Agency, Learning, and Your Own Adaptations

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For the Person With FND
For Family, Friends, and Other Supporters
For Clinicians and the Care Team
Research and Sources

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For the Person With FND

But I didn’t mean to do that!

Amira is standing at her kitchen counter, reaching for a glass of water. Her hand moves toward the glass, just as she intended.

Then her arm suddenly jerks, and the glass rattles against another cup.

Amira stops and looks at her hand. She wanted to pick up the glass. She certainly didn’t want to knock it sideways, and yet her arm moved.

Now imagine something slightly different.

Daniel is standing near his front door. He wants to walk into the garden and knows exactly where he’s going.

But when he tries to take a step, his leg doesn’t move as expected. He tries again, with the same result.

The intention is there, but the movement isn’t cooperating.

Amira experienced a movement she didn’t choose. Daniel couldn’t carry out a movement he wanted to make.

Both experiences raise an interesting question.

What happens when what we intend and what our bodies actually do don’t match?

That brings us to a new idea.

What is intention?

Imagine you’re sitting on the sofa and decide to stand up and get a drink.

You have a goal: you want to get to the kitchen.

Usually, your body carries out all kinds of movements without your having to think about each one. You stand, turn and walk without telling every muscle what to do.

Intention: What you mean or plan to do. An intention can guide an action, even when the action doesn’t happen as expected.

Think back to Daniel.

He intended to walk into the garden. He knew what he wanted to do, but his leg didn’t cooperate.

That doesn’t mean his intention disappeared, and it doesn’t mean he wasn’t trying.

Wanting to make a movement and being able to make it are different things.

The same distinction can matter when someone intends to answer a question but can’t find their words, or wants to continue an activity but becomes unable to do so.

We’ve encountered this throughout our course. But there’s another part of movement we haven’t fully explored.

How do you know that you made a movement happen?

Imagine raising your hand to wave at someone.

You decide to wave, your hand moves, and it feels like you made it move. That feeling is so ordinary that we rarely stop to notice it.

Now imagine someone gently lifting your hand for you.

Your hand still moves, and you can see it happening. But it doesn’t feel the same. You know someone else made the movement happen.

Scientists call this feeling the sense of agency.

Sense of agency: The feeling that you are making an action happen, rather than simply experiencing the action.

Let’s return to Amira.

Her arm jerked as she reached for the glass. She saw the movement and knew it was her arm, but the jerk didn’t feel like something she chose or caused.

Her experience of making an action happen didn’t match what her body did.

This distinction helps us understand why someone can say:

“My arm moved, but I didn’t make it move.”

Both parts of that sentence can be true.

Isn’t that just the same as controlling something?

Not quite.

Imagine learning to type. At first, you have to search for the letters, look down at the keyboard and deliberately choose which finger to move.

After enough practice, typing becomes easier. You begin writing sentences without thinking about every finger movement.

Your fingers are doing something you intended, even though you’re no longer paying attention to every little action.

We do many ordinary activities this way, including walking across a familiar room, reaching for a cup and brushing our teeth.

Some of these actions feel almost automatic, but that doesn’t mean they’re involuntary symptoms. Your nervous system has simply learned to carry out familiar movements without requiring your full attention.

We don’t need conscious control over every small movement to carry out an intended action.

And feeling in control isn’t exactly the same as how much control we actually have.

This is why scientists separate our intentions, our movements and our experience of making them happen.

What might be different in FND?

Return to Amira.

She wanted to pick up the glass, but her arm moved unexpectedly. The unwanted movement didn’t feel like something she had decided to do.

Daniel’s experience was different. He wanted to step forward, but his leg seemed unable to carry out the movement.

For people with functional movement symptoms, experiences like these can be deeply confusing.

Ordinary movement usually feels natural. We expect that when we decide to move, our bodies will cooperate.

So when movement becomes unreliable, it’s natural to wonder why.

Scientists have investigated whether the brain processes involved in preparing movements, carrying them out and recognizing them as our own may work differently in some forms of FND.

Some studies have found differences in brain activity and the experience of control among groups of people with functional movement symptoms. These findings offer clues about how movement and our feeling of controlling it are connected. [1][2]

But they don’t establish one explanation for everyone’s FND.

