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Hello, everybody and welcome to the Neuro transmitters, a podcast about everything related to clinical neurology with the goal of reducing your neuro phobia. Uh I'm very fortunate today to be joined by Zachary Grin, a doctor of physical therapy uh with some unique focuses in his practice. Uh Did you go by Zach or Zachary? All right. Hey, thank you so much for joining me this morning. Um Would you mind starting us off just a little bit? How, how did you wind up? I know physical therapy is a very unique and attractive field, but what was it that brought you into it? Yeah. Yeah. Um Well, I wanted to say first thanks. Thank you so much for having me. I really appreciate this. Um Yeah, I, I really like the fact that I get to help people, but also I'm there for their like entire recovery journey really. So it's not, you know, 10, 15, 20 minute appointments and I'll see him again in a few months. Some of these people I'm seeing 34 times a week, sometimes once a week and I really like to be able to, to connect with people. Yeah, that, that is a very longitudinal aspect of care is, is certainly attractive. And I know at, at one point in my train, I was very attracted to the rehab side of things. But I got, uh I got drawn away to neurology at one point. But, so where did you start your training? Yeah, I, I graduated from Clarkson University. It's in upstate New York. Um That's where I got my doctorate degree. And then, um, do you want me to go into like afterwards? Yeah. So um I started working at a hospital system here in New York City for um a year about, yeah, about a year and working in, in the hospital outpatient. Um and then I decided to open up my own practice. You know, I know, uh you know, we kind of met online on Twitter and, you know, we've been kind of running in some of the similar circles in terms of like functional neurologic disorders and things may be adjacent to that. Now, you know, in my experience and probably I'm going to guess in yours as well. A lot of traditional physical therapy treatment plans may not be the best suited for, for those types of people. Um How did you initially kind of make the connection and then kind of tale your practice to that? Yeah. So I really started my practice for people with functional neurological disorders. So I kind of right off the bat. Um my business plan, my, my way of practice was tailored to this already. Um, when I was working in the hospital. Yeah, it was very different. Working with other patient populations. Um, the biggest change was learning to not talk so much to, to, to people. So we tend to really, um, want to help people, really do, like corrective exercise, make sure they're doing the exercises correctly. Good form. And, and we do a lot of education and talking in terms of the exercise and how people are moving their bodies. Um, that doesn't work for people with typically and, and it does make them worse a lot of the time. So, um, you know, unfortunately most of, most of the people I see with functional neurological disorders right now, I'm the 3rd, 4th, maybe even fifth physical therapist that they've seen. And they're always a little skeptical which is completely normal because they've just had so many, so many trials of this more because you can say traditional physical therapy, it's, I guess hard to define what traditional means. But, um, in the sense of this very body attention like focused, um, waste. Yeah. And how does, what kind of things have you found in, you know, both in the literature and in your own personal experience tends to work best. I know, you know, FND is kind of an umbrella term. Um, when we have so many different subtypes of it. Yeah. And, and it really does depend on the subtype and So for people with like a functional movement disorder, whether that's tremor a gate disorder, dystonia, um, it's really helpful to have this what we call like an external focus attention, an external attentional focus. And, um, that can be anything. Sometimes it can be like just thinking about it. Other times we're actually using stuff so I can, you know, tell somebody to imagine kicking a ball while they're walking. So someone with a functional weakness that can't progress, they're, they're lymph forward. If they are thinking about progressing that lymph forward, they're not going to be able to, and it tends to get stuck and it usually gets stuck in a very specific way, um which is a positive ruling sign for, for a functional movement disorder. But, um, that, that, that increased attention to it makes it not want to move. And so what I do is, for example, I'll have them, uh, think about kicking a ball forward and boom, that, that leg will just swing right forward. They're able, they're able to walk if they don't think about walking. Now, I might also put a ball in front of them and actually have them kick the ball too. It kind of depends on what equipment we have at the time. Um It depends on the activity but um yeah, very cool. So, so yeah, that, that does kind of mirror what we would think in terms it's more of like a task specific, uh kind of problem for, for many like the functional