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Falls & Balance Matter

Stay Steady, Stay Strong

Understanding
Falls & Balance?

Falls are when a person accidentally loses their balance and ends up on the ground or another lower level. Poor balance is a major factor in falls, especially in older people. Balance is the ability to control the body’s position, which requires a combination of sensory information and motor responses.

Understanding your condition step by step

Diagnose

We carefully identify your Falls & Balance patterns, triggers, and symptoms to understand what’s driving your condition.
History

1. History of Present Illness:

Nature of the Fall:
  • What happened before, during, and after the fall?
  • Was it preceded by dizziness, loss of consciousness, or a sudden loss of balance?
Frequency of Falls:
  • Are falls a single event or recurrent?
  • If recurrent, is there a pattern or specific trigger?
Location and Time:
  • Did the fall occur indoors or outdoors?
  • Was it during the day or night?

2. Associated Symptoms:

Neurological Symptoms:
  • Dizziness, vertigo, or unsteadiness.
  • Numbness, tingling, or weakness in the legs.
  • Headache or visual disturbances.
Cardiovascular Symptoms:
  • Palpitations, chest pain, or lightheadedness.
  • Symptoms suggestive of orthostatic hypotension (dizziness upon standing).

3. Medical History:

Chronic Conditions:
  • Neurological disorders (Parkinson’s Disease, stroke, neuropathy).
  • Cardiovascular issues (arrhythmias, orthostatic hypotension).
  • Musculoskeletal problems (arthritis, joint instability).
Recent Illnesses or Hospitalizations:
  • Infections, dehydration, or acute injuries that might contribute to falls.

4. Medication Review:

Polypharmacy:
  • Use of multiple medications increases fall risk.
Specific Drugs:
  • Sedatives, antidepressants, antihypertensives, and diuretics are common culprits.

5. Lifestyle and Environment:

Home Setup:
  • Are there hazards such as loose rugs, poor lighting, or clutter?
Daily Activities:
  • Are falls linked to specific activities or tasks?
  • Use of assistive devices like canes or walkers.

6. Previous Falls:

  • Details about past falls, including injuries or fractures.
  • Psychological impact, such as fear of falling again.

1. General Assessment:

  • Observe the patient’s posture, movements, and gait as they enter the room.
  • Check for signs of frailty, fatigue, or distress.

2. Neurological Examination:

  • Cranial Nerves: Assess visual fields, eye movements, and hearing.
  • Motor Strength: Test for weakness, especially in the legs.
  • Sensation: Evaluate for numbness, tingling, or altered proprioception.
  • Reflexes: Look for hyperreflexia or absent reflexes that might indicate nerve or spinal cord issues.
Cerebellar Function:
  • Finger-to-nose test or heel-to-shin test for coordination.
  • Observe for tremors or ataxia.

3. Gait and Balance Testing:

  • Timed Up and Go (TUG) Test: Measures mobility and fall risk.
  • Romberg Test: Assesses balance with eyes open and closed.
  • Get Up and Go Test: Observes posture, gait, and transitions.

4. Cardiovascular Assessment:

  • Measure blood pressure in different positions (lying, sitting, standing) to identify orthostatic hypotension.
  • Auscultate heart sounds for arrhythmias or murmurs.

5. Musculoskeletal Examination:

  • Joint Stability: Check for pain, stiffness, or instability in the hips, knees, and ankles.
  • Range of Motion: Evaluate flexibility in the lower limbs and spine.
  • Strength Testing: Focus on major muscle groups, especially in the lower extremities.

6. Visual and Vestibular Examination:

  • Visual Acuity: Assess for vision problems that could impair hazard recognition.
  • Vestibular Function: Perform head thrust or Dix-Hallpike maneuvers to identify inner ear disorders like BPPV.

1. Timed Up and Go (TUG) Test

Purpose:
  • Evaluates basic mobility, balance, and fall risk.
Procedure:
  • The patient starts seated in a chair.
  • They stand up, walk a distance of 10 feet (3 meters), turn around, walk back, and sit down.
Assessment Criteria:
  • Time taken to complete the task:
  • Normal: Less than 10 seconds.
  • Increased Fall Risk: More than 12 seconds.
What It Measures:
  • Gait speed, postural transitions, and overall functional mobility.
Clinical Relevance:
  • Longer completion times indicate a higher risk of falls, particularly in older adults or those with neurological conditions like Parkinson’s disease or stroke.