There also isn’t a simple brain scan or sense-of-control test that can explain why one person’s hand jerks or another person’s leg becomes weak.

An altered feeling of control is a real experience, but it isn’t a diagnosis or a complete explanation by itself.

We can learn from the research without assuming it has answered every question.

Can movement change without someone choosing the change?

Daniel has an appointment with a physiotherapist.

He explains that walking has become difficult. His leg often feels stuck when he tries to step forward.

The physiotherapist asks about different activities. Are there times when his leg moves more easily? Does changing the activity make a difference?

During the examination, the therapist notices that Daniel can carry out certain movements more easily in one situation than another.

Why would that interest the therapist?

Imagine trying to remember the words to a familiar song. You struggle when asked to recite them, but when the music starts, the words become easier to remember.

The information wasn’t necessarily gone. Something about the task changed how easily you could use it.

Movement can also be affected by how an activity is organized, what we’re attending to and what we’re trying to accomplish.

For some people with functional movement symptoms, an ability may become easier to use when the task or focus changes.

This is one reason clinicians examine movement in different ways.

They aren’t trying to catch someone pretending. They’re looking for information about how the nervous system is working and which approaches may help.

A movement becoming possible in one situation doesn’t prove that the person could have done it at will in another.

Not every person with FND experiences these changes. Clinicians still need to make a careful diagnosis using appropriate findings, medical history and examination.

But if my brain can do it sometimes, why can’t I just make it happen?

Daniel was able to move his leg more easily during part of his examination.

Later that afternoon, walking is difficult again. He remembers what happened at the appointment.

If I could do it there, why can’t I do it now?

He tries harder and concentrates on his leg, but the movement doesn’t become easier.

Now he’s frustrated. He begins wondering whether he’s doing something wrong.

But think back to our earlier lessons.

Not every process in the nervous system is under conscious control. We can decide what we want to do without being able to command every part of how the action happens.

An ability becoming available under one set of conditions doesn’t mean we can reproduce those conditions whenever we choose.

Being able to move during one activity isn’t the same as being able to switch a symptom off.

Trying harder isn’t always the most useful response. A different approach to the activity may be worth exploring with an appropriate therapist.

What does learning have to do with this?

Imagine learning to ride a bicycle.

At first, there’s so much to think about. You need to balance, steer, pedal and watch where you’re going.

It feels as though every movement requires effort.

After enough practice, some of those movements become easier and more automatic. Your nervous system has learned.

Learning doesn’t only mean remembering facts. It also involves changes in how we carry out familiar activities.

Scientists call the nervous system’s ability to change with experience neuroplasticity.

Neuroplasticity: The nervous system’s ability to change and adapt through experience, learning and other influences.

We discussed learning earlier in the course, and we’ll explore rehabilitation and neuroplasticity much more in Module 9. For now, the important idea is that learning a new way to do something doesn’t always require consciously controlling every part of it. [6]

In FND rehabilitation, therapy may help some people practise meaningful movements in situations that make them easier to carry out. Over time, practice may help those movements become more reliable.

Learning and rehabilitation can be complicated. They may require suitable professional guidance, time, changes to activities and attention to other health conditions. Improvement also varies from person to person. [5]

What might rehabilitation look like?

Let’s visit Daniel again. He wants to walk into the garden. That’s his goal—not passing a movement test or proving he can walk normally for a few seconds. He wants to enjoy being outside.

His physiotherapist can use that goal to guide rehabilitation. They may work on safe ways to practise walking, focusing on the activity rather than repeatedly checking every movement.

The therapist can adjust the task to Daniel’s abilities and make sure the practice is appropriate for his balance and safety. Progress might mean walking more reliably, managing a familiar route with less effort or finding a different way to reach the garden when walking remains difficult. [5]

The goal belongs to Daniel. The treatment should help him work toward it.

And using a mobility aid or another adaptation doesn’t cancel out progress. Being able to participate safely matters, even when symptoms haven’t disappeared.

Does the same idea help Amira?

Remember Amira and the glass of water? She’s become cautious about reaching for things because her arm sometimes jerks unexpectedly. At home, she begins using a cup with a lid. It doesn’t change the cause of her symptoms, but it makes spills less likely.

Now she can carry a drink with more confidence.