movement disorder, uh types of patient's at least. Exactly. Yeah. Test score. E ent ID goal oriented. It has to really be focused externally. Yep. Gotcha. And would you find that in your practice is mostly functional movement disorders or have you had other flavours of FND as well that you've been incorporating? Yes. So, um I've had some people with uh three PD or functional dizziness, persistent postural perceptual dizziness. Uh um Yes, it is three pds good. And so, uh Yep. And so that's uh so functional dizziness that, that definitely takes on, you know, the treatment principles are, are similar though. Um It does obviously look different um in terms of the dizziness. So, you know, we're looking at the stimular function, ocular motor function, some medicine serie function. Um and, and we're still having that external focus. Um Another one of the treatment principles is really like that I use is um like sensory input too. So a lot of times people find certain sensory input, whether that's waiting, vibration, um some type of tactile sensation um can really help kinda modulate their, their movements or even even dizziness as well. Um Yeah. And then, no, no, I'm sorry, just clear my throat. But uh you know, I, I find myself in a similar boat where, you know, I'll see these folks and, you know, you've, you know, you do your assessment, you do your dix Hallpike. Uh you know, all of your kind of gate evaluations and, you know, if someone coming, like you said, you know, I'm like the third neurologist they've seen for dizziness and like, well, you've kind of been through the Ringer and then you wind up and I'm sure these people show up on your, uh, treatment schedule as well where they're, you know, maybe they're on chronic benzodiazepines or, you know, meclizine for, I know it's the bane of my existence, like it, you know, doesn't even work that well, even if you're a legitimate vertigo. But, but you have all these people and then they, like you said, they kind of develop these maladaptive behaviors and um it's really hard to find, uh shouldn't say really, but it's, let's just say, challenging to find a, uh a phys skilled physical therapist who is, has more than one protocol for like dizziness if you will. Uh But um I know you mentioned some of things with like, like uh like ocular motor retraining. Does it depend on like, what kind of flavor? The dizziness manifests itself in with the three PD type folks? Yeah, it can be. And really, it's about like on the surface it doesn't seem all two different. But um like a typical, like retraining for like, um the singular ocular reflex and stuff is really just like sitting there finger held out in and you're turning your head back and forth, right? Like those types of activities it's still really body focused and you're looking at like a certain body part and, and so those types of things make people worse typically with three PD. And so it's more the same, we want to get that same type of input and that same type of training, but we want to do those things with like externally. So, um, that might be throwing and catching a ball that might be, um, you know, anything that really is kind of fun, but play fun is a really important part of it too that, um, you know, we're not just sitting there doing these, these exercises and, and they should be meaningful to the person. Gotcha. And I imagine those people have a lot of gait disability as well. Uh, typically, typically they do. Yeah. And it's typically a very, more like rigid, um, kind of some block, turning going on and really looking like they might fall over if they don't do that. Um, but there's that internal inconsistency where other times you won't see that at all. And the gates actually pretty good and pretty normal. But if I ask them to walk and do things, it starts to, they start to really tense up. Gotcha. How do you tend to help them overcome that in that particular patient population? Yeah. So that comes with a lot of education, lots and lots of education. Um, and with, without having a proper understanding of these functional neurological disorders, it's really, it's really hard to implement these other, um, treatment strategies. You have to really be able to explain the diagnosis to them and, and they have to really have a good understanding of that diagnosis. Yeah, it does seem, and this has been my experience, I'm just curious if you've noticed the same thing where, like you, if you are, say, you know, anyth number healthcare worker that they've worked with down the line and they've seen like all these doctors or other members of the treatment team who just say like, oh, well, we don't really know what's wrong with you when, and they kind of get like, pushed and pushed and pushed and they just kind of wind up not getting any help or getting maybe things that, you know, medications that aren't helpful or they put through physical therapy that again is more body awareness in necessarily the wrong kind of way. How hard is it for you to, you know, to basically explain things like this is what it is and this is a plan that has a good chance of helping you. Yeah, that's a great question. It really depends on