FUNCTIONAL NEUROLOGICAL DISORDER One of the most important diagnoses in neurology… is often missed because clinicians are looking too hard at the MRI and not hard enough at the EXAMINATION. A patient says: I cannot move my leg. But then: • Hoover sign appears • gait changes with distraction • tremor entrains • strength returns during automatic movement That is not nothing. That is a POSITIVE neurological pattern. Modern FND is no longer: “Diagnosis of exclusion.” It is a diagnosis of: ✅ inconsistency ✅ incongruence ✅ preserved automatic circuitry ✅ positive bedside signs The nervous system pathway exists. The brain is failing to ACCESS it normally. That single shift changes how you examine the patient. Hoover sign stops becoming a trick. It becomes a window into motor control. The patient CAN generate movement. But voluntary access becomes disrupted. And this is exactly why: • distraction may improve weakness • backward walking may normalize gait • tremor changes rhythm • functional seizures fluctuate dramatically FND sits at the intersection of: movement attention prediction emotion agency and motor control. The dangerous part? Patients are often harmed from BOTH sides. ⚠️ One clinician dismisses: Everything is psychological. ⚠️ Another escalates: benzodiazepines antiepileptics ICU admissions intubation Especially in functional seizures. Real expertise is knowing: when to stop escalating, without losing diagnostic vigilance. The best FND clinicians do 3 things well: 1️⃣ Rule out dangerous neurological disease carefully. 2️⃣ Rule IN FND positively. 3️⃣ Explain the diagnosis respectfully. Because the explanation itself becomes treatment. One sentence changes the entire consultation: 🧠 “Your nervous system pathways are still present. The problem is in how the brain is accessing control of them.” Not: “Nothing is wrong.” Modern FND management is not: “Reassure and discharge.” It is: • targeted physiotherapy • movement retraining • speech/swallow rehabilitation • psychiatric comorbidity management • nervous-system retraining FND is not anti-neurology. It IS neurology. And perhaps one of the purest examinations of how the brain converts intention into movement. #neurotwitter #Medtwitter #FND #Functionaldisorders