If she works with a therapist, they might explore safe activities involving reaching, grasping or using her arm in everyday tasks. The activities would need to fit her particular symptoms and abilities.

Amira has two possible goals: making her movements more reliable and managing daily life safely while working toward that improvement. Neither goal has to wait for the other.

Recovery work and practical adaptations can happen together. When improvement is limited or slow, useful adaptations can still make life better.

What does responsibility mean when a symptom isn’t chosen?

Let’s return to Amira’s unexpected arm movement. She didn’t choose the jerk or intend to knock the glass. Does that mean there’s nothing she can do about the situation? Not necessarily.

She can make reasonable decisions about safety, such as choosing a cup with a lid or asking a clinician about treatment options.

But those decisions are different from choosing whether an involuntary jerk happens.

Now think about Daniel. He didn’t choose for walking to become difficult, but he can still have preferences and make decisions about his care.

He may choose which goals matter most, consider whether a proposed treatment suits him and ask for help when he needs it.

Responsibility: In this lesson, making reasonable choices about safety, care and participation where choices are available—not being blamed for symptoms we cannot simply control.

This distinction matters. A person can take part in recovery without accepting blame for having FND. Someone who cannot make a particular adaptation, access therapy or prevent an episode has not failed.

Having choices about how we respond doesn’t mean having complete control over what happens to us.

Can I use what I’ve learned to make my own adaptations?

We’ve spent several lessons exploring how our nervous system works. But you don’t need to become a scientist to benefit from them.

Think about one ordinary activity that matters to you, such as preparing a meal, visiting a friend, reading, walking outside or communicating with someone.

Now imagine that part of the activity has become difficult. You don’t have to identify the exact brain process responsible. Instead, consider what you’re trying to do, which part has become difficult and whether a safe change or some help could make it easier.

Let’s try this with Amira. She wants to enjoy a drink at the table without worrying about spilling it. A cup with a lid helps. Later, she discovers that keeping the cup on a stable surface makes reaching for it easier.

Does this prove which brain network caused her jerks?

No. But it gives Amira a better way to participate in an activity that matters to her.

Now consider Daniel. He wants to spend time in the garden. On days when walking is difficult, he may use an appropriate mobility aid or another safe way to get there. On other days, he may be able to walk more comfortably.

He doesn’t need to ignore the difficult days or prove anything on the easier ones. He can work with what’s available while continuing appropriate care.

What if an adaptation doesn’t help?

Imagine Amira trying a different cup. She discovers that it’s awkward to hold and makes drinking harder.

Does that mean the idea of adaptation has failed? No. It means that particular change wasn’t useful for her, so she can leave it behind.

An adaptation is a tool, not a test. Something helpful for one person may be uncomfortable or impractical for another, and what helps today may need changing later.

We judge an adaptation by whether it improves something meaningful—such as safety, effort, independence or enjoyment—not by whether it proves a theory about FND.

That gives us a practical way to use what we’ve learned. We can stay curious without constantly monitoring or testing ourselves.

What about other kinds of FND?

We’ve focused mainly on movement because it’s an easy way to understand intention and the sense of agency.

But the difference between wanting to do something and being able to do it matters elsewhere.

Remember Jamie from Lesson 22? He wanted to answer Alex’s questions. When his thinking or speech became difficult, his intentions hadn’t necessarily changed.

Someone experiencing a functional seizure may want to remain aware and responsive but find that they cannot.

A person with functional cognitive difficulties may want to remember an important conversation and still be unable to retrieve it later.

These experiences aren’t all the same condition or mechanism. Their assessment and treatment may be quite different.

But the broader distinction remains useful:

The ability to do something does not always match the intention to do it.

Understanding that can help us describe our experiences more accurately and seek the right support.

When should I ask a clinician for help?

Imagine Daniel noticing that his leg weakness has changed significantly and no longer resembles his usual symptoms.

Or Amira develops a new problem affecting her ability to use her arm. They shouldn’t simply assume that every change is FND. New, sudden or substantially changed neurological symptoms need appropriate medical assessment.

When symptoms fit an established diagnosis, clinicians can help identify safe rehabilitation and meaningful adaptations.

A physiotherapist may help with functional movement and walking, while an occupational therapist may help with everyday tasks and accessibility.

