Functional neurological disorders after COVID-19 and SARS-CoV-2 vaccines

Long COVID functional manifestations differ from post-vaccine effects

I stumbled upon this article yesterday in mainstream media, which linked to the Medpage Today review of an important study detailing functional neurologic disorders after COVID-19 infection or vaccination. I don’t usually bother to re-publish items from Medpage Today because of their extreme bias against physicians and scientists who have spoken out about the pseudo-mRNA vaccine. Today, I am making an exception because they actually published this review without bias.

Most of this article is behind a paywall, so I am posting sections of it here for educational purposes only.

Please note the subtitle from Medpage article below (“Long COVID functional manifestations differ from post-vaccine effects”). Within the body of the text, Medpage is actually admitting adverse events from the vaccine are more common than previously thought! Is this evidence that the tide of misinformation from medical journals geared towards physician education may be decreasing? One can only hope….

In my experience, post-vaccination twitching is almost as common a tinnitus (ringing in the ears). Based on this casual observation, I suspect that post-vaccination FND is quite common, which (if true) is likely to predict long term neurologic consequences for a large fraction of the population.

Functional Neurological Disorder Emerges After COVID Infection, Vaccines

— Long COVID functional manifestations differ from post-vaccine effects

Medpage Today, March 24, 2023

Patients with functional neurologic disorder (FND) after SARS-CoV-2 infection had different symptoms than people with FND after COVID vaccines, retrospective data showed.

Patients with post-COVID FND tended to be older, had more insidious onset, and had higher disability, according to Araceli Alonso-Canovas, MD, PhD, of Hospital Universitario Ramón y Cajal in Madrid, and co-authors.

Those with FND after COVID vaccination more closely resembled classic FND: they were younger, had an acute onset, and tremor was the most common phenotype, the researchers reported in Journal of Neurology, Neurosurgery & Psychiatryopens in a new tab or window.

"We show for the first time evidence from a multicenter national study that FNDs after COVID-19 infections and vaccines are more common than previously reported and have distinct clinical profiles," Alonso-Canovas told MedPage Today.

The findings point to a need to consider FND when diagnosing patients with post-COVID neurologic symptoms, she added.

"Long COVID is an umbrella term and many different circumstances have to be considered," Alonso-Canovas said. "If there are neurological symptoms, a careful history and examination is mandatory to rule out FND, as it is a well-defined clinical condition that is potentially treatable."

FND refers to disorders caused by an abnormality in brain signaling with no significant structural brain damage. It occurs in an estimated four to 12 people per 100,000 per year and accounts for about 6%opens in a new tab or window of outpatient neurology visits.

Vaccinations can trigger FNDopens in a new tab or window, as can other stressors including infections. While experts maintain some people with FND might be long COVID patients, little research has been conducted opens in a new tab or window to evaluate this.

"If the neurological examination is not searching for these features, the diagnosis will be missed," Espay told MedPage Today. "Given the therapeutic implications, ascertaining the functional subtype of long COVID is imperative."

Phenotype was purely motor in 65% of FND patients and mixed sensorimotor in 32%. One patient had isolated sensory syndrome. Fatigue (72%), pain (57%), and cognitive difficulties (30%) were common.

People in the post-COVID group were older (46 vs 35 years in the post-vaccine group) and had higher disability (76% vs 31%, respectively). The post-COVID group also trended toward having more men (24% vs 15%), more people with previous psychological difficulties (50% vs 23%), and less frequent abrupt FND onset (38% vs 62%).

In the post-COVID group, 58% had previously received a long COVID diagnosis, and FND symptoms started within the convalescence period in 87% of patients. In the post-vaccine group, FND symptoms started within 1 week after vaccination in most cases.

Overall, 22 FND patients (48%) required treatment with psychiatry or psychology specialists, 15 (33%) needed physical therapy, and one needed speech therapy. After a mean follow-up of 14 months from onset, 46% had improved, 39% remained stable, and 9% had worsened. Three patients were unavailable for follow-up after diagnosis…

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The actual scientific article may also interest readers, therefore highlights from that are posted below. Again, the main article is behind a paywall.