the person. Um, and it can vary greatly. Um, yeah, you have to, you have to kind of gauge the person's reaction to it. Um, there are some people that their, that's just not where they're, they're at right now and trying to kind of force force it on them almost of like no, this is what you have like that. Just we're talking about people's beliefs and it's really hard to, to change that or influence that. Um, depending on kind of where they're at in their, in their stage of recovery. And so, um, there are some people that I just had to kind of refer back and said, I don't think, you know, physical therapy is the right, the right time right now because without that, it's really hard to also do these treatment strategies that we're going to be doing throughout, throughout the episode of care. And without, you know, somebody's full commitment, we're, we're talking about changing brain connections here, neuroplasticity. Like you have to be fully committed, you have to do this repetition after repetition all the time. And without that belief, it's really hard to, to do that. Um other people though, it makes perfect sense to them. And that's, that's the norm. Uh from what I've found that most people, it, they often tell me, I feel like I'm finally in the right place and that's like, really resonates with them and is what they've been looking for. Very cool. How now I know one of the things that we see a lot or at least hear a lot about in, in folks with different types of FND is if you, let's say you've gone through a successful treatment protocol with somebody and you know, like, like so many of us, you know, you kind of fall off the wagon with your exercise regimen? And how often are you seeing people coming back after like reemergence or kind of like doing like a re education session or things like that? Yeah. So I'll typically depends on the person, but I'll typically schedule maybe like a three month or even like six month follow up. Um, just to do like an evaluation check in, make sure, you know, everything is good. Um I find most people don't feel really confident after, after going through treatment because the whole idea is I'm giving them the tools that they need to self manage this and almost universally, that's been what people say is the most helpful thing. They feel a lot more confident in their and their ability to manage their symptoms and and it's all uh about regaining control because at its core, do FND is this kind of loss of self agency and in control. Um So you have to re establish that and once that, that starts to become reestablished, it's, it's life changing for people really. And they, they often are able to, to go on with life with that. That's awesome. Yeah, people underestimate how disability disabling uh some of these symptoms can be especially I think on the medical side of things or they're like, oh, you know, it's all just in your head, so to speak. Um So yeah, I mean, if you look at all the data, right? Like the number of days of work lost, uh you know, for, you know, functional or dissociative seizures. Uh The risk of morbidity and mortality is comparable to someone with refractory epilepsy. So it's, it's not okay just to kind of rush these, these people off, especially when there are legitimate treatment options that can help them get better. Yep. And I do always recommend the continue to, to follow up with typically. Uh the referring provider is usually for me, a movement disorder specialist. Um because we, we do want, we want you to know follow up of people with this just to ensure the diagnosis is stable, make sure nothing's changing in that regard right there is that, uh you know, there is data that s to and you know, again, these kind of poor, poorly defined nebulous groups, sometimes uh the numbers shift a little bit like anywhere from 10 to 20% of people with FND may also have a concurrent neurologic or other type of disorder. So, you know, you do have to keep your antenna up for something else, declaring itself down the line. Absolutely. Yeah. Now, now you said you work pretty closely with some of the movement disorder specialists in uh in New York City. Um How does, how does that relationship develop? I mean, other than being one of the only people who specialize in it and it's one of the biggest cities on the planet. Yeah. Yeah. Um, pretty much through the patient's, them themselves actually is where it started. So I, I kind of put my name out there on the FND Hope website and their, their provider look up tool. Um, and yes, I am the only physical therapist on there in New York City. So anytime people go to their, they do get me. Um, and so really have been connecting through, through the, to the referring providers through them. Um, and I've established a really good relationship with one of them at a large hospital system here. And um that's kind of spilled over to me now giving uh lectures on FND to their movement disorders, like multidisciplinary clinic. Um and even working with like a local Parkinson's Disease Foundation for people with functional tremors and with, with PD as well. Um very challenging population. It is. Yes. And you know, how did you go? Because