Other professionals can become involved when particular symptoms call for their expertise. You don’t necessarily need a large team. The important thing is that the help fits the difficulty and your circumstances.

What have we learned?

We began with Amira reaching for a glass of water. She intended to pick it up, but her arm moved unexpectedly. Then we met Daniel, who wanted to walk into his garden but found that his leg wouldn’t cooperate.

Their experiences helped us understand three different things.

Intention: What we want or mean to do.

Sense of agency: The feeling that we’re making an action happen.

Ability: What we can actually do at a particular moment.

These don’t always match.

We’ve also learned that many ordinary actions become more automatic with practice, and that rehabilitation may help some people improve movement through suitable activities.

But learning isn’t proof that symptoms were chosen, and improvement isn’t something anyone can simply command. Finally, we’ve learned that responsibility doesn’t mean blame.

We can make reasonable choices about care, safety and meaningful activities while recognizing that involuntary symptoms aren’t entirely under our control.

Something to think about

Remember Amira reaching for her glass and Daniel wanting to walk into the garden. Is there something you want to do that your body doesn’t always cooperate with? What are you trying to do, and what actually happens? You don’t need to work out which part of the brain is involved.

How might that feel?

If the symptom stayed for now, what part of the activity would you still want in your life? Perhaps it’s enjoying a drink at the table, getting outside, or spending time with someone. Would doing it a different way still feel like progress to you?

One small step

Think about one way to keep that important activity within reach. A stable place for a cup, a suitable mobility aid, more time, or a question for your therapist could be a start. You may already have found a change that helps. It still counts, even if your symptoms haven’t improved.

Where do we go next?

In Module 7, we’ve learned how our nervous system prepares for actions, receives information, gives some things priority and responds to emotions and changing demands.

We’ve also learned why thinking, intention and movement don’t always work together as expected.

But understanding how these systems work is only part of living with FND. We also need to describe our symptoms clearly, recognize important differences and find reliable information about our own experiences.

That’s where we’re going next.

In Module 8 — Recognizing Symptoms and Finding Information, we’ll learn how to put those experiences into words and use the Reference Library to explore diagnosis, safety and recovery options without needing to become our own doctors.

Optional crossword

Revisit the lesson with a crossword. The easy edition includes a word bank.

Optional colouring activity

Open the Lesson 23 colouring PDF (new tab), or browse the colouring collection.

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For the Person With FND
For Family, Friends, and Other Supporters
For Clinicians and the Care Team
Research and Sources

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For Family, Friends, and Other Supporters

When someone wants to do something but can’t

Martin and his brother Lewis have played cards together for years. Every Friday, they get together for a few games, usually with plenty of joking and friendly competition.

Martin has FND, and recently his hand movements have become unreliable.

Tonight, he’s trying to shuffle the cards. He picks up the deck, separates it into two halves and begins bringing them together. His hand starts trembling, and several cards fall onto the table.

He tries again, but the same thing happens.

Lewis offers to shuffle for him, but Martin wants to try once more.

A few minutes later, Martin reaches across the table and picks up his drink without difficulty.

Lewis notices. He doesn’t say anything, but he’s puzzled.

If Martin could pick up his drink so easily, why couldn’t he shuffle the cards?

Martin is wondering something similar. He knows how to shuffle. He’s done it thousands of times. But knowing what he wants his hands to do and making the movement happen have become two different things.

Wanting, doing and feeling in control

Think about how easily we usually move.

You decide to pick up your phone. Your hand reaches toward it, your fingers close around it and you lift it. You don’t have to consciously plan every little movement.

And when your hand moves, it feels like you made that movement happen.

Scientists call that experience the sense of agency. It’s the feeling that we’re causing our own actions.

Researchers have found differences in brain activity associated with the experience of control in some people with functional movement symptoms. This has helped scientists investigate how intended movements and the experience of making them happen may become disconnected in FND. [1][2]

Imagine how strange that could feel. You want your hand to remain steady, but it begins trembling. Or you want to take a step, but your leg won’t cooperate.

From the outside, someone sees the movement or the difficulty moving. From the person’s perspective, there’s an additional experience: their body isn’t responding to what they intended to do.