Functional neurological disorders after COVID-19 and SARS-CoV-2 vaccines: a national multicentre observational study

Journal of Neurology, Neurosurgery & Psychiatry, a BMJ Journal

(Most of this article is behind a paywall, so I am posting sections of it here for educational purposes only).

Introduction

Functional neurological disorders (FNDs) are a common cause of neurology consultations. Dissociative seizures, motor and cognitive disorders are the main phenotypes. Diagnosis is made on positive terms: signs of inconsistency, incongruence and variability of physical signs with attention on clinical examination.  Abnormal emotional processing and expectations are involved in the genesis and perpetuation of FND…

On the development of SARS-CoV-2 vaccines, several cases of FND following vaccination were published, as well as an official warning from the Functional Neurological Society. Post-COVID-19 symptoms (known as Long-COVID-19) have also become a frequent reason for neurology consultation. Somatic symptom disorder may be common in these patients, and socioeconomic implications are vast.

Our experience is that a proportion of patients with FND describe an association with COVID-19 infection/vaccination. Here, we report a cohort of patients with FND for whom COVID-19 or SARS-CoV-2 vaccines were the main precipitant factors.

Methods

We performed an observational retrospective analysis in eight tertiary university hospitals with special interest in FND. Electronic clinical records (March 2020–November 2022) were reviewed and FND which developed after COVID-19 disease (Co-FND) or SARS-CoV2 vaccines (Va-FND) were recorded. Diagnosis of FND was performed by an expert, based on clinical history and positive motor or sensory signs on examination. Hence, isolated phenotypes such as dissociative seizures, cognitive disorders or PPPD were excluded. Disability was defined as a situation of work-leave due to symptoms for active subjects and disability to perform daily-living activities for students or retired subjects.

Results

Forty-six patients, 36 (78%) women, mean age of 43±13 years, were included. Thirty-three (72%) in the Co-FND and 13 (28%) in the Va-FND groups. Phenotype was purely motor in 30 (65%), mixed sensorimotor in 15 (32%) and 1 isolated sensory syndrome. Most patients displayed a mixed motor phenotype, being tremor/jerks (23) and gait abnormalities the most frequent (22). Fatigue (72%), pain (57%) and cognitive difficulties (30%) were common.

In the Co-FND group, 19 (58%) patients had previously received a Long-COVID diagnosis. FND symptoms started within the convalescence period in 87%. In the Va-FND group, FND symptoms started within 1 week after vaccination in most cases.

Twenty-two (48%) patients required treatment with psychiatry/psychology specialists, 15 (33%) physical therapy and 1 case speech therapy. After a mean follow-up of 14±8 months from onset, 46% had improved, 39% remained stable and 9% patients had worsened (follow-up unavailable after diagnosis in 3). Disability was present in 63% at the end of follow-up.

When comparing Co-FND and Va-FND groups, a significantly older age (46±12 vs 35±10, p=0.0229) and higher disability (76% vs 31%, p=0.0071) were found in Co-FND. A trend towards more frequent male gender (24% vs 15%), previous psychological difficulties (50% vs 23%) and less frequent abrupt onset (38% vs 62%) was also noted in that group.

Discussion

Our results are of interest for several reasons. First, they suggest there might be a different clinical profile for patients who develop FND after COVID-19 infection and after SARS-CoV-2 vaccines. The features of the latter group closely resemble the classic FND, with younger patients, an acute onset and tremor as the most common phenotype.¹ Consequently, FND diagnosis in this group may be more straight-forward, which could explain why most published reports of FND have been related to SARS-CoV-2 vaccines. In contrast, patients with FND after COVID-19 infection tended to be older, with a more insidious onset and higher disability. This, along with the uncertainty surrounding many post-COVID-19 symptoms, might render FND diagnosis more difficult in the absence of appropriate clinical expertise.

