Transcript

Tim Beames (00:01.784)
Hello and welcome to the pain podcast. I'm Tim Beames. host today and founder of the pup scene to feet. And I have Bart van Buchem pain specialist physio and co-founder of the pub with me. And also I think relevant for this topic, we're going to talk about FND. So spotlight on functional neurological disorder today and

It's an area where you specialize. So Bart has a special interest in functional neurological disorder. And we're going to dive into some of your specialist knowledge. And particularly today, the flavor is around powering up recovery through physical therapies.

Bart Van Buchem (00:44.746)
Yes. Well, couldn't agree more.

Tim Beames (00:48.622)
Yay. So the first thing that we wanted to just talk a little bit about is a lot of people probably don't realize that physical therapy, physiotherapy has a place in the treatment of FND. So why is that? mean, what's the block there at the moment?

Bart Van Buchem (01:13.27)
Yeah, well, it's just a little bit of a history on F and D would be.

If you just check out the, you should just look at do a Google search right now, pause the podcast and check out a Google search on hysteria. And you will find out that the name of FND wasn't always been FND obviously. It's been hysteria, it's been conversion disorder. So it's going through the ages and as primarily a female health issue.

which obviously wasn't true, but by the time it was the hysteria as a, as a label for, when, when symptoms has converted into something like a, was obviously like a psychiatric disorder. And, I'm not going into the details because we will have our, FND, our FND program that will be released.

probably really early next year or this year. I'm not sure when we're going to publish this podcast, but early 2025, you will learn lots about a bit of history, because it's important to understand that it's come a long way and it's primarily a psychiatric disorder has been labeled within the DSM. But I think like about a decade ago, they decided that

conversion disorder is not and this story obviously was always was already left while a while ago. But it's that was not the suitable term. It was not. It doesn't. It was not the right term because conversion basically says it's translated to something. And we now know it's not always translated from a psychiatric problem or issue that arises. And therefore people have motor symptoms like

Bart Van Buchem (03:20.382)
loss of, let's say motor control, loss of their feeling, their limb or seizures. About 30%, 30 to 40 % did not meet, it's not meeting the criteria, but do have functional symptoms. And therefore saying they don't have anything that's, that's not, that's not helpful for people.

and not helpful for psychiatrists is not helpful for neurologists because people will sort of being in a, they will just flip around and just getting lost in translation. And John Stone, a neurologist from Edinburgh, who we also have had on the pub, has been probably one of the main frontiers of...

Jane making this change as his research has shown that we have to revisit the criteria. that's happened. So the DSM-5 has changed the name to FND version and then slash conversion disorder. But the next one will be the conversion will be left for sure. But in the criteria, it doesn't say you need this psychological, let's say, conflict.

as a minimum criteria like inclusion. and that's massively important because that's arising that it moved to a more neurological diagnosis because we basically diagnose by what we see. that's obviously, does people have motor symptoms or sensory loss or seizures, which are typically neurological disorders.

It will be the doctor, the medical specialist, where people will be looking for when they have. So visiting your GP will probably referring to a neurologist if you lose feeling or have loss of or impairment in movement, which also makes it more accessible.

Bart Van Buchem (05:37.676)
And I think the main reason why physical therapists nowadays are more or physiotherapists are more involved in the treatment of FND is because it's used to be a psychiatric disorder and diagnosis. And now it's a neurological diagnosis. And therefore physiotherapists may be involved, may have been involved. And I know they have been always been involved in the treatment, but

depending on the type of healthcare system you work in, the mental health department is not as, let's say, not as biopsychosocial as you would think, or would be helpful. And therefore you can see this distinction is either mentally issue or it's physical like a soma department. And

I'm pretty sure that any, every psychiatrist or a psychologist, psychologists who work and working with people with what would be used to be conversion disorder would absolutely see people can benefit from movement strategies because that's how it works. And, getting physiotherapists involved has opened up a whole new era and therefore more accessibility for treatment. So people don't need to be,

admitted to or need to be sort of patient in a psychiatry department. So they can also have treatment for FND with not being in the mental health department as a part of their treatment, which I'm not saying it's not important because it's hugely important because there's a majority of people with FND also have mental issues. So it would be very helpful for them.

Tim Beames (07:16.973)
Hmm.