Not everyone with FND experiences the same change in their sense of control. But this research helps us understand why someone’s intentions, movements and experience of controlling those movements are worth considering separately.

Why can the same movement look different?

Let’s return to the card game.

Lewis saw Martin struggle to shuffle, then pick up his drink quite comfortably. It’s natural to notice the difference.

But those two activities aren’t identical.

Shuffling requires several carefully coordinated finger movements. Martin has to hold the cards, control their position and bring the two halves together.

Picking up a drink is a more familiar movement with different demands.

Someone with functional movement symptoms may find that certain activities are easier than others. Sometimes an ability changes when the task, surroundings or focus of attention changes.

The nervous system performs many familiar movements automatically. When that coordination becomes unreliable, concentrating harder doesn’t necessarily restore it.

And successfully completing one movement doesn’t mean someone can repeat it whenever they choose.

Seeing what someone’s body can do in one situation doesn’t tell us how much control they have over their symptoms in another.

That’s worth remembering when an ability seems to come and go without an obvious explanation. The change may be just as confusing to the person experiencing it.

When helping changes the experience

Lewis wants Martin to enjoy their usual game.

He could simply take the cards and shuffle them himself. Perhaps Martin would appreciate that.

But perhaps he would feel disappointed. He was already frustrated that his hands weren’t cooperating, and now his brother has taken over something he wanted to do.

Lewis might not realize how that feels. After all, he’s only trying to help.

There’s another possibility.

“What would you prefer?” he asks. “I can shuffle, or we could try that card shuffler you bought.”

Martin laughs.

“I forgot I even had that thing!”

They find the shuffler in a cupboard.

Martin decides to give it a try. If it works comfortably, he can still manage the deck and enjoy playing. If it doesn’t, Lewis can shuffle while Martin takes part in another way.

The important difference is that Martin has a choice.

The movement may not be under his control, but his preferences still matter.

An adaptation isn’t giving up

Some people worry that using an adaptation means they’ve stopped trying to recover.

But making an activity easier and working toward improvement aren’t opposites.

Imagine Martin finding that the card shuffler works well. He still has functional movement symptoms, and his hand may tremble during other tasks. Yet he can enjoy something that matters to him.

If Martin later works with a physiotherapist or occupational therapist, they may help him explore activities that support more reliable movement or develop useful practical adaptations.

Our nervous systems can change with learning and practice. Scientists call this neuroplasticity, and rehabilitation may draw on that ability to help improve function over time. [5][6]

But learning doesn’t mean someone should be able to command an involuntary symptom to stop. And an adaptation doesn’t have to disappear just because someone’s abilities improve.

Being able to enjoy an activity with a useful adjustment is still a meaningful achievement.

Sometimes it’s the offer that matters

There’s a lovely example of this principle in an account from the FND community.

A spouse described offering to accompany his wife to medical appointments:

“I always offer and then it’s her choice if she wants me there or not.”

Figure 1. Community experience — spouse of someone with FND. Original public discussion. [4]

It’s such an ordinary gesture, isn’t it? He’s available if she wants him there, but he hasn’t assumed that she needs him at every appointment.

The same idea applies to Lewis and Martin.

Sometimes Martin might appreciate his brother shuffling the cards. Other evenings, he may want to do it himself, even if it takes longer. Perhaps on a particularly difficult day, he’d rather Lewis handle the cards entirely.

Lewis doesn’t need to guess which option is right every Friday.

He can ask.

Of course, there are situations where safety requires more planning or professional guidance. But during an ordinary activity like their card game, there’s often plenty of room to let the person decide what help feels useful.

And that can make quite a difference to how receiving help feels.

What if Martin wants to keep trying?

Imagine another Friday evening.

Martin is having difficulty shuffling again, but this time he doesn’t want to use the card shuffler.

“I want to see if I can do it,” he tells Lewis.

Lewis might be tempted to remind him that the shuffler worked perfectly last week. It would certainly get the game started faster.

But perhaps Martin has a reason for wanting to try.

Maybe he’s noticed his hands feel more reliable tonight. Perhaps he’s been practising certain activities with his therapist. Or maybe he simply misses shuffling the cards.

As long as the activity is safe, there’s room for that choice too.

An adaptation is there to help Martin, not become another rule about what he must do.

