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• What is the evidence for neurological follow-up of patients with FNS?
  Marinus Vermeulen, Rob J de Haan
  Published on: 16 October 2017
• Neurologists have an important role in follow up of patients with functional neurological symptoms.
  Jan A Coebergh, Mark Edwards and Mahinda Yogarajah
  Published on: 22 June 2017

• Published on: 16 October 2017

  What is the evidence for neurological follow-up of patients with FNS?

  • Marinus Vermeulen, emeritus professor of neurology dpt of neurology Academic Medical Center Amsterdam, The Netherlands
  • Other Contributors:
    • Rob J de Haan, clinical epidemiologist

  We thank dr. Coebergh and colleagues for their interest in our study. We agree that(a) there are many differences between the health care systems of the UK and the Netherlands, (b) the results of our study do not apply to excluded patients, and (c) the management of new neurological symptoms, relapses of previous FNS and relevant neurological and other co-morbidities remain very important in order to prevent inappropriate re-referrals and investigations of patients. However, in the absence of sound evidence from appropriate clinical studies,we disagree with the authors’ conclusion that neurological follow-up of these patients is often beneficial.
  We wish to emphasize that in our study, firstly a neurologist established the diagnosis and briefly explained the diagnosis to the patient. Secondly, the first neurologist referred the patient to a specially trained second neurologist, who scheduled half an hour to discuss the diagnosis with the patient. This approach is clearly different from immediate referral to a GP after the diagnosis.

  Conflict of Interest:
  None declared.

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• Published on: 22 June 2017

  Neurologists have an important role in follow up of patients with functional neurological symptoms.

  • Jan A Coebergh, Neurologist St Georges Hospitals Foundation Trust and Ashford St Peter's Hospitals Foundation Trust
  • Other Contributors:
    • Mark Edwards, Professor of Neurology
    • Mahinda Yogarajah, Consultant Neurologist

  It is good to see that trials are being done to answer the critical question of how best to provide care for those patients with functional neurological symptoms (FNS). The research paper, ‘Management of patients with functional neurological symptoms: a single-centre randomised controlled trial’, by Pleizier, de Haan and Vermeulen, randomizes outpatients with functional neurological symptoms after diagnosis, to either two outpatient appointments with a neurologist, or referral back to a GP. Intriguingly, it finds no difference in outcome, that is quality of life scores, between the two groups.[1] While this study attempts to address an important question, namely the role of the neurologist in the care of patients with functional neurological disorders, we feel it has a number of problems that limit its generalizability, particularly to UK neurology practice.
  The Netherlands is a country that compared to the UK, has approximately four times as many neurologists per head of the population, and many more GPs with higher levels of job satisfaction,[2] and often have mental health nurse support in the practice itself. Neurology outpatient waiting times are shorter in the Netherlands, and in-patient neurology review happens routinely and is quicker, unlike in the UK where it may not occur at all.[3] Because of this lack of prompt neurological review in the UK, it is common for patients to receive erroneous diagnoses, often necessitating an “undiagnosis” at the eventual neu...

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  It is good to see that trials are being done to answer the critical question of how best to provide care for those patients with functional neurological symptoms (FNS). The research paper, ‘Management of patients with functional neurological symptoms: a single-centre randomised controlled trial’, by Pleizier, de Haan and Vermeulen, randomizes outpatients with functional neurological symptoms after diagnosis, to either two outpatient appointments with a neurologist, or referral back to a GP. Intriguingly, it finds no difference in outcome, that is quality of life scores, between the two groups.[1] While this study attempts to address an important question, namely the role of the neurologist in the care of patients with functional neurological disorders, we feel it has a number of problems that limit its generalizability, particularly to UK neurology practice.
  The Netherlands is a country that compared to the UK, has approximately four times as many neurologists per head of the population, and many more GPs with higher levels of job satisfaction,[2] and often have mental health nurse support in the practice itself. Neurology outpatient waiting times are shorter in the Netherlands, and in-patient neurology review happens routinely and is quicker, unlike in the UK where it may not occur at all.[3] Because of this lack of prompt neurological review in the UK, it is common for patients to receive erroneous diagnoses, often necessitating an “undiagnosis” at the eventual neurology review.[4] Given these starkly different clinical contexts, we believe that a single neurology appointment in the UK, as compared to neurological follow-up for patients with FNS, would not lead to similar outcomes as published in this study.
  Not withstanding these cultural differences, there is also significant, multi-faceted selection bias in this study, which limits the interpretation of the results. Firstly, the authors only include patients referred by GPs in this study. In our experience, patients that come via A&E or have been recently discharged from hospital are different to those referred by GPs, having had more investigations, and have more severe symptoms and a poorer prognosis if there is
  no improvement in hospital.[5] The authors also exclude patients who have been symptomatic for over a year. In reality, this would mean the exclusion of large numbers of patients. Indeed in this study 923/1147 patients are excluded for this very reason,[1] and the proportion of patients is likely to be higher in the UK for the reasons of delayed diagnosis explained above. It is likely that the longer patients are symptomatic with FNS, the poorer their prognosis.[6] These strict criteria therefore exclude the very patients who need treatment and follow-up care most, and are likely to bias the results of this study, and limit its interpretability when applied to the broader population of patients with FNS.
  Lastly, a single neurologist accounted for treatment of 90% of the patients in the intervention arm of the study. It is therefore conceivable that the (high) standard of care received by patients from this neurologist who had a specific interest in FNS reduced any additional benefit from further neurology follow-up appointments. Indeed 34% of the patients who were supposed to receive at least 2 follow-up appointments failed to do so either because they thought it was unnecessary, or because they did not attend the follow-up appointments. The generalizability of these findings must therefore be in question.
  The authors suggest many useful ideas for future studies. However, the variability present in their approach to follow up appointments and the use of physiotherapy and psychotherapy, demonstrates that ultimately, individualized treatment and follow up plans remain the gold standard in this complex group of patients with competing biological, psychological and social factors relevant to their FNS. Furthermore, the management of new neurological symptoms, relapses of previous FNS and relevant neurological and other co-morbidities remains very important in order to prevent inappropriate re-referrals and investigations of patients.[7] For these reasons and those discussed above, we believe that neurological follow-up of these patients is often beneficial.
  Reference list
  1. Pleizier M, de Haan RJ, Vermeulen M. Management of patients with functional neurological symptoms: a single-centre randomised controlled trial. J Neurol Neurosurg Psychiatry. 2017;88(5):430-436.

  2. Arie S. Why are Dutch GPs so much happier? BMJ. 2015;351:h6870.
  3. Gregory R, Nicholl D, Lawrence J, et al. Association of British Neurologists (ABN) 2017 Acute Neurology Survey. March 2017.

  4. Coebergh JA, Wren DR, Mumford CJ. ‘Undiagnosing’ neurological disease: how to do it, and when not to. Practical Neurology. 2014;14:436-439.
  5. Couprie W, Wijdicks EF, Rooijmans HG, et al. Outcome in conversion disorder: a follow up study. J Neurol Neurosurg Psychiatry. 1995;58(6):750-2.
  6. Gelauff J, Stone J, Edwards M, et al. The prognosis of functional (psychogenic) motor symptoms: a systematic review. J Neurol Neurosurg Psychiatry. 2014;85(2):220-6.
  7. Crimlisk HL, Bhatia KP, Cope H, et al. Patterns of referral in patients with medically unexplained motor symptoms. J Psychosom Res. 2000;49(3):217-9.

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  Conflict of Interest:
  None declared.

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