I know the shift from like, you know, I work in a hospital primarily and, you know, I, I had one attending, he was a formal physical therapist before he went to medical school and he uh not so kindly referred to inpatient hospital PT as Ambu dragging. Um And you know, it is, there's a lot like you got to have some good upper body strength, especially for like those people who just had a stroke and things like that. But you know, how do, how does one go from that to kind of this much more nuanced practice that you've built. Yeah, it's very different and it, it's, it's still challenging. Sometimes I sit there and think, like, am I still doing PT, am I still pt like it because it just doesn't feel like that sometimes. Yeah, you get so used to hands on treatment and it's, and really you don't want hands on treatment for, for people with that can be, that's, that's the other big change that I didn't mention is, you know, this all has to be internally generated. I'm more of the guide in this and, and yeah, it's, it's challenging but you get comfortable with it and you also see that you are making a huge difference and that it's necessary to properly um provide these people with, with treatment. Awesome. So in terms of like, like I say a standard, you know, PT curriculum, you know, where does the management of FND come in or where did, where did you learn about it? I know in, in my own career, you know, we had some kind of surface level, you know, exposure to it, but a lot of it was not necessarily getting into the weeds in terms of like what do you actually do? How do you, you know, provide optimal care for these people? Yeah. Yeah. So in our Neurological section, uh PT school, we, we did some like students ran like presentations and, and one group had Conversion disorder. Um and this was only like two years ago. Really 23 years ago. And so, um I had looked at, I've heard of it before, like when I was on a clinical rotation to um at a hospital and, and a patient presented with, with functional seizures. But um so I started looking up a little bit more than, and I was like, oh, it's not really called conversion disorder anymore. And that was kind of the first time. Um And I even kind of spoke up during, during their presentation because it was all based on like the sm for criteria and it seemed outdated. Um And everyone's kind of like, okay, and, and then we kind of just like moved on. And so, um so I started kind of researching more and more about it and I found it fascinating and I'm like, why is everyone not fascinated by this? Yeah. Yeah. It's, it is, you know, kind of that, uh that stigma that's, that's stuck to it for over 100 years. Um But yeah, it's, it's like one of the most neuroplasty type things that that happens all the time. Uh It is, I agree with you. I, I do think it's, it's fascinating and you know, why don't, why don't we have better evidence? Uh It is just that dye that, that lag and interest in the medical community at large. But thankfully, that seems to be turning around at this, you know, the last couple of decades. Yes. So you mentioned functional seizures as well, which I have a personal interest in uh having worked in the epilepsy sphere. Uh a little bit more are their protocols on the physical therapy side that tend to help with, with those dissociative events as well. Yes. So officially, no, not really. Um The reality is most people don't have just one specific type of functional neurological disorder. I've Ellie's rarely, rarely have come across that. Um Typically people that, that I see that also have functional seizures also have like motor and vocal ticks as well. Um And even even a functional gate disorder, functional tremors, the kind of the whole, the whole thing. And so, um so I think we need to address that. I don't think you can really fully treat someone with just like just focus on this. This provider is just going to focus on that. I feel like all providers need to focus on everything I need to focus on the person really. And so, um so I've, I've tried some things out with, with, with people with um functional seizures. And um I have this patient right now, actually, they're doing so awesome. I'm so proud of them. They three weeks now seizure free and the first time in the year. Um and all it really took for her was to really identify um this like pre like sensation that, that she typically gets before, before having a seizure. Um And then we use a distraction technique. So distraction just not that external focus but also distraction away from the symptoms. Um, and so I kind of work with them on things that are that they like to do. And she likes to whistle. We noticed, you know, when we're working on gait training, whistling completely result her, her gait disorder in that moment when she's whistling. So she, she went out on her own, bought a whistle that she wears around her neck when that, you know, sensation comes on that she's about to have a functional seizure. She starts whistling a tune with it and she's totally able to, to suppress it and, and not have it occur. Fascinating in terms of that. That is very, I, cause I think back to, um, a patient I had, uh, in