2. Get Up and Go Test

Purpose:
  • Similar to the TUG test but focuses more on qualitative observation of movement patterns.
Procedure:
  • The patient is observed standing from a seated position, walking a short distance, turning, and returning to sit.
Assessment Criteria:
  • Clinician evaluates:
  • Stability during transitions.
  • Gait characteristics, such as stride length and symmetry.
  • Use of assistive devices.
What It Measures:
  • Postural control, balance, and ability to adapt to functional tasks.

3. Romberg Test

  • Assesses balance and proprioception.
  • The patient stands with feet together and arms at their sides: First with eyes open, then with eyes closed.
  • Observe for swaying or loss of balance: Significant swaying or falling with eyes closed indicates proprioceptive or vestibular dysfunction.
What It Measures:
  • Integrity of the sensory systems (proprioception, vestibular, and vision).

MRI

  • Identifies structural abnormalities in the brain or spine, such as strokes, tumors, or vestibular system damage.

Modify

We help you make thoughtful adjustments to daily habits and triggers that can influence the frequency and intensity of Balance & Falls.
“Big and Loud” Therapy
Household Safety Modifications
Mobility Aids

Treat

We provide personalized treatment options to relieve symptoms and support long-term Balance management.

Medications

Therapies

Injections

Ketamine Therapy

Surgical Interventions

Causes

1. Neurological Disorders:

  • Parkinson’s Disease (PD): Postural instability and slow movements make it difficult to recover from sudden balance loss.
  • Stroke: Weakness, poor coordination, and sensory deficits increase the likelihood of falls.
  • Neuropathy: Impaired sensation in the feet and legs disrupts balance and gait.

2. Vestibular Dysfunction:

  • Inner ear disorders like Benign Paroxysmal Positional Vertigo (BPPV) or Meniere’s Disease lead to dizziness, vertigo, and imbalance.

3. Orthostatic Hypotension:

  • Sudden drops in blood pressure when standing cause lightheadedness, fainting, or loss of balance.

4. Vision Problems:

  • Reduced depth perception, blurred vision, or conditions like cataracts make it harder to navigate surroundings.

5. Muscle Weakness and Joint Instability:

  • Weak leg muscles and unstable joints, particularly in the knees and hips, impair mobility.

6. Medications:

  • Sedatives, antihypertensives, or medications causing dizziness or drowsiness increase fall risk.

7. Environmental Hazards:

  • Poor lighting, loose rugs, cluttered pathways, or uneven surfaces in homes or public spaces.

8. Age-Related Changes:

  • Slower reflexes, reduced flexibility, and impaired proprioception (body position awareness).

Predictors of Falls

1. History of Previous Falls:

  • The strongest predictor of future falls.
  • A previous fall indicates underlying risk factors such as balance issues, muscle weakness, or environmental hazards.

2. Balance and Gait Impairments:

  • Unsteady Gait: Difficulty walking in a straight line, shuffling steps, or irregular stride length.
  • Impaired Balance: Inability to stand or walk without support or frequent swaying while standing.

3. Muscle Weakness:

  • Weakness in the legs, hips, or core muscles affects mobility and the ability to recover from balance disturbances.
  • Particularly common in older adults and those with sedentary lifestyles.

4. Medications:

  • Polypharmacy (use of multiple medications) increases fall risk.

Specific drug classes that elevate risk:

  • Sedatives and hypnotics.
  • Antihypertensives (can cause orthostatic hypotension).
  • Antidepressants and antipsychotics (linked to dizziness or drowsiness).

5. Cognitive Impairment:

Conditions such as dementia or mild cognitive impairment (MCI):

  • Reduce hazard awareness.
  • Affect judgment and response times.

6. Sensory Deficits:

  • Vision Impairments: Blurred vision, cataracts, or macular degeneration hinder hazard recognition.
  • Hearing Loss: Reduces awareness of environmental cues, such as approaching obstacles.
  • Neuropathy: Decreased sensation in the feet disrupts proprioception and balance.