Bart Van Buchem (07:33.12)
Perhaps it will be very helpful for them to have both approaches available, which I think FND therefore is right in the middle of the bias cycle. So it's split. You can't get away with just purely making it psychiatric and you can't say it's a mechanical issue or even like a brain function thing. It's not just that. It's typically right in the middle. That's why you need to understand.

both areas.

Tim Beames (08:03.534)
Yeah, Can I say and then thanks for that. So there's a sort of let's just say a historical perspective of hysteria. I mean, even the word hysteria sort of evokes. Yeah, something in me of like what you're exposed to as you're growing up that someone's hysterical. And yeah, you can imagine then what that might do to other people as well in their expectation of what this might be.

I wanted to play a devil's advocate here because I mean, we're saying physiotherapy or physical therapies, but I wouldn't see your role as purely being based on understanding and treating from a movement perspective because

You obviously have skills, you have your psychological therapeutic skills as well, don't you? And I'm just thinking, if you lost the awareness or the ability to be able to move, or you had these tremors that were part of the experience, that must be hugely scary for some people.

Bart Van Buchem (09:15.432)
Absolutely. Yeah, yeah. And it's quite diverse. So FND doesn't capture the, let's say the diversity because it could be basically any type of neurological loss of sensory information, but also the experience of walking. could be a very specific movement. It could be very task specific. So the diversity is massive and therefore you don't, you can't say this is a typical FND patient.

Although what you could say is that once you see the page, you have to take it all on board, right? So there might be fear, there might be unknown, there might be incapability of changing it, might be context that's super important. People might be traumatized, but not all of them. And I think the most important thing is that we used to

label this as a trauma induced problem. Let's say that Freud has basically written a lot about this, a lot about conversion because the name came from Freud, his work. So therapists will be mainly focusing on what's the trauma. And if you don't know,

about any trauma in your life, you will have to figure out where it is actually, because you were probably not aware of it. So that's a very strong direction of treatment. So psychiatrists wouldn't necessarily been interested in the movement disorder. The patient actually is. So my experience is people are worried about the loss of function. And may not be.

Tim Beames (11:01.934)
Yeah.

Bart Van Buchem (11:05.352)
related to anything else, which is maybe right. It be correct because there might be no trauma, traumatic event at all, because that's about 37 % does not have a traumatic event. So therefore you have to be aware of that it could be anything. But the main concern for the patient is that they have loss of function. And it makes sense to connect with the patient to take that seriously listening and

see if you can sort of do something about that. And that's, think, where physiotherapy is key, because we are pretty comfortable in movement strategies, motor impairments, motor control. That's our area.

Tim Beames (11:52.398)
So can you summarize where you would see your role with someone presenting with FND? Are they coming to you with prior diagnosis as well? where are you in the journey and what is it that you are as a physical therapist?

Bart Van Buchem (12:08.042)
Yeah, that's a great question, Tim, because I think it's because it's there is some.

I would say that you need the diagnosis. And ideally it's been, the diagnosis is being made by a neurologist because they can rule out other neurology degenerated issues. For example, when you trying to figure out whether it's a functional trauma, trauma compared to Parkinson's disease, that's typically the area of a neurologist and not a physiotherapist.

We can have an educated guess, obviously, but we know not in the position to do that. And I think it's especially great when you collaborate, when the neurologist ideally refers to the physiotherapy with this diagnosis. And therefore you can start treatment pretty much straight away. And that's where I positioning us as a physiotherapy, as a, a referral, I would be slightly uncomfortable when people did not.

seen a neurologist or maybe just a GP who is not really comfortable and not trained to make this distinction. I think that's pretty key. know, and interestingly, when the neurologist has has diagnosed FND, it's very likely that's correct. So that the uncertainty is not

You like there's only a 5 % of misdiagnosis in F and D once the once the diagnosis is set, which basically means it's not lower than multiple sclerosis and it's worse than Parkinson's disease. So it sort of creates a more stable. Fundament to start your education, to start figuring out how you can improve movement because there is a

Bart Van Buchem (14:14.592)
I would say you could have a more positive prognosis with FND compared to Parkinson's disease, depending on the stage.

Does that make sense?

Tim Beames (14:25.07)
Yeah, yeah, yeah, absolutely. so to just summarise in that is it's very, very usual, typical, or you want really someone to have come through a diagnostic route of having seen a neurologist when they make a diagnosis of FND, then usually it's pretty bang on. You know, get certain to get it right, very unusual not.