And if he changes his mind halfway through, that’s fine.

This is something that can be easy to forget when you’re helping someone regularly. Once you’ve discovered a useful arrangement, it’s natural to keep offering it.

But a helpful arrangement can change as someone’s abilities, preferences or circumstances change.

What worked last week is worth remembering. It isn’t necessarily what the person wants today.

Enjoying the game together

As their evening continues, Martin and Lewis settle into their familiar routine.

Martin is still a little annoyed that his hands haven’t been cooperating. Lewis understands that. He’s known his brother long enough to recognize when something matters to him.

But they’ve found a way to play, and soon they’re arguing cheerfully over whether Lewis is bluffing.

The card shuffler sits beside the table, ready if they need it.

There’s something important about that ordinary scene.

Lewis has learned that Martin’s ability to move can change without his intentions changing. He’s also learned that offering help doesn’t always mean taking over.

And Martin hasn’t had to choose between working toward improvement and enjoying his evening as things are.

They can have both.

As we’ve explored throughout this module, understanding FND can help us make sense of experiences that seem confusing from the outside. But we don’t have to understand every neurological detail before we can make an ordinary activity more enjoyable.

Sometimes a useful question is all that’s needed.

“Would you like a hand, or do you want to give it another try?”

And sometimes the answer will be different tomorrow.

A person may not always be able to control what their body does, but there’s still a great deal they can have a say in. Good support makes room for those choices.

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For the Person With FND
For Family, Friends, and Other Supporters
For Clinicians and the Care Team
Research and Sources

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For Clinicians and the Care Team

When intention and action don’t match

In Lesson 22, we explored why a person’s intention to participate may remain unchanged even when an involuntary symptom interrupts their ability to do so. Our final lesson examines this distinction more closely, particularly in movement and the experience of control.

Three concepts are important:

• Intention: What a person wants or plans to do.
• Sense of agency: The subjective experience of initiating or causing an action.
• Motor capacity and performance: What the person can actually do under particular conditions.

These concepts usually work together. Someone intends to reach for an object, their arm moves, and they experience the movement as something they caused.

But they are not identical. A person may intend to move without being able to produce the movement reliably. Another may experience an unwanted movement that does not feel self-generated.

The distinction has clinical importance because observing what a person can do does not, by itself, reveal their intention or their experience of control.

Clinical case: A task that no longer feels reliable

Ruth is a fictional patient with an established diagnosis of functional tremor, supported by appropriate positive neurological findings.

She enjoys building small wooden models and has been working on a boat for her grandson.

Recently, painting the model has become difficult.

When Ruth tries to position the brush carefully, her hand sometimes begins trembling. She knows exactly where she wants the brush to go, but the movement no longer follows her intention reliably.

“The shaking doesn’t feel like something I’m doing,” she explains.

Ruth has noticed something else. When she’s rearranging pieces on the workbench or handing an object to her husband, her hand sometimes moves more comfortably.

She finds that difference difficult to understand.

“If it can move properly then, why can’t I make it do that when I’m painting?”

Her clinician now has several kinds of information to consider: Ruth’s intended movement, her reported experience of control, the movement observed during different activities, and the consequences for something she enjoys.

What can these differences tell us, and how might they help her?

Understanding movement without assuming intention

Ruth intends to guide the brush. The tremor interferes with the movement, and she experiences the shaking as involuntary.

That subjective experience matters. The sense of agency concerns whether a person feels that they are making an action happen; it is not a direct measure of how much motor capacity they possess.

The difference between painting and handling other objects is also clinically interesting. It suggests that movement performance changes across tasks.

Painting requires precise movements toward a small target, sustained positioning and visual monitoring. Passing an object to another person involves different demands, even though some of the same muscles are used. Differences in attention, anticipation and automatic control may also contribute.

Understanding where movement becomes more accessible can inform rehabilitation without equating that ability with voluntary control over symptoms.

What has research found about agency in FND?

Voon and colleagues (2010) studied eight people with functional tremor, comparing brain activity during their involuntary tremor with activity while they deliberately mimicked it. The involuntary movement was associated with lower activity in the right temporoparietal junction and differences in its connections with other regions. This small, selected study helps investigate the experience of agency; its findings apply to that comparison rather than explaining every FND presentation. [1]

The study provides evidence that the subjective experience of involuntary movement deserves neurological investigation. It also offers a possible connection between functional motor symptoms and processes involved in the sense of agency.