my, my previous practice before I moved and, you know, she had a diagnosis of pots, uh, you know, floridly positive, you know, occasionally needed to use a wheelchair when the flare ups were particularly bad. But, um, but she came to me for spells and so I, I brought her into the epilepsy unit and, you know, we, we captured some spells and, you know, they were, uh, it was kind of like, uh a pseudo syncope, quote unquote if you will and you know, with I fluttering and all that kind of stuff and, you know, we did have a recumbent just to make sure that, uh, you know, we weren't seeing any drops from the pots or things like that and BP. But, but she ended up sticking with me, uh, for her pots and, you know, I, I had some exposure to it in training but I, I'm not necessarily an autonomic specialist per se. Uh, it was more just that I, I tried to learn more, uh, which, you know, unfortunately for, for so many doctors in particular it's, um, not something everyone gets very siloed, you know, a little bit balkanized and they're not really wanting to step outside of that area. But I, I was fortunate I did have a little bit of training in my fellowship. So I was able to maybe stick my toe into the water a little bit. Uh But, but yeah, sometimes some of the things that you do, like you said, they're, the evidence isn't necessarily there in terms of the treatment strategies. Um So you're, you're always kind of strategy that line between I want to help this person, but I also don't want to necessarily be too aggressive and potentially cause harm to them. And that, that becomes sometimes a bit of a dicey line. Yeah. And I think that's where communication with the rest of the healthcare team is also really important too. So, um you know, typically the gold standard treatment for people functional seizures, usually psychotherapy. Um And so I, I speak to every person's psychotherapist, we, we kind of sit down and have a talk and um none of them have ever heard of a Fendi and even like conversion disorder weren't even really like too familiar on that, which I was surprised about. So I'm typically sending them resources literature and, and everyone's been super open to learning more about it, which has been great. Um But yeah, I think that's kind of pulling in the other team members becomes really important in that case. Yeah, and that is something that I also find somewhat surprising is that our, our colleagues more on the mental health side of the care spectrum, you know, it is, you know, conversion disorder from the DSN for FND. Now, uh it's not something that necessarily have a lot of experience or exposure to treating that and that always just boggles my mind like I see it all the times like do these and uh like, I, I can only imagine that because, you know, to your earlier point, do they have the insight? Do they have the understanding of the diagnosis? And if the person who diagnosed them making air quotes here uh did not communicate that effectively, then they're like, I don't have, you know, functional neurologic disorder, I have some unexplained rare disorder that I need to undergo further testing for because this doctor didn't figure it out and I find that that's all too common. Very, very common. Yes. So I'm hoping to change that with, with, with educating others and, you know, I have no problem, you know, explaining the diagnosis a lot. Like that's, uh, one of my favorite parts actually is really educating on it. But, you know, uh these things need to be reinforced over time to, for, for some people and having all team members, you know, be at that level of being able to really effectively communicate. That is super important. Absolutely. Yeah, a concordant message amongst all the team is good. You don't want to go to your, your psychiatrist or therapist and be like, I think they're missing something uh that really undermines the process. Does that happen to you? I imagine it's happened once. Yes. Yeah, it's really, really difficult. It does. Um But on the other side, how often have you gotten a referral um from, let's say, you know, outside of your usual referral base in the movement disorders community. And you're like, I do think there's something else going on here and you send them for a second opinion somewhere else. Yes, I love that. And it happened a couple of times when I was working at the hospital actually. Um and that was, that was pretty frustrating to be honest too because um hospital systems tend to uh look at pt from a lens of like, just kind of taking orders and just doing exercise and like, not really being an independent clinician that has a doctorate level education that, that does, you know, have the knowledge and capacity to do this initial like differential and really our job is to make sure like that the diagnosis is correct when, and this goes across anybody, any type of condition, like you have to make sure it matches up and if you're seeing signs and symptoms that that could suggest something else, you need to get that person to the appropriate uh, physician for, for further uh investigation. And so, yeah, I've, I've had a couple of people where mostly after surgeries to is the