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Editorial
New framework for the continuum of concussion and functional neurological disorder
  1. Matthew J Burke1,2,
  2. Noah D Silverberg3,4,5
  1. 1 Neuropsychiatry Program, Department of Psychiatry and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
  2. 2 Hurvitz Brain Sciences Program and Tory Trauma Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
  3. 3 Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
  4. 4 Rehabilitation Research Program, Centre for Aging SMART, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
  5. 5 Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Matthew J Burke; matt.burke{at}utoronto.ca

https://doi.org/10.1136/bjsports-2024-108154

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    Over the past 20 years, scientific investigation and public awareness of concussion has expanded exponentially. This has represented a critical swing of the pendulum for a field that previously had been somewhat ignored by the medical establishment, research funders and health policy-makers. Although substantial progress has been made in better identification and management of acute concussion, many knowledge gaps remain.1 One of the largest ongoing conundrums surrounds the 15%–30% of patients who experience persistent postconcussion symptoms (PPCS) that can last months to years.2 3 This editorial explores how better understanding the continuum between concussion/PPCS and functional neurological disorder (FND) could advance concussion care and research.

    Diagnosis of FND

    Running parallel over this time has been an evolving understanding of FND (previously termed conversion disorder). FND can be defined as the presence of involuntary neurological symptoms that are incompatible with conventional neurological diseases.4 This can be likened to a ‘software’ (functional) problem of brain circuits rather than a ‘hardware’ (structural) disease of the nervous system. FND is involuntary and should not be conflated with malingering (deliberate production or exaggeration of symptoms for external gain, eg, financial compensation). FND symptom subtypes include functional movement disorders, functional paralysis, functional seizures, functional sensory disorders, functional cognitive disorder and functional dizziness (also known as persistent postural perceptual dizziness (PPPD)). The latter two phenotypes have particular relevance to considerations surrounding PPCS. Recent efforts in the study of FND have focused on transitioning away from a diagnosis of exclusion towards incorporating validated ‘rule-in’ signs based on characteristics of internal inconsistency, distractibility and variability of symptoms (ie, fluctuations with shifts in attention).5

    Epidemiology and management of FND

    FND is commonly seen across medical practice and is among the most frequent clinical presentations in outpatient general neurology clinics.6 There is a female preponderance (60%–80%) with the mean age of onset being between …

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    Footnotes

    • X @MattBurkeMD

    • Contributors MJB and NDS conceived of the idea for this editorial. MJB and NDS drafted this editorial. MJB and NDS provided critical review. MJB is the guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.