Drane and colleagues (2021) discussed agency within a broader framework of interacting neural mechanisms in FND, including attention, predictive processing and motor control. [2]

Why do these findings matter? They help explain why movement, intention and the experience of making a movement happen can be studied as distinct aspects of neurological function.

Ruth’s reported experience and observed movement each provide useful clinical information. Together, they can inform how her difficulties are understood and approached in rehabilitation.

From observation to rehabilitation

Ruth’s goal is to finish the model boat, not merely demonstrate that she can hold her hand still during an examination.

That difference changes how the clinical problem can be understood.

A clinician may identify task conditions in which movement becomes more accessible. Those observations can help inform suitable functional motor rehabilitation, particularly when the activity can be explored safely and adapted to the person’s abilities.

For Ruth, the size of the painting task, the need for precise brush control and the arrangement of her workbench may all influence how successfully she can participate.

One possibility is an activity adaptation that gives the model more stability, allowing Ruth to concentrate on guiding the brush without also managing the movement of the object.

Another is exploring whether a different painting task or tool provides a more accessible starting point.

Why might such changes help?

They alter the demands of the task while preserving Ruth’s intended goal.

A stable work surface may reduce the number of movements she needs to coordinate. A different tool or activity arrangement may make it easier to complete part of the model without requiring the same degree of precise control.

The clinical value of these adaptations lies in how they change the activity. If Ruth can guide the brush more comfortably or complete more of her model, the clinician has learned something useful about the conditions supporting her participation.

What role does learning play?

Functional rehabilitation can involve more than compensating for a current difficulty. In some circumstances, meaningful practice may help movement become more reliable.

This brings us to neuroplasticity: the nervous system’s capacity to change through experience, learning and other influences.

Ordinary motor learning demonstrates how repeated experience can change movement performance. Familiar actions often become more efficient and require less conscious attention with practice.

These principles are relevant to rehabilitation, including task-oriented approaches used in functional motor disorders.

Neuroplasticity provides a foundation for understanding how meaningful practice may improve movement over time. In FND, the particular difficulties, suitable rehabilitation approaches and opportunities for improvement still need to be understood individually. [5][6]

For Ruth, an appropriately supported rehabilitation activity might provide opportunities to practise movements that become more accessible under selected conditions.

An occupational adaptation could also help her continue building models while that work progresses.

Rehabilitation and accommodation serve different purposes, but they can complement each other. One may aim to improve the reliability of an ability; the other may make an activity accessible despite an ongoing limitation.

The detailed evidence and methods for movement retraining belong in the Recovery Techniques Reference Library and the later rehabilitation modules.

What would meaningful progress look like?

Suppose Ruth begins using a stable work surface and finds that she can paint larger sections of the boat more comfortably.

Her tremor still occurs, particularly during delicate work, but she is completing parts of the project she had stopped attempting.

That is a meaningful functional improvement. Whether her tremor becomes less frequent, her movements become more reliable or her experience of control changes are additional questions that can help the clinician understand her progress.

Ruth’s experience also helps distinguish what progress means to her. Finishing the boat may matter more than achieving a particular result on a movement test.

An adaptation that works in therapy but cannot be used at home may offer limited practical benefit. One that allows Ruth to enjoy her hobby independently may remain valuable even when her symptoms persist.

The most useful outcome is not always the disappearance of an abnormal movement. It may be the return of an activity the person values.

How does responsibility fit into the picture?

Agency and responsibility are related concepts, but they refer to different things.

The sense of agency concerns the experience of causing an action. Responsibility involves decisions and actions for which a person can reasonably be held accountable.

Ruth did not choose to develop functional tremor, and her unexpected movements are not evidence of a deliberate intention.

Nevertheless, she can still make choices about which activities matter to her, what risks she is comfortable considering, and whether an adaptation or rehabilitation approach suits her circumstances.

Those choices do not amount to complete control over her symptoms.

Consider a patient who declines a particular therapeutic activity because it increases pain or presents an unacceptable risk. Their decision may reflect reasonable judgment rather than unwillingness to recover.