Bart Van Buchem (14:44.265)
Absolutely.

Tim Beames (14:50.478)
So we're starting in a place of confidence then aren't we, of where my treatment fits in. So then let's talk about that then. So what does that look like in terms of your relationship with your clients and how are you working together?

Bart Van Buchem (15:09.302)
So the referral would be nothing more than a referral from any kind of disorder you would get. It wouldn't be very different. Though you'll have to check with your patient whether they are comfortable with the diagnosis. Do they understand it? Do they actually believe it? We've learned that people who do not...

who do not accept the diagnosis are less likely to improve whatsoever. and the acceptance of this diagnosis is much greater when a neurologist has discussed it, but you cannot necessarily expect the neurologist has got, well, hit the sweet spot.

Tim Beames (15:40.334)
Okay, yep.

Bart Van Buchem (15:58.54)
if they did, it's great. You just reinforcing if they not, you just probably have to go through the procedure where you'd sort of checking out and maybe start treatment by saying, well, this is typically fitting the diagnosis because you're improving that this is unlikely to happen in Parkinson's disease. There are strategies actually that that can actually be very helpful there to make the distinction. because it is mainly fear driving.

Well, it might be something else. The other way would be that it's all in the head, right?

Tim Beames (16:34.848)
That old helpful one.

Bart Van Buchem (16:36.636)
Yeah, absolutely. And it depends on how it's been introduced. Although people do see it's not a peripheral issue. So you could easily say that, actually this is a central neurological issue in the central neurological issue and therefore disorder. And you can easily say that because it's actually, we know it's there and it's sort of a mechanistic well.

approach towards and we know that central neurological disorders are affected by well what's happening in the brain from any any perspective as well as social environmental and also psychological things and people would and I don't find too much resistance there what I

do see when people have uncertainty about might it it sort of turn out to be an early stage of multiple sclerosis or might it be an early stage of which I can't deny that it it's not like 100 % because it it might turn out at some point because these generative diseases or disorders are obviously that's hard to to diagnose like on a on a one time in place you just probably just have to follow up on

the long term. my, my, my, I would say comfortably say when we go through the procedure with the neurologist, people would not necessarily dismissing it, especially when you start, start focusing on their primary problem. And that's a motor problem. And people would typically, well, they would absolutely feel comfortable going that direction as it's their

main issue, regardless what they think about it. So that will be, if that make any sense in the context of treatment or therapy.

Tim Beames (18:41.388)
Yeah. So I've got a question for you then, because we've talked about the potential relationship crossover within nociplastic pain of FND and CRPS, complex regional pain syndrome. And you said about the obvious emphasis on the central nervous system with FND. Do you ever get...

signs like you do in CRPS of changes within the tissues like the autonomic signs or the trophic signs alongside your motor signs or is that more of a rare or unlikely phenomenon with FND?

Bart Van Buchem (19:25.844)
that's a great question. My first answer was in it will be different. You won't see the tropic changes whatsoever. What you would see if you test sensibility, example, by pinprick, you would you would think like if it's something that even if the neurologists basically have shown that the peripheral nerves are working.

through EMG, then you would expect then some of the pinprick at some point they will sort of present some experience. But I've repeatedly did that with people to be honest, just to make sure and how it works, just finding and experiencing how people go through like pinprick and like seriously doing it. And you can see you can't fake it. It's just important.

It's just impossible to fake it. As some people will have loss of feeling and it will basically no feeling at all. I'm not sure what would happen if you basically proceed having a surgery procedure there. when my, well, by just pinpricking, they're giving very noxious, a very strong nociceptive input. They won't feel it at all.

So that's, that's, if that's where you're asking for, is there something objectifying that well, but you will be.

Tim Beames (20:58.734)
Which would be very different, wouldn't it? say often with CRPS it's a gain in function, a sensory function, so yeah, an increase in awareness.

Bart Van Buchem (21:08.16)
Yeah, it will be. So I would most most of the case you will find a loss of sensory loss of sensory effect, but there will be in some cases you will find an increase. But I'm not sure whether that's necessarily related to F &D itself, to be honest. Yeah.

Tim Beames (21:36.088)
So I want to geek out on this for a second if that's all right then. So that's a really interesting observation. And then is that a regional thing? that just within one limb? Is it a whole body? Is it on one side of the body? What's the presentation like there?

Bart Van Buchem (21:40.193)
Yeah.

