it right. Fundamentally, we really want to select the right treatment for our patients, and that relies on us understanding what symptoms are most bothersome to our patients, and we want to then provide that treatment at the right time. And I think right time is really what I would emphasize as being so, so important. So this means that patients are ready for active participation and rehabilitation, they're enthusiastically opted in. They think that treatment's going to help, and there aren't major barriers that are going to impact their ability to participate fully, so things like severe pain that could get in the way. And this is a conversation that I have really openly with my patients, and I really try to let them guide the timing. They will let me know, "Hey, I'm a teacher, and I'm in school right now. Now is not the right time for me to embark on this, but what about in June or July?" And then we revisit and regroup at that time. So really I do let my patients guide this process, but I would say that there are a subset of patients that don't need these more advanced rehabilitation type programs. Maybe are spontaneously improved or are able to implement some of their own self-management strategies on their own and have a significant improvement in symptoms already. Dr. Jon Stone: We need to make it easy for our patients to tell us when it's not the right time, but also, there's no one-size-fits-all, basically. Dr. Gabriela Gilmour: Absolutely. Dr. Jon Stone: So we'll be back for more Neurology Minute to continue our discussion on FND. We'll be talking about prognosis. Thanks for listening.

Dr. Zohaib Siddiqi talks with Dr. Catarina Bernardes about a case involving a 35-year-old woman presenting with personality changes and gait impairment.  Show citation:  Bernardes C, Lemos JM, Santo GC. Clinical Reasoning: A 35-Year-Old Woman With Personality Change and Gait Impairment. Neurology. 2025;104(2):e210252. doi:10.1212/WNL.0000000000210252  Show transcript:  Dr. Zohaib Siddiqi: Hi, everyone. My name is Zohaib Siddiqi and I'm a fifth-year neurology resident and a part of the Neurology® Resident and Fellow Section Editorial Board. I just finished interviewing Catarina Bernardes about her article, Clinical Reasoning: A 35-year-old Woman with Personality Change and Gait Impairment. Catarina, can you tell us the main points of the article? Dr. Catarina Bernardes: So in this article, we discussed the case of a 35-year-old woman who presented with a three-year history of walking difficulties. On examination, she had signs of a frontal temporal dysfunction, a dorsal lateral myelopathy, optic atrophy, and pes cavus. Her brain and spinal cord MRI was completely normal, but her son's brain MRI was being studied for spastic paraparesis showed signs of hypomyelination involving the subcortical U fibers. Given the suggestive inheritance pattern, we considered an X-linked leukoencephalopathy and central nervous system hypomyelination points to Pelizaeus-Merzbacher disease. Important learning points. When differentiating leukoencephalopathies, remember that hypomyelinating disorders often have less pronounced hypointensity on T2 and hypointensity on T1, and in demyelinating disorders, there is very prominent hyperintensity on T2 and hypointensity on T1. Also, Pelizaeus-Merzbacher is a hypomyelinating disorder affecting the subcortical U fibers, while X-linked adrenoleukodystrophy presents a demyelinating pattern sparing the subcortical U fibers and involving mainly the parietooccipital regions. Dr. Zohaib Siddiqi: Thanks so much for that summary, Catarina. A lot of learning points there. For those of you who want to learn more about the case, you can listen to the full-length podcast available now on all streaming platforms and find the article titled, Clinical Reasoning: A 35-year-old Woman with Personality Change and Gait Impairment on the Neurology® Resident Fellow Website. Thanks so much for joining today, and see you next time. 

In part four of this seven-part series on FND, Dr. Jon Stone and Dr. Gabriela Gilmour discuss the diagnostic explanation.  Show citation:  Stone J. Functional neurological disorders: the neurological assessment as treatment. Pract Neurol. 2016;16(1):7-17. doi:10.1136/practneurol-2015-001241  Gilmour GS, Lidstone SC. Moving Beyond Movement: Diagnosing Functional Movement Disorder. Semin Neurol. 2023;43(1):106-122. doi:10.1055/s-0043-1763505  Podcast transcript:  Dr. Gabriela Gilmour: This is Gabriela Gilmour with the Neurology Minute. Jon Stone and I are back to continue with part four, of seven, of our series on functional neurological disorder. Today we will focus on the diagnostic explanation. So many patients have never heard of FND before receiving this diagnosis. Can you share how you explain the diagnosis to your patients? Dr. Jon Stone: So I'm aware that many neurologists do find this difficult. And I have to say, having thought about it for 20 years or so now, I think the answer is, don't be weird. Do what you normally do with any condition, when you explain it to patients. I think what goes wrong is that people see FND as something weird and other, and they start to do weird things like telling people that their scans are normal, or telling them what they don't have before they've started to tell them what they do. If you go with the normal rules of explanation, first of all, starting by giving it a name that you prefer, so you've got FND, or try and be specific if you can. You've got functional seizures, functional movement disorder. Give it a name to start with. Don't sort of spend a long time beating around the bush before you do that. Talk a bit about why you've made the diagnosis, because that's what you normally do. So if someone's got a weak leg, show them their Hoover's sign. I think actually showing people their physical signs is probably one of the most powerful things you can do, brings the diagnosis away from the scanner and into the clinic room. And also, they can see in front of them the potential for improvement. So it feeds forward into treatment. Yes, you might need to explain why they don't have some other conditions that they're worried about, but you can leave discussions about why it's happened for later. I think what tends to go wrong is people jump into that too early. So the bottom line, just do what you normally do and things generally go a lot more smoothly. Dr. Gabriela Gilmour: And when you're providing the diagnostic explanation, it can be really helpful to link the patient's experience and their symptoms to the diagnosis. And so, I wonder how you integrate that piece into your diagnostic explanation, or how you tailor your explanation to an individual patient. Dr. Jon Stone: Yeah, I think tailoring is really important here. And this is where obviously if you've done your assessment, so helpful to ask the patient is, "Well, what do you think's wrong? What things were you worried about? " Some people say, "Look, I'm really worried I've got MS." Or some people say, "I haven't got FND. I've read about that. " Or sometimes people are wondering if they've got FND. So, you've got to try and tailor it to what the person is expecting and particularly previous experiences. If they're telling you how angry they were about doctors A, B, and C, then obviously you want to use that and try not to end up with the same outcome. Why would there be a problem with this diagnosis? It's because they haven't heard about it, because they've got misconceptions about it. Do they feel that this diagnosis would be saying it's all in their mind or something like that? You might need to be explicit about that. But I think this links into how, it's not just about the diagnostic label, it's about a formulation, which is something we don't think about much in neurology. So there's a label for what's wrong, but in FND, a formulation, why have you got FND, in your particular case, is what we're sort of moving on to there based on the story that you've heard. Dr. Gabriela Gilmour: Yeah. And I think in my experience and in working with trainees, really just practicing, saying it, is so important and saying it in a way that feels honest and correct to you as a clinician. Dr. Jon Stone: Yeah, absolutely. Dr. Gabriela Gilmour: So we will be back for more Neurology Minute episodes to continue our discussion on FND. Next, we're going to be talking about treatment. Thanks for listening.