7. Dizziness or Vertigo:

  • Vestibular dysfunction, orthostatic hypotension, or inner ear disorders contribute to dizziness and falls, particularly during position changes.

8. Chronic Medical Conditions:

Conditions that affect mobility, strength, or coordination, including:

  • Parkinson’s Disease.
  • Stroke (post-stroke weakness or hemiparesis).
  • Arthritis or other musculoskeletal conditions.

9. Fear of Falling:

  • Leads to reduced activity and physical deconditioning, which weakens muscles and exacerbates balance problems.
  • Often creates a cycle of inactivity and increased fall risk.

10. Environmental Hazards:

  • Poorly lit rooms, loose rugs, uneven flooring, or cluttered pathways significantly increase the likelihood of falls.

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    Causes of Seizures

    1. Structural Causes:

    • Brain Injury: Trauma from accidents or falls.
    • Stroke: Disruption in blood supply to the brain.
    • Brain Tumors: Tumors or lesions can cause seizures by disrupting normal brain activity.
    • Infections: Meningitis, encephalitis, and other infections can trigger seizures.

    2. Genetic Causes:

    • Some types of epilepsy are inherited, with mutations in specific genes affecting brain function and increasing seizure susceptibility.

    3. Metabolic Causes:

    • Electrolyte Imbalances: Low sodium, calcium, or magnesium levels can trigger seizures.
    • Hypoglycemia: Low blood sugar can cause seizures, especially in diabetics.
    • Toxins: Exposure to heavy metals, alcohol withdrawal, or drug toxicity.

    4. Other Causes:

    • Electrolyte Imbalances: Low sodium, calcium, or magnesium levels can trigger seizures.
    • Hypoglycemia: Low blood sugar can cause seizures, especially in diabetics.
    • Toxins: Exposure to heavy metals, alcohol withdrawal, or drug toxicity.

    Types

    There are several types of strokes, each requiring different treatment approaches:

    1. Ischemic Stroke:

    • The most common type, caused by a blood clot blocking blood flow to the brain.
    • Can result from conditions like atherosclerosis (narrowed arteries) or embolism (clots traveling from another part of the body).

    2. Hemorrhagic Stroke:

    • Caused by bleeding in or around the brain, often due to high blood pressure, aneurysms, or trauma.
    • This type is less common but more severe, requiring urgent surgical intervention in many cases.

    3. Transient Ischemic Attack (TIA):

    • Often called a mini-stroke TIA occurs when blood flow is temporarily blocked but resolves within minutes to hours without causing lasting damage.
    • It is a serious warning sign of a potential future stroke and must not be ignored.

    4. Cryptogenic Stroke:

    • Strokes with no identifiable cause even after extensive testing.
    • Often linked to undiagnosed heart or blood vessel conditions.

    Recognizing Stroke Symptoms

    Recognizing the symptoms of a stroke quickly can save lives. Use the acronym FAST to identify key warning signs:

    • F: Facial drooping – Is one side of the face drooping or numb? Ask the person to smile to check for asymmetry.
    • A: Arm weakness – Is one arm weak or numb? Ask the person to raise both arms and see if one drifts downward.
    • S: Speech difficulty – Is the person’s speech slurred or hard to understand? Ask them to repeat a simple sentence.
    • T: Time to call 911 – If any of these signs are present, seek immediate emergency help.

    Other symptoms may include:

    • Sudden numbness or weakness in the legs.
    • Trouble seeing in one or both eyes.
    • Dizziness, loss of balance, or difficulty walking.
    • Severe headache with no known cause.

    Neuromyelitis Optica Spectrum Disorder (NMOSD)

    NMOSD Overview:

    • NMOSD, formerly known as Devic's Disease, is a rare autoimmune condition that primarily affects the optic nerves and spinal cord, leading to episodes of optic neuritis and transverse myelitis.
    • It is often mistaken for MS but is distinct, involving different immune mechanisms and requiring specific treatments.

    Symptoms of NMOSD:

    • Optic Neuritis: Sudden vision loss or pain in one or both eyes.
    • Transverse Myelitis: Inflammation of the spinal cord, causing weakness, numbness, or paralysis.
    • Nausea and Vomiting: Due to brainstem involvement in some cases.