Bart Van Buchem (21:55.872)
Yes, so the presentation will be very unlike, let's say the dermatomes. It will be the whole leg or just the foot will be just left sided or just right sided. Like the hand, it will be just up to the wrist and then slowly improving the sensory, let's say experience again when you move up to the upper arm or the

forearm. So you have a very, I would say, non-typical neurology, neurologic, neurologic goal presentation, obviously, we did have some people like having, well, for example, when you have loss of feeling in the face, and they will instead of like having people have a stroke, you will find out that they're the area in the, what's it called?

Tim Beames (22:37.997)
Yeah.

Bart Van Buchem (22:54.636)
just below the head. Yeah, yeah, the next, sorry, just grabbed the neck. Yeah, yeah, sorry. When the neck will be actually have the same loss, have the same sensory loss. So you would, that's a way of distincting from the stroke, for example. So people have the whole right side of the face, including the neck and then

Tim Beames (22:56.566)
anterior triangle of the neck.

I didn't know how specific you wanted to get.

Bart Van Buchem (23:22.262)
the chest, example, and shoulder. And sometimes it's people like having a parolized by from, say from, the belly downwards, but it may have a, an overlapping sort of transition area and it may even, may even be fluctuating. And some people I would find they do have function in their genitals and

but not in the thigh. So, so, so that's why I'm just saying it's not, it's, it's, be quite unlike for anything like that. And there will be a way of distinctive for neurologists. That's why it's important to have this, this knowledge of, of how they diagnose and others things like stroke and any kind of neurological problem there, which also bring us like, when you're checking in, you will find

Tim Beames (24:02.348)
Yeah, see.

Bart Van Buchem (24:22.75)
old patterns. They're not in the textbooks, for sure. But they are there. You can pinprick them.

Tim Beames (24:23.916)
Yeah.

Yeah, yeah, yeah, yeah. So you see you're well out of like a nice practical, like peripheral neuropathic or a a ridiculous symptom. And so so then let me just go beyond that because I'm interested. So from a spatial based processing point of view, can will that if you bring that affected side onto the opposite side of the body, does that have any effect or if you change the vision like relating to that body part?

does that have any effect then?

Bart Van Buchem (24:57.322)
Yeah, I've been trying out some really funky things. I did have some people who viewed, indeed, if you just bring the right, let's say the parallel side to the left where it wasn't in, they people did experience, they did have different experiences and sometimes improvement in motor function and

Tim Beames (25:19.884)
And when you say improvement in motor function, is that an immediate thing?

Bart Van Buchem (25:22.956)
Yeah, like they can do more when the, when the limb is moved to the other side, let's say fruits from this, let's say from the right to the left, they, experienced more control, which is probably the most, among the most evidence based thing you can say about, the things that have changed compared to healthy controls in FND is that people have a change or a

They have a distorted sense of agency. And therefore, you would expect that people have a different perception of their body. It could be either that it's a loss or it's change or it's twisted or it's bigger or it's not there. They don't experience of them. They don't have ownership over that body part, but not necessarily pain. So this will be different to...

Tim Beames (25:56.673)
Okay, yeah.

Bart Van Buchem (26:19.968)
to CRPS, for example, where people just experiencing pain and not experience their limp, it's theirs, but people just, there's nothing. It just doesn't feel like so. So, but I do also got examples where people do have pain in that part.

Tim Beames (26:35.756)
Yeah, So I guess then the sort of natural progression of this, I'd love to just spend a few minutes thinking about the potential for recovery doing some sort of physical therapy. if there's if there's a loss of the sense of ownership or they lack agency of a body part and they don't have awareness, sensory awareness of information from the affected body part.

How can we work to bring back a sense of ownership or the ability to regain agency of my movements again?

Bart Van Buchem (27:09.834)
Yeah. So that, yeah, that's the, that's the one million dollar question, but actually this is, I can give you, because we, I don't, I do think we, there is, it's something that we can figure out with the patient on a, I would say N is one, condition because every person with FND would have different responses to different

approaches, just in a briefly, would say you would need or people will be sensitive to attention. So if you, if you drive their attention towards or away from, or basically learning people to, to that, it will change the experience. And you will find out actually that it may cause or it triggers a

let's say a modal response and it will be merely a positive response because it will be more or better than it was.

Tim Beames (28:16.526)
And by doing that, you could do something like use vision or you could do a task on another part of the body or something like that.