big one of these, you know, long history of abnormal unusual movements that nobody's there. Kind of just going through the healthcare system, every appointments kind of like the patient's talking about their symptoms, the providers like, okay, you have these, maybe you do this test or go see this person, see me in three months and then it like just keeps repeating and you just get people that have been doing this for years and years and years and, and to be able to catch that then and be like, okay, these are distractible that tremors in trainable that like all of these things that, that, that rule in this diagnosis and then being able to get them to, to a movement disorder immunologist is that's also one of my favorite parts to have. Think. Uh I, I love that. Yeah, I think I remember seeing some study that was, it was approximately somewhere like 20 to 40% of referrals to movement disorders. Clinics end up being like functional movement disorders, which to be fair, you know, in the epilepsy clinic, it's comparable um in terms of being non epileptic events of some stripe or another. So it, that's what I always tell people. Like, you know, uh have you ever seen this before? I'm like, yes, all the time. Uh but that's okay, you know, there's a different treatment plan we need to, you know, especially like if they're on a bunch of meds, like, for tremor, like, you know, on barbiturates, like Primidone, uh, which is just making them super sleepy and probably worsening, like any sort of dissociative type features they might have. Uh, yeah, cleaning up that medication list is, like you said, it's a very satisfying piece of it sometimes. Yes. And, uh, yeah, and I'll even kind of refer people back to, uh, to their physician to, to kind of talk about treatment because most people say, like, I'm on all these medications and I think they're all just making me worse and I'm like, they probably are, let's get you to someone that can help you figure that out more. Yeah, that, that is a very challenging piece. Um, it, yeah, there's, there's a lot of, let's just throw a medication at it and see what happens, which, you know, in the first couple of visits maybe, you know, but eventually it's like, it's not working well, maybe we just need more medicine. And that's, yeah, I, I can see the conundrum, uh, if you're not super familiar with some of these problems, but, but it does become frustrating on the, when you come in at the tail end and you're like, oh, this is just a disaster. And, uh, yeah, like you said, the education, the, because a lot of these, you can't just stop cold turkey, you gotta kick them down nice and slow. So you don't put someone in withdrawal. And, um, yeah, it's, it's a whole process getting that, that in from your perspective, like when you take on a new client, uh what's a typical like let's just say someone with like a a functional tremor um approx remedy. What's a typical treatment protocol or like types of sessions? Like how many sessions do you typically do before you usually start seeing improvements in an average person? So one of the great things about functional movement disorders are you can start seeing improvement day one and really that, yeah, and so on, on that initial evaluation day, like one of my main goals is to show this person that they do have the capacity for normal movement and they, and they do have some control over it. That is one of the most important things. Um And that's typically possible. I mean, most people are we're able to do that. So whether that's even just pointing out to them, you know, when, when we're doing some type of activity that, oh, look your, your tremor is gone, right? Now, like, it's completely gone and a lot of times people have difficulty recognizing that unless it's brought up. And I think caregivers and stuff, family members, sometimes they're either hesitant because they don't wanna make it seem like they're telling the person, like, you don't have a tremor, like, you know, you have the tremor one time and now it's like you're doing all of these things without it. They don't want to do that or the opposite end of that. They really hound the person and are like, really, like you can do it, just keep doing it, like stop with the tremor and stuff. And so, um for me to be able to show them that and explain why that is and that's really the important piece, it's not just like they can do that because they probably do at some, you know, certain level do know that it's not all the time, although it does feel like that often to them. Um They don't know why that is, which can be really confusing and being able to explain that um in a way that makes sense to them. Um is really that that light bulb moment and try to get that on that first visit um of starting to normalize movement. But, you know, and then, you know, over a couple of weeks you start seeing that people are because that's the I we we end that visit with them doing that now for the rest of the week. So it's all about that, that repetition, that practice. Um And over a couple of weeks they start getting the hang of it, they start implementing these things more and more. Um And really, it's about