    Diagnosis:

    • Blood tests to check for aquaporin-4 antibodies (AQP4), which are specific to NMOSD and not present in MS.
    • MRI scans to differentiate NMOSD lesions from MS lesions.
    • Spinal fluid analysis may also help rule out MS.

    Treatment for NMOSD:

    • Immunosuppressive Therapy: To prevent attacks (e.g., rituximab, azathioprine, mycophenolate mofetil).
    • Corticosteroids and Plasma Exchange: Used during acute attacks.

    Types

    1. Relapsing-Remitting MS (RRMS):

    • Most common form (85% of cases).
    • Periods of flare-ups (relapses) followed by recovery (remission).
    • Characterized by clear flare-ups followed by periods of remission. At our center, multiple sclerosis therapies and multiple sclerosis therapy treatment are tailored to reduce episodes and prolong remission.

    2. Primary Progressive MS (PPMS):

    • Gradual Worsening: From the start, the disease progresses steadily without clear relapses or remissions.
    • Less Inflammation: PPMS has fewer inflammatory lesions on MRI compared to RRMS.
    • Prevalence: Affects about 10-15% of MS patients.
    • Symptoms: Often involves more mobility issues and progressive weakness.
    • Marked by gradual, steady progression without remission phases. Multiple sclerosis treatments for PPMS at the Brain and Spine Center focus on managing symptoms and slowing progression.

    3. Secondary Progressive MS (SPMS):

    • Transition from RRMS: Starts as RRMS but transitions to a more progressive form.
    • Progression: Symptoms gradually worsen over time with fewer or no relapses.
    • Disability: SPMS leads to more significant disability, although the speed of progression can vary.
    • Treatment for secondary progressive ms is designed to manage the gradual escalation of disability, focusing on slowing progression and maintaining functionality.

    4. Progressive-Relapsing MS (PRMS):

    • Rare Form: Steadily worsens from onset with occasional relapses.
    • Prevalence: Less than 5% of MS cases.

    MS Symptoms

    Physical Symptoms:

    • Fatigue: One of the most common symptoms.
    • Vision Problems: Blurred vision, double vision, or vision loss.
    • Muscle Weakness: Typically affects the legs and causes difficulty walking.
    • Spasticity: Stiffness and muscle spasms.
    • Balance and Coordination Problems: Difficulty walking or maintaining balance.
    • Numbness and Tingling: Sensations in arms, legs, or face.
    • Bladder and Bowel Issues: Urgency, incontinence, or constipation.

    Cognitive and Emotional Symptoms:

    • Cognitive Issues: Problems with memory, focus, and problem-solving.
    • Depression and Anxiety: Common in MS patients.
    • Emotional Lability: Uncontrollable laughing or crying.

    Pain Characteristics

    1. Positive Symptoms (New Sensations):

    • Burning pain.
    • Electric shock sensations.
    • Stabbing or shooting pain.
    • Hypersensitivity to touch.
    • Pins and needles sensations.

    2. Negative Symptoms (Loss of Normal Sensation):

    • Numbness.
    • Reduced temperature sensation.
    • Decreased sensitivity to touch.
    • Loss of positional awareness.

    Types

    Neurological pain stems from dysfunction or damage in the nervous system and manifests differently based on its origin.

    1. Central Pain:

    • Originates from damage to the brain or spinal cord.

    Symptoms:

    • Persistent burning sensations.
    • Sharp, stabbing pain.
    • Altered perception of temperature.
    • Hypersensitivity to touch or movement.

    2. Peripheral Pain:

    • Arises from damage or irritation in peripheral nerves outside the brain and spinal cord.

    Symptoms:

    • Shooting, electric shock-like pain.
    • Tingling or numbness.
    • Burning sensations.
    • Increased sensitivity to stimuli (hyperalgesia).

    Types of Tremor

    • Essential Tremor (ET): Affects hands, head, voice; worsens with movement.
    • Resting Tremor: Occurs when muscles are relaxed (common in PD).
    • Action Tremor: Occurs during voluntary movements.
    • Physiological Tremor: Normal, becomes noticeable under stress.