Likewise, someone who requires a mobility aid, assistance or a different way to complete a task has not failed to take responsibility for their care.

Responsibility in rehabilitation means having a meaningful role in decisions about care, safety and participation. It includes choosing useful supports, recognizing personal limits and working toward goals that matter. This understanding protects autonomy while respecting the involuntary nature of functional symptoms.

When might different professionals contribute?

Ruth’s presentation involves both functional movement and difficulty participating in a valued everyday activity.

A physiotherapist with appropriate functional motor rehabilitation expertise may contribute to understanding movement variability and opportunities for meaningful motor practice.

Occupational therapy offers a complementary perspective on tools, work surfaces, activity demands and practical adaptations. Professional consensus recommendations emphasize collaborative goals and the importance of participation in everyday life. [3]

A neurologist’s role remains relevant to establishing and reviewing the neurological diagnosis and assessing clinically significant changes. New or substantially different motor findings warrant appropriate consideration rather than automatic attribution to established FND.

Psychological support may be useful if Ruth experiences significant distress, loss of confidence or other concerns for which she wants help. Its involvement need not imply that her movement symptoms have a psychological cause.

The clinical question determines whether additional expertise is useful. A person who can achieve their goals with an appropriate existing clinician does not necessarily benefit from more referrals.

Bringing the module together

Across Module 7, we have explored how the nervous system uses predictions, integrates sensory information, prioritizes signals, responds to changing demands, and supports cognition and emotional experiences.

The final distinction concerns what a person intends, what they experience as self-generated, and what they can actually do.

These processes may influence one another, but understanding them does not require attributing every functional symptom to a single mechanism.

Ruth’s experience brings these distinctions together. She intends to paint, experiences tremor as involuntary and demonstrates different movement abilities across activities. Each observation contributes something useful to clinical understanding and rehabilitation.

This completes Module 7’s progression from prediction and sensory information through attention, cognition, emotion and agency. Module 8 builds on these foundations by examining individual symptom presentations, clinical evidence and the Reference Library.

Clinical takeaway: Understanding intention, the sense of agency and demonstrated ability as distinct aspects of neurological function helps clinicians recognize rehabilitation opportunities, support autonomy and develop care around the activities that matter to each person.

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For the Person With FND
For Family, Friends, and Other Supporters
For Clinicians and the Care Team
Research and Sources

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Further reading in the Reference Library

For more examples, explore the Recovery Techniques library, where assessment, practice and everyday adaptations are considered for different symptoms.

Research and Sources

A small agency experiment, an FND framework and a general motor-learning review address different questions. Physiotherapy and occupational-therapy consensus guidance inform rehabilitation examples. The community quotation illustrates consent in everyday support.

Citation	Figure	Full citation
[1]	—	Voon V, Gallea C, Hattori N, et al. The involuntary nature of conversion disorder. Neurology. 2010;74:223–228. doi:10.1212/WNL.0b013e3181ca00e9. FND-CIT-0305.
[2]	—	Drane DL, Fani N, Hallett M, Khalsa SS, Perez DL, Roberts NA. A framework for understanding the pathophysiology of functional neurological disorder. CNS Spectr. 2021;26:555–561. doi:10.1017/S1092852920001789. Original · PubMed. FND-CIT-0006.
[3]	—	Nicholson C, Edwards MJ, Carson AJ, et al. Occupational therapy consensus recommendations for functional neurological disorder. JNNP. 2020;91:1037–1045. doi:10.1136/jnnp-2019-322281. Original · PubMed. FND-CIT-0011.
[4]	Figure 1	Public Reddit contribution, r/FND. Original. Wording and relevant context checked October 26, 2026. Individual experience. FND-CIT-0312.
[5]	—	Nielsen G, Stone J, Matthews A, et al. Physiotherapy for functional motor disorders: a consensus recommendation. JNNP. 2015;86:1113–1119. doi:10.1136/jnnp-2014-309255. Original · PubMed. FND-CIT-0028.
[6]	—	Dayan E, Cohen LG. Neuroplasticity subserving motor skill learning. Neuron. 2011;72:443–454. DOI · FND-CIT-0306. General motor-learning review; FND rehabilitation is considered separately.