Second, our results highlight the challenges of the Long-COVID diagnosis. This umbrella term includes more than 200 heterogeneous symptoms such as fatigue, cognitive complaints or pain, which are also common in FND, and especially frequent in our sample. Long-COVID lacks consensus definition, diagnostic criteria, biomarkers and a clear underlying pathology. In this context of uncertainty, a guiding principle should be that not all patients with post-COVID-19 symptoms necessarily have a Long-COVID, and a broad differential diagnosis should be considered. Our results suggest that FND should be part of this differential as nearly 60% of our patients had received the diagnosis of Long-COVID. Viral infections and vaccines have long been recognised as potential triggers for FND.

Lastly, FNDs are a source of treatable disability. Since there is no specific therapy for Long-COVID, recognising patients with FND is essential to plan early treatment and improve prognosis. A multidisciplinary approach based on an empathetic communication of the diagnosis, specific physical and psychological therapies might be of help in a proportion of patients.

Our study has limitations, mainly the small sample size and its retrospective nature. A selection bias is likely, since only patients with motor or sensory positive signs on exam were included. They were recruited mainly from FND clinics, a highly specialised resource. This likely leads to an underestimation of FND after COVID-19 infection and SARS-CoV-2 vaccines.

Conclusions

COVID-19 pandemic has introduced a complex worldwide stressor and an increased incidence of FND has been noted. Specific occurrence of FND after COVID-19 infection and vaccines are increasingly recognised, but likely under-reported or misdiagnosed as Long-COVID. FNDs are source of treatable disability, and its early recognition is essential to plan therapies and improve prognosis.

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One of the more interesting aspects of this paper, other than the obvious results that both the disease and the vaccines cause FND and that the vaccines affect a younger cohort of patients, is that the journal did not feel a need to conclude that, despite these findings, the vaccines are “safe and effective.”  Could it be that the era of policing of COVID-19 vaccine adverse events from journals is finally coming to an end?

Also of interest is that the authors believe that FND is under-reported due to systemic failures of the medical system in detection, and that treatments are not being provided because of an under diagnosis.

Now that journals are publishing that neurologic conditions are associated with the vaccine and are much more common than once believed, will people stop being gaslit for discussing their neurologic conditions?

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Finally, the text above mentions that Functional Neurological Society had issued an official warning about FND and the SARS-CoV-2 pseudo-mRNA vaccines. Their reference did not lead to that warning, instead that reference linked to another paper, “Functional disorders after COVID-19 vaccine fuel vaccination hesitancy.” In that paper, published a year ago, the authors conclude that there have been cases of FND, but that somehow these needed to be underemphasized, because they might create vaccine hesitancy. Just think about the implications on this in terms of censorship and propaganda.

From the paper:

Among the various adverse events which might observed after COVID-19 vaccination, the occurrence of functional—once called psychogenic—neurological disorders (FNDs) might be a challenging issue for healthcare providers, media and public opinion with a negative impact on vaccination campaigns. In fact, in the past few months, as the vaccination campaign against SARS-COV-2 was finally reaching larger slices of the general population, we have seen two young women manifesting FND after COVID-19 vaccination….

The success of vaccination programmes relies on high rates of public acceptance and population coverage, which is contingent on encouraging scientific data about safety and efficacy of the vaccines as well as effective information campaigns. Vaccine hesitancy, characterised by lack of confidence in vaccination and/or complacency about vaccination that may lead to delay or refusal of vaccination despite the availability of services, threatens to undermine the success of COVID-19 vaccination programmes.

Although the WHO recently ranked vaccine hesitancy as one of the top 10 threats to global health, a new report by the Centre for Countering Digital Hate has lambasted social media companies for allowing the anti-vaccine movement to remain on their platforms. For this reason, while health experts have attempted to stress that in various instances, no direct link between COVID-19 vaccines and various media-covered adverse events has been established, such attempt is probably not enough. With regard to FND, we suggest that the medical community should be more vocal in informing the media and public opinion about FND, thus making a further step towards the establishment of ‘eHealth literacy’.

The public needed truth tellers from sciences and medicine. They need this in order to rebuild trust in science and medicine. That trust has been erased, and for good reason. Until the official gatekeepers of science and medicine clean up their act, they do not deserve the trust of the people.

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