Occupational Therapy in Functional Neurological Disorder Rehabilitation Mapped in 41-Study Review

Occupational therapy has long been described as a core ingredient of rehabilitation for functional neurological disorder, yet a new scoping review suggests the profession’s specific contribution has been remarkably difficult to pin down. The review, published in Frontiers in Neurology, mapped 41 peer-reviewed intervention studies involving 1,284 adults with functional neurological disorder, published between 1985 and July 2026. It found that occupational therapy was present in every eligible study, almost always embedded within multidisciplinary rehabilitation, but that profession-specific interventions and outcomes were inconsistently described, leaving the independent effect of occupational therapy largely unquantified.

Functional neurological disorder is characterized by neurological symptoms, such as weakness, tremor, cognitive difficulties and functional seizures, that arise from a problem with how the nervous system functions rather than from structural disease. Symptoms are genuine and involuntary, and can affect every facet of daily life, causing distress and disability. Fatigue and pain commonly accompany the condition and can further erode function and quality of life. Diagnosis rests on identifying positive clinical signs and internal inconsistency on neurological examination, and the disorder is best understood within a biopsychosocial framework that recognizes the interplay between biological, psychological and social factors in the development and persistence of symptoms. It is one of the most common conditions encountered in neurology services, accounting for roughly 5 to 15 percent of presentations, predominantly affecting adults of working age, with a higher prevalence in women than men.

The review team, led by Clare Nicholson of The National Hospital for Neurology and Neurosurgery and University College London, with colleagues from UCL and City St George’s University of London, followed Joanna Briggs Institute methodology for scoping reviews. They searched OVID Medline, Embase, APA PsycInfo and CINAHL Plus from inception to 28 July 2026, supplemented by reference list screening, and included peer-reviewed English-language intervention studies of adults aged 18 or over with a diagnosis of functional neurological disorder who received occupational therapy delivered independently or as part of multidisciplinary rehabilitation and reported treatment outcomes. Of 901 records screened, 41 studies met the criteria. Consistent with scoping review guidance, the authors did not undertake formal critical appraisal of methodological quality; the aim was to map the nature of the available evidence rather than evaluate intervention effectiveness.

The evidence base was dominated by uncontrolled observational work. Among the 41 studies were 14 case series, 10 case reports, 12 retrospective cohort studies, three prospective cohort studies, one retrospective cohort study with a historical control group and a single randomized study with a waiting-list control. Sample sizes ranged from 1 to 201 participants. Thirty-six studies reported sex data, showing 893 of 1,274 participants, or 70.1 percent, were female and 381, or 29.9 percent, were male, with one participant identified as non-binary. The weighted mean age across the 25 studies reporting mean age was 42.7 years, with reported ages spanning 18 to 82 years. Mixed functional neurological symptoms and functional motor symptoms were the most frequently studied presentations, and symptom duration varied enormously, from one day to 40 years among studies reporting these data, with a weighted mean of 4.9 years calculated from 13 studies with sufficient data.

Delivery settings leaned heavily toward inpatient care. Twenty-nine studies were conducted in inpatient settings, ten in outpatient services, one in the community and one in a mixed inpatient-outpatient arrangement. Treatment took place in person in all studies but one, which combined in-person and tele-health sessions. Duration varied widely: inpatient rehabilitation ranged from five days to 12 months, with short five-day intensive programmes predominantly offered to patients with motor symptoms, while longer admissions of three months or more typically involved cohorts with mixed functional symptoms, psychiatric comorbidities or complex presentations. Outpatient treatment ranged from three hours of total input to six months. Treatment intensity was inconsistently reported, but five-day intensive inpatient programmes typically involved daily multidisciplinary therapy, longer admissions provided between three hours of therapy per day and three hours per discipline per week, and outpatient occupational therapy ranged from one to two sessions daily within intensive programmes to three to four 60-minute sessions per week.

Because occupational therapy was delivered within multidisciplinary rehabilitation or alongside other therapies in all 41 studies, the reviewers categorized intervention components according to whether they were explicitly attributed to occupational therapists in the original reports. Only one study included a subgroup of 11 participants who received occupational therapy alone. Where the profession’s contribution could not be distinguished from the wider team, components were reported as multidisciplinary rehabilitation elements. Goal setting appeared in 20 studies and education about the disorder in 21, though descriptions rarely specified the process or which professions were involved. Multidisciplinary teams most commonly included physiotherapy in 40 studies and psychological therapy in 35, followed by psychiatry or neuropsychiatry in 19, speech and language therapy in 16, rehabilitation medicine in 16 and neurology in 14. Explicit interdisciplinary co-delivery involving occupational therapists was described in only three studies.