Bart Van Buchem (28:24.392)
Exactly. Yeah. Like a tremor, for example, typically will be, is it's a functional tremor by using entrainment is basically using the other limb to induce movement. And therefore the tremor will slow down. It will change its rhythm and people will actually be able to driving that attention will actually change it because, they wouldn't be aware. that's gaining sense of agency over movement again.

So that will be people will experience that. Wow, that's that's there could be life changing again. So that's what I've experienced. People thought that could never ever move again or wouldn't be able to to to to change it or to control it whatsoever. And then suddenly happens.

Tim Beames (29:09.718)
And having found that is part of the process to practice, to rehearse, to train that then.

Bart Van Buchem (29:18.088)
Exactly. So giving control by doing something you haven't done for a while. And sometimes it's very, contract intuitive for people. So for people with like walking disorders, functional walking disorders, they might walk backwards and found it surprisingly easy to do so. And therefore people will be surprised by.

doing that because it's not intuitive. You're not going to think about walking backwards. It usually is harder, right? So by doing it and perhaps even filming it, showing it and asking for the experience how they experienced it, how it felt, that will be sort of the first step in the treatment and start shaping it. Because people are sort of, in F &D, they're very strong and very...

sort of stuck in a pattern, you would say like a, expectation in the motor system is basically primed for this. It's there's no error when people drag their feet. You would expect it will be this not. So I would say one of the things that people are sort of stuck in a pattern and therefore you just kind of basically trigger them to do something different and gaining self agency.

Tim Beames (30:41.24)
Yeah.

Bart Van Buchem (30:42.238)
And maybe you need to give them some cognitive control. Just they know what it is. It's safe to move and it will be education. And for some people, it's very important to regulate their emotions. So when they experiencing fear, you have to sort of look after them very well, regarding their, their feelings and feelings of fear and anxiety, which is, may driving the condition as well. So, so it's, I think I, I'm labeled like five things now.

that you have to take in account at the same time. And as I would say, a successful exercise will be something that consists everything. And hitting that switch button, people got that. You could call it a motor or a sensory positive experience. And that's the first thing for your behavioral therapeutic approach. You can start shaping it.

Tim Beames (31:34.368)
And it sounds like you need a bit of creativity there then.

Bart Van Buchem (31:38.668)
Absolutely. There's no one, there's no one way to do it. There's, you have to be focusing on older patterns. People would love to, they might be dancing around and feel like haven't done it for a while. And so the people just have to pretend swimming and you can do think of all types of things. So, but we got heaps of examples that I'm going to show in our F and D program where you can actually see it's happening.

And that's pretty cool, actually, to be honest. It's quite obvious. And then you can see how it may shape from there onwards. And it's definitely bringing back creativity in the clinic.

Tim Beames (32:22.658)
Yeah. Can I try something? Can I just repeat back to you using some maybe some terminology, maybe it's a bit old, maybe it's like how some people might think about things, but it sounds like what is a part of that presentation is it's like this movement representation that they're playing out again and again and again and they've strengthened the connections between different...

parts of the brain and we could probably guess some of them, couldn't we? We'd be thinking about the certain parietal regions and motor regions and the interparietal sulcus and what have you that might be a part of that and maybe the basal ganglia if there's a bit of emotion involved in the movement and the cerebellum. And so I don't know, I'm just guessing here, but we've got this sort of movement representation that plays out again and again and again. And a part of your therapeutic role is to find an alternate

path or an alternate strategy. So the destination is the same walk, move the limb, but you're getting to it in a different way. And we're trying to build more variability, more flexibility in the way that you get to that end game. Does that sound like it's what we're looking at?

Bart Van Buchem (33:38.902)
Yeah.

Bart Van Buchem (33:43.308)
Yeah, that would be a nice summary. It sounds easy, but sometimes can be quite tough, right? And I think that the challenge there is to connect and have a confidence doing it. Because if there's no confidence from the therapeutic approach or from the therapist, it's not going to work as good as it could be. As confidence is massively important in this.

Tim Beames (33:51.95)
you

Tim Beames (34:01.814)
Yes.

Tim Beames (34:09.678)
Yeah.

Bart Van Buchem (34:13.1)
Basically showing people that actually can do much more, but doing it in a way and you have to, you have to, you have to express that confidence. Otherwise, it's not going to be, let's say helpful. Yeah.

