FND Education Project

REFERENCE · RECOVERY TECHNIQUE

Individualized Whole-Person Treatment for Functional Tremor

Most likely fit: Tremor affects several activities or coexists with pain, fatigue, sleep disturbance, anxiety, trauma-related symptoms, low mood, cognitive symptoms or another health condition, so isolated movement drills cannot address the person’s full treatment priorities. [Programme-level research and multidisciplinary clinical consensus; no single combination fits everyone]

Not the same as: Assuming stress caused the tremor, requiring psychotherapy before physical rehabilitation or promising that one multidisciplinary package will remove symptoms. Care should be selected from the individual formulation, goals, access needs and preferences.

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What individualized treatment means

Functional tremor can affect drinking, eating, writing, phone use, dressing, mobility, sleep, work and social participation. A plan may combine movement retraining with occupational therapy, psychological treatment, communication therapy, pain or fatigue management, medication review, equipment and practical support. You may need only some of these.

Psychological treatment can help with fear, symptom monitoring, panic, trauma, adjustment, low mood or other concerns when those are relevant. It is not evidence that the movement is imagined. Medication may treat a coexisting condition, but no medication is established as a specific universal treatment for functional tremor.

Anatomy in everyday language

Different tremor locations involve different movement systems. An arm task links the shoulder blade, shoulder, elbow, forearm, wrist and hand. Standing links the trunk and pelvis with hip, knee and ankle control. Voice production links breathing, the larynx (voice box) and the mouth. This is why a useful hand exercise cannot simply be copied to the head, trunk or voice, and why the professional leading treatment may differ by goal.

Who may contribute

  • A neurologist or movement-disorder clinician can confirm the diagnosis, explain positive signs and review new or changed symptoms and coexisting disorders.
  • A physiotherapist can analyse tremor activation, posture, balance and movement retraining.
  • An occupational therapist can adapt eating, dressing, writing, technology, work and home tasks while building functional practice.
  • A psychologist, psychiatrist or therapist can address agreed psychological or behavioural targets without blame.
  • A speech-language therapist may assess functional voice tremor or associated communication and swallowing problems; laryngeal or other medical assessment may also be required.
  • Primary-care and other clinicians can coordinate pain, sleep, medication and general health care.

Building the plan

  1. Choose goals that matter in life, not only a lower tremor score.
  2. Identify the tremor appearances and contexts that interfere with those goals.
  3. Select the smallest useful combination of treatments and name who is responsible for each part.
  4. Preserve adaptations and equipment needed for safety and access while practising change.
  5. Agree on measures, review date, flare plan and reasons to reassess.
  6. Change or stop components that cause harm, overload or no meaningful progress after an adequate trial.

Severity, recurrence and response are not measures of effort. A person may improve in participation while tremor remains, or symptoms may change before daily function does.

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Ask which goals and appointments the person wants help with. Support adaptations, transport, practice or note-taking without becoming a therapist or monitoring every symptom. Do not use a psychological referral to dismiss physical symptoms, and do not treat a difficult flare as failure to follow the plan.

Supporters may also need information, respite and boundaries. Their wellbeing can be included without transferring responsibility for recovery to them.

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

Build a shared formulation

Describe the positive basis for the functional-tremor diagnosis, the specific phenotype and the factors relevant to this person. Separate predisposing, precipitating and perpetuating hypotheses from confirmed facts. Screen for coexisting neurological, musculoskeletal, psychiatric and medical conditions without making any one condition a universal explanation.

Anatomy, phenotype and discipline matching

Map tremor by body region and task. Upper-limb oscillation may require scapulothoracic, glenohumeral, elbow, forearm, wrist and hand analysis; lower-limb tremor requires stance, centre-of-mass and falls assessment. Head or trunk tremor requires axial and cervical differential assessment. Voice tremor requires perceptual and task-specific analysis of phonation and may involve laryngeal evaluation. Explain this plainly: “Different body regions use different movement and communication systems, so we should not copy a hand exercise into your voice.”

Match discipline to the participation restriction. OT may lead feeding or workplace adaptation; PT may lead standing and gait retraining; speech-language therapy may lead functional voice work; psychology may lead agreed fear, avoidance, trauma or attention work. Maintain a common explanation across the team.

Explicit care-planning sequence

  1. Confirm diagnostic communication and the patient’s understanding, questions and treatment priorities.
  2. Establish baseline symptoms, activities, participation, quality of life, injuries, fatigue, pain and treatment burden.
  3. Select one or two primary goals and assign a lead clinician for each.
  4. Choose motor techniques from observed response, not a fixed protocol. Define dose, stopping rules and a functional transfer task.
  5. Treat coexisting conditions on their own merits. Document what medication is intended to treat and review adverse effects that could worsen tremor.
  6. Integrate accommodations, equipment and communication access. Do not withhold access supports to motivate recovery.
  7. Agree on information sharing, review interval, flare plan and thresholds for neurological or medical reassessment.
  8. Evaluate net benefit and burden. Step care up, down or sideways according to response and preference.

Outcomes and treatment boundaries

Use patient-chosen outcomes across symptoms and participation: safe drinking, device access, dressing, walking, work attendance, social engagement, confidence, pain, fatigue and quality of life. Record harms and burden. A tremor scale may add information but should not displace the person’s goal.

Avoid contradictory messages, repeated unstructured examinations, coercive psychotherapy and claims that acceptance or motivation determines outcome. When specialist access is limited, a coordinated generalist team can still use shared principles within competence.

Safety and evidence boundary

Keep one clinician responsible for reviewing new or changed neurological features, medication effects, injuries and discipline-specific risks. A coordinated plan should reduce duplicated testing and treatment overload, not multiply appointments without a shared goal.

Specialist physiotherapy and combined physiotherapy/CBT trials concern mixed functional motor-disorder groups and multi-component programmes; they do not identify which component works for functional tremor or who should receive the same combination. Consensus supports multidisciplinary, individualized care. [1][2][3][4]

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For Family, Friends, and Other Supporters
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Research and Sources

Citation Full citation
[1] Nielsen G, Stone J, Matthews A, et al. Physiotherapy for functional motor disorders: a consensus recommendation. Journal of Neurology, Neurosurgery & Psychiatry. 2015;86(10):1113–1119. FND-CIT-0028. https://doi.org/10.1136/jnnp-2014-309255
[2] Nicholson C, Edwards MJ, Carson AJ, et al. Occupational therapy consensus recommendations for functional neurological disorder. Journal of Neurology, Neurosurgery & Psychiatry. 2020;91(10):1037–1045. FND-CIT-0011. https://doi.org/10.1136/jnnp-2019-322281
[3] Nielsen G, Stone J, Lee TC, et al. Specialist physiotherapy for functional motor disorder in England and Scotland (Physio4FMD). The Lancet Neurology. 2024;23(7):675–686. FND-CIT-0029. https://doi.org/10.1016/S1474-4422(24)00135-2
[4] Macías-García D, Méndez-Del Barrio M, Canal-Rivero M, et al. Combined physiotherapy and cognitive behavioral therapy for functional movement disorders: a randomized clinical trial. JAMA Neurology. 2024;81(9):966–976. FND-CIT-0030. https://doi.org/10.1001/jamaneurol.2024.2393

Detailed technique page created: September 11, 2026 · Clinical and accessibility review pending

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