Descriptions of occupational therapy itself were provided in 23 studies, with varying detail, and the reviewers grouped the components into seven categories: facilitating occupational engagement, movement retraining, anxiety management and relaxation strategies, sensory modulation interventions, community reintegration, care with aids and adaptations, and relapse prevention and self-management planning. Facilitating occupational engagement, described in 15 studies, focused on identifying barriers to participation in daily activities and roles and supporting graded re-engagement through tailored activity planning, routine development and strategies to promote independence and confidence. Graded exposure to avoided activities incorporated pacing strategies for pain and fatigue and a scaffolded introduction of increasingly challenging tasks alongside techniques addressing anxiety and reduced confidence. Movement retraining involved teaching techniques that allowed access to normal movement, such as diverting attention away from symptoms toward the environment or the task goal, sometimes using tremor entrainment, mental imagery or mirror therapy, with strategies then applied within functional tasks like meal preparation and personal care.

Anxiety management and relaxation strategies were integrated into occupational therapy sessions, including diaphragmatic breathing, progressive muscle relaxation and body scanning, applied during functional tasks to reduce the impact of anxiety and hyperarousal on symptoms. Less frequently reported approaches included heart rate variability biofeedback, sensory-enhanced yoga, smartphone-based relaxation apps, meditation and mindfulness training. Two studies described sensory-based assessment and interventions for people experiencing hypersensitivity to light, noise, touch and movement, aiming to promote self-regulation through personalized symptom management plans and graded exposure to avoided stimuli. Community reintegration, including home visits, returning to driving and vocational rehabilitation, appeared in three studies, as did a graded approach to reducing carer support and assistive aids. Relapse prevention and self-management planning were typically multidisciplinary components, encompassing written summaries of formulation, symptom triggers and warning signs, structured home programmes and guidance for significant others.

Outcome measurement emerged as a major weakness. More than 60 different outcome measures were used across the 41 studies, limiting comparison between interventions and settings. Only four occupational therapy-specific measures were identified: the Canadian Occupational Performance Measure, the most frequently reported at eight studies, the adolescent and adult sensory profile in two, and the assessment of motor and process skills and the Chessington occupational therapy neurological assessment battery in one each. Commonly used multidisciplinary measures included the Clinical Global Impression scale and Berg Balance Scale in six studies each, the Functional Independence Measure in five, and the Generalized Anxiety Disorder-7, Patient Health Questionnaire-9 and EQ-5D-5L in four each. Many studies also relied on non-standardized patient and clinician ratings, including visual analog scales, ordinal scales of change, seizure frequency and employment status.

Treatment outcomes were generally favorable, with all 41 studies reporting improvements across one or more physical, psychological or quality of life domains, but the reviewers stressed that these findings reflect rehabilitation programmes that included occupational therapy rather than the independent effects of occupational therapy itself. The single randomized trial compared a three-week inpatient multidisciplinary programme with a waiting-list control in 60 participants with functional gait disorder and reported significant improvements on the Functional Independence Measure, Functional Mobility Scale and the physical and mental subscales of the 12-Item Short Form Health Survey, with gains sustained at one year for all measures except the mental subscale. Across uncontrolled studies, improvements were reported in symptom severity, disability and function, including reduced reliance on mobility aids in seven studies. Mental health gains were commonly reported in the short term, though two studies found these outcomes less durable than physical gains, returning to baseline at 12 months. Vocational outcomes were mixed, with some studies reporting return to work or education and others finding employment rates unchanged or declined at 24 to 36 months. Two studies even reported stable or increased receipt of disability benefits despite clinical improvement. The only occupational therapy-specific intervention study identified was an outpatient sensory-modulation programme reporting discharge gains in symptom severity, stress management and occupational performance, though most of its 77 participants also received concurrent therapies. The authors conclude that future research should clearly define and evaluate occupational therapy components, examine proposed mechanisms and treatment fidelity, and test defined interventions in robust prospective controlled trials, including in community and non-specialist settings.

Subject of Research: A scoping review mapping occupational therapy interventions within multidisciplinary rehabilitation for functional neurological disorder.

Article Title: Occupational therapy interventions for functional neurological disorder: a scoping review

Article References: Nicholson, C., Lorencatto, F., Yogarajah, M., & Nielsen, G. (2026). Occupational therapy interventions for functional neurological disorder: a scoping review. Frontiers in Neurology, 17, Article 1926640. https://doi.org/10.3389/fneur.2026.1926640

Image Credits: AI Generated

DOI: 10.3389/fneur.2026.1926640

Keywords: functional neurological disorder, occupational therapy, scoping review, multidisciplinary rehabilitation, movement retraining, sensory modulation, outcome measures, neurorehabilitation, occupational engagement, relapse prevention, vocational rehabilitation, Occupational