using these strategies like during just everyday text, not even necessarily like sitting down, you know, 30 minutes carving out that 30 minute time for, to do your exercises. Like, no, this is you're doing this every day all throughout the day. Um, I use things like, um, headlamp laser pointers to kind of focus somebody's attention on something, um, while they're washing the dishes which allows them to do the dishes without their tremor anymore. Um, putting a cup down on coasters if they're focusing on a coaster, that's a similar sizes, like the bottom of a cup. So they really have to, like, focus on that. It's a task really. And it's a goal, um, and having those all throughout the house. And so it's, it's more about modifying that environment and then doing it all the time. Sounds like a lot of creatives. I've problem solving has to go into, uh, these types of assessments for FND in particular, constantly every time and it's always different and that's why I love it too. It, it really does get you thinking and no one's the same. Yeah, that's never gonna get your board. I bet. Uh, so you do home home assessments as well? Yeah. So I actually do primarily home and we'll actually really, I'm kind of more telehealth right now. Um, which is nice for me but because I do see people quite far away. Um, like even on Long Island, upstate New York, um, and even I'm licensed in New Jersey to, so I'll also see some people in New Jersey. Um, and, yeah, and the great part about this is it doing telehealth works pretty well also. Um, and we use just everyday household items. But, yeah, that or, or if they're close enough I'll go to the home and, and typically, then we'll kind of transfer to, to telehealth over time. Nice. Now, do you find it? Is it usually just the, the client themselves or do you usually have like a family member or close friend with, like, in the room with them as well in case there is any need for hands on type thing. It depends. Some people don't want the family member like there at all, which is understandable, depending on their relationship, other people. Yeah, tell them we really, I don't think I can do telehealth unless, unless we have somebody there. Um, so that, that's variable. But, um, it typically works out. Yeah. Excellent. So, I, I imagine being, uh, the only person specialized in this, in such a huge environment, uh, your schedule is probably pretty fold up. Right. It is. And, yeah, I don't know what to do from here. I'm like, we need more people doing this. So, just, and I know you said you've been doing lectures for, like, local, local groups. Uh, are you part of the faculty at any of, like, the local PT programs? I am not. And I have some been in the back of my mind and it's something I would, I would really like to do. Awesome. Yeah, it's, it's definitely a very, uh, in demand population. Certainly. Um, any, uh, any hopes to bring on more associates into your practice in the near future, maybe we'll see. Yeah. One of the things is I really have to trust them that they're, they're going to know like, what to do. Um, so, so we'll see if that's definitely not out of the question. Awesome. Yeah, I know. It's, uh, it is hard to bring on people when, when you built a practice that is just to call your baby if you will and you have the way that you do things, especially when they're, then you have, like you said, you kind of had to go out and learn and figure out what, what works and doesn't, to a large extent. Um, yeah, that's amazing. It's, it's really great. And for people in, like, say other parts of the country, how can one go about finding, uh, someone with, like, a physical therapist or occupational therapist or what have you, who is, uh, more focused on, on FND in its various types? Is there any good resources out there. Not so much. Um, there's not a lot but, you know, I, I really like the F and G Hope website. Um, their, their provider tool. Um, typically people, people will be on there. Um, there's also the F and G Society, uh, they have a directory as well and so people can go on there and, and look people up also. Um, we're hoping in the near future here to have a special interest group in the Academy of Neurological Physical Therapy to um for, for FMD um because it doesn't really fit any of the other ones. And so, um hopefully we, we start getting that up and running and hopefully start putting providers on uh provider portal also. Awesome. Has there been any wider advocacy within the PT community in terms of FND and like increasing its education in the curriculum? Yes. And one of the, the biggest leaders in that is a practice out in Los Angeles, reactive therapy and wellness. Um The owner is Julie Hirschberg. She's an amazing physical therapist. They're all amazing PT ot neuro psych. Uh They do a lot of education for healthcare providers and for patient's. Um they have uh online mentoring community that I'm a part of two and that's been a huge child. So for anyone that is wanting to do that, I like highly recommend having mentoring about people who have been doing this, you know, for a little bit longer. And um yeah, they're a great resource for patients and providers. Yeah, I