Tim Beames (34:13.111)
And.

Tim Beames (34:28.748)
Yeah, cool. And I want to say because, you know, we've talked about certain models to understand things, but you can see where something like predictive processing could explain some of this, couldn't you, where the confidence and the precision is very high on this specific experience. it might mean that we're trying to just bring in the potential of other predictions, other expectations, other outcomes.

Bart Van Buchem (34:45.854)
Exactly,

Tim Beames (34:55.734)
And you need to be really quite creative and sometimes very experimental in order to just bring options onto the table. Yeah.

Bart Van Buchem (35:05.29)
Yeah, and I know it's been the there is a paper called FND and

it's Bayesian and predictive processing models as an introduction for this. And it has been widely referenced and people like Karl Friston have worked on that paper as well. So people on the forefront of predictive processing as being part of that. So you can see there's F and D, it lends itself quite nice to fit the model, maybe even better than

as you can see the change, which is really interesting because you can sort of measuring it. can objectify the change in movement and not just the experience, but you can basically just film it and see how it changes. So that's really pretty cool.

Tim Beames (35:43.491)
Yeah.

Tim Beames (36:01.262)
Nice to get some immediate feedback, isn't it? Yeah. I'm afraid we're running out of time. We're going to have to do our best to summarize this. So this episode was just putting a spotlight on functional neurological disorder, FND, we've been calling it all the way through, we? And we wanted to ask the question whether or not physical therapy, physiotherapy fits the process of recovery and...

Bart Van Buchem (36:08.202)
Well, like always.

Tim Beames (36:29.846)
And we're completely biased, obviously, but we feel that there's the ability to power up recovery through physical therapies. You started to introduce historical perspectives of FND and talked about hysteria and conversion disorder and how we are finally, you know, at this stage of actually accepting that it's more than just hysterical, psychological.

emotional and in some people doesn't even have a traumatic incident that relates to the onset of FND. But a huge part of it is the presentation, you know, what someone how someone experiences themselves with FND and you discuss the need for the neurologist to do a workup.

And for when they do their workup, then usually they are great at ruling in FND and ruling out alternative diagnosis like Parkinson's and MS you mentioned. Although we talked about that, you know, some people will still have in the back of their mind, could it be, you know, is it, and you can't 100 % be certain that it isn't a part of this beginning. And as you mentioned about

having one assessment, sometimes not being enough, maybe you need to have a follow up and to recheck and be sure whether or not that's the presentation. And then you mentioned about where you sit as a physical therapist, that yes, there's a role in the physical, in the movement, in the behaviors, but there's also the role in you understanding, validating, educating.

understanding where fear and emotion might relate to it. in fact, there were some cool examples that you gave, where you were talking about how, for instance, fear might be a part of the presentation, for instance, of tremor in a limb. And actually being able to regulate that can be a part of a therapeutic process, but so could finding alternate movement patterns.

Tim Beames (38:45.46)
you gave an example of when walking was problematic, perhaps walking backwards may not be. So about sort of finding these creative alternative ways to get to where you want to get. I mean, we could carry on talking about this all day, couldn't we? And you've mentioned a couple of times that Le Pub are putting out a short course. We haven't decided what we're going to even call it. I think a masterclass is probably likely, but

We've got a few guests, haven't we, coming in and explaining it in great depth. So a neurologist, a researcher, a clinician, all coming together and giving us a real in-depth knowledge of FND.

Bart Van Buchem (39:29.472)
Yeah, which, in my view, we we've tested it quite well. we doing these live courses for a while now. And like the consistent to the feedback was like, I think I can start doing this now. So I would expect a very similar experience. So hang in there for a bit and we will release it and you will have like a full like a, there will be a neurologist, a psychiatrist that will be the physio background will be a research background for the.

like the motor retraining programs we've developed and it's quite exciting. So this is like a full program. I don't think you can get it anywhere in the world. So we're putting this together and we're really excited to hear what people can do with it.

Tim Beames (40:18.102)
Yeah, exactly. So we want to build a bit of hope out there for people diagnosed with FND, don't Awesome. Thanks so much for checking in. If you got to the end of the podcast here, please do share it, like it, shout about it. We want to get some of this information out there for everybody. So thank you very much and see you next time.

Bart Van Buchem (40:23.538)
Absolutely.

Bart Van Buchem (40:41.174)
Thank you, ciao.