In part three of this seven-part series on FND, Dr. Jon Stone and Dr. Gabriela Gilmour discuss causes of functional neurologic disorder.  Show citation:  Hallett M, Aybek S, Dworetzky BA, McWhirter L, Staab JP, Stone J. Functional neurological disorder: new subtypes and shared mechanisms. Lancet Neurol. 2022;21(6):537-550. doi:10.1016/S1474-4422(21)00422-1 Show transcript:  Dr. Gabriela Gilmour: This is Gabriela Gilmour with the Neurology Minute. Jon Stone and I are back to continue with part three of our seven-part series on functional neurological disorder. Today, we will focus on the causes of FND. So Jon, there have been many advances in our understanding of the mechanism of FND in the last 10, 15 years. And so what do we know about this now? Dr. Jon Stone: I think the key message I want to get across here is that whereas previously we had a very psychiatric, purely psychiatric view of FND, it used to be called conversion disorder, what we've got now is a multi-perspective view of the mechanisms, which mean that we can understand FND at a kind of neural level or brain circuit level, but we can also still retain the importance of psychological factors, traumatic events. And I think it's also important to separate out, as you've done here with a question, what's the mechanism? How is the symptom happening versus why is it happening? Which often people don't do. So for this question, how is it happening? How is it that somebody, for example, gets a weak leg? Well, at a very simple level, their brain is disconnecting from their leg and that's what dissociation is. And you can explain that to patients at sort of brain circuit level. We've learned that there are disruptions probably in the circuits in our brain that relate to that sense of agency, the parts of our brain that tell us that our bodies belong to us. And people are particularly interested in an area called the temporary parietal junction. And at a higher broader level, people are particularly interested in the idea that FND is a disorder that you would expect to happen based on our understanding of the brain as a predictive organ. So if the brain spends its time predicting things, maybe in FND what's gone wrong is this is very strong prediction that the leg is weak or that there's a tremor or that a seizure's about to happen that overrides sensory input telling our brain otherwise. Dr. Gabriela Gilmour: And I guess to follow into that, you mentioned what is going on. So now can you talk a little bit about why somebody might develop FND or the etiology of FND? Dr. Jon Stone:  I think this helps clinically as well as neurologists, because we can talk about mechanism as we would, for example, with MS as inflammation, but why is there inflammation? So okay, the brain's gone wrong, but why has it gone wrong? And there we need a much more complex view of multiple range of risk factors, predisposing, precipitating, and perpetuating that we know are associated with FND, but vary a lot from person to person. So no one person's the same. If you've had traumatic experiences in the past, that will make you more prone to dissociation. If you've had other functional disorders, if you have almost certainly some forms of genetics make people predisposed. And then as we said in the last episode, having another neurological condition, so having migraine aura, a physical injury, an infective illness, these are powerful reasons to trigger neurological symptoms. And it's not so much why they happen. It's more why do they get there and get stuck? We all probably have transient functional symptoms actually, but why they get stuck in people with FND for various reasons to do with the way their brains work or their past experiences, or sometimes what happens to them in medical systems. So developing a very open idea about why someone might have FND really helps you, I think, explain that back to patients and produce individual sort of formulations of the problem. Dr. Gabriela Gilmour: Yeah. And I often say to my patients, "I don't know exactly why you, why today have this." And that's true in medicine in general. We actually often don't know why anybody develops any medical condition with a few exceptions, but we know about risk factors really. Dr. Jon Stone: Absolutely. It's one of the reasons I hate the term medically unexplained. Actually, I think FND is perhaps more explained in some ways than some of the other conditions like multiple sclerosis and ALS that we actually deal with where we really don't know why they happen. Dr. Gabriela Gilmour: Well, we will be back for more Neurology Minute episodes to continue our discussion on FND. Thanks for listening.