do get their, uh, email newsletter, which is, like you said, it's quite nice. Yeah. Um, if people want to or I should ask any, any final thoughts things, uh, like, say for patient's or for other physical therapists out there and if they encounter these patient's, um, what should they be thinking? Like, let's say they get someone who's sent for tremor and then, like, I think they might have a functional tremor. Uh How would, uh let's say a therapist and, you know, I'm in a pretty ruhr away area where there might not be like, well, there isn't, uh within 60 miles, there's no movement disorder specialist. What would they do for, for someone in that situation? That's a good question. Um It would be really about finding a provider that's, that's open to learning more about it. Um And, and working with them even if they don't have, you know, this extensive knowledge in it. Um, listening, acknowledging validating is, can go a really, really long way um, with people that have gone through so much and I are currently still going through a lot. Um And it's kind of sometimes hard to find and so finding a provider that, that is able to, to do that and work with them would be the first step and seeing if anything, you know, it is, if it's gonna work, if not, some people do have to, you know, go out of state and go to some of these bigger, um, clinics like at, uh, Mass General or Stanford, um, Mayo Clinic. Um, and sometimes that is an option for people. Gotcha. And, you know, conversely, let's say that you're, you know, someone with a, let's say, some sort of movement disorder and you've been, been told it's potentially functional you're going through, let's call it, like you said, standard traditional physical therapy and it's not helping or it's making it worse. Um, how is there any way that, uh, the patient themselves can identify that this isn't helping as much as it should be? Yeah. I think being, you know, directly open with your physical therapist and physician, your, your whole treatment team that, you know, something's not right here, something isn't working and, and I want to try something else. Can, can you help me with that? Um, is that, that can go a long way to, I think, you know, it's, and it's, that's hard to do and also, you know, um, from a patient perspective that, that can be a very challenging thing. Right. Right. Yeah, there is that, you know, power dynamic to a degree which, you know, sometimes, yeah, if you get a cranky, uh, healthcare provider and they're just like, well, maybe you just need to see somebody else unfortunately, which is not an uncommon situation. Um, but yeah, I think it all comes back, uh, having more than one tool in your toolbox is, is really essential for, for these types of people. Absolutely. And there are, I forgot to mention there are expert consensus guidelines to for, for PT for ot for speech um uh for, for functional neurological disorders. There's also, you know, some summaries on psycho therapies for people with FND. And so, uh those are also really, really good resources to look up. Excellent, excellent. Well, if people want to find you online, where should they look for you? Yeah, they can go to my website Rewire hyphen pt dot com. Um They can reach out to me through there. Um Hopefully I'll be once I get some time, hopefully updating that and getting some more content out. Um Also follow me on Twitter and Twitter is Zachary Grand DPT uh on my Instagram is rewire PT. Um Yeah, and I hope to be providing a lot of content out there to, to start educating more and more people. I've, I've certainly found your treatment videos fascinating. It's not something on the opposition side that I get to see in person very often. So it's, it's always amazing to uh to see people who, you know, like you said, we're having so many difficulties with something as simple as walking a flight of stairs doing I thought that one that the one where you had the young woman walking down the flight of stairs. Quite amazing. That was, that was great. Um She's doing awesome. Yeah. And do people need a referral to come and see you or do you take self referrals as well? So, in, in New York people can come to me and I can do an evaluation but then to, to treat, we do need, uh, I do need a referral, um, but people can just reach out and I can get them scheduled and then I work with them to, to work with their physician, whoever it may be. Um Sometimes it's just a primary care um to get that referral. Well, thank you so much. I really appreciate you taking the time to talk with me. This has been very educational for me as well. Uh You know, it's such a unique niche, especially in the physical therapy sphere and uh I really appreciate it. Yeah. Yeah, I really appreciate you for having me. Thank you so much. Thanks. Thank you everyone for listening. If you enjoy this podcast, please rate review and share it on Apple Spotify or wherever you get your podcast and please subscribe for future episodes. You can reach me on Twitter at Doctor Ken Trees, that's Drkentris or by email at the Neuro transmitters podcast at gmail dot com. With any questions or show suggestions. We'll see you all next time.