    Symptoms

    Cardiovascular Symptoms:

    • Orthostatic hypotension (lightheadedness or fainting when standing), tachycardia (rapid heart rate), palpitations, or blood pressure fluctuations.

    Gastrointestinal Symptoms:

    • Nausea, bloating, diarrhea, constipation, or difficulty swallowing.

    Thermoregulatory Symptoms:

    • Heat intolerance, excessive sweating (hyperhidrosis), or lack of sweating (anhidrosis).

    Neurological Symptoms:

    • Fatigue, brain fog, headaches, or neuropathic pain.

    Other Symptoms:

    • Visual disturbances, urinary retention, or bladder dysfunction.

    Tremor Symptoms

    Parkinson’s Disease

    • Progressive neurological disorder affecting movement due to loss of dopamine-producing neurons.

    Motor Symptoms (PD):

    • Tremor: Pill-rolling tremor at rest.
    • Rigidity: Stiffness causing discomfort (Shoulder and back pain).
    • Bradykinesia: Slowness of movement.
    • Postural Instability: Tendency to fall backward, shuffling gait.

    Non-Motor Symptoms (PD) :

    • Cognitive impairment, depression, anxiety.
    • Hallucinations, REM sleep disorder (acting out dreams), daytime sleepiness.
    • Orthostatic hypotension, constipation, urinary problems.
    • Loss of smell, pain, speech difficulties.

    Types of Parkinson’s Disease (PD)

    • Idiopathic PD: Most common form, unknown causes.
    • Vascular Parkinsonism: Caused by strokes or blood vessel issues.
    • Atypical Parkinsonism: Mimics PD but doesn’t respond to traditional treatments. Examples include Lewy Body, Multi system atrophy, PSP.

    Types of Sleep Disorders

    1. Insomnia

    • Definition: Difficulty falling asleep, staying asleep, or waking up too early and not being able to go back to sleep. It results in poor sleep quality and impairs daily functioning.

    Types of Insomnia:

    • Acute Insomnia: Short-term, often triggered by stress, illness, or environmental factors (e.g., noise or temperature).
    • Chronic Insomnia: Occurs at least 3 times per week and lasts for 3 months or more. Can be associated with medical or psychiatric conditions.
    • Primary Insomnia: Not caused by another health condition or substance use.
    • Secondary Insomnia (Comorbid Insomnia): Linked to another issue such as depression, anxiety, pain, or medications.

    2. Hypersomnia

    • Definition: Excessive daytime sleepiness despite adequate or prolonged nighttime sleep. People with hypersomnia may also struggle to stay awake during the day.

    Types of Hypersomnia:

    • Primary Hypersomnia: Characterized by excessive daytime sleepiness without any other sleep disorders being present (e.g., idiopathic hypersomnia).
    • Secondary Hypersomnia: Caused by other conditions, such as sleep apnea, narcolepsy, or medications. It can also be linked to depression, head injury, or drug or alcohol use.

    Symptoms of Sleep Disorder

    1. Insomnia

    Symptoms:

    • Difficulty falling asleep at night.
    • Waking up frequently during the night.
    • Waking up too early and being unable to go back to sleep.
    • Daytime fatigue, irritability, or poor concentration.

    2. Hypersomnia

    Symptoms:

    • Difficulty waking up after long periods of sleep.
    • Persistent daytime drowsiness.
    • Falling asleep during conversations, eating, or driving.

    3. Obstructive Sleep Apnea (OSA)

    • Definition: A common sleep disorder where the upper airway becomes blocked repeatedly during sleep, reducing or stopping airflow.

    Symptoms:

    • Loud snoring.
    • Gasping or choking during sleep.
    • Daytime sleepiness and fatigue.
    • Morning headaches or dry mouth.

    Risk Factors:

    • Obesity, age, large neck circumference, and family history.

    Complications:

    • Untreated OSA can lead to heart disease, hypertension, stroke, and diabetes.

    4. Narcolepsy

    • Definition: A chronic sleep disorder characterized by overwhelming daytime sleepiness and sudden attacks of sleep, regardless of the amount of sleep obtained at night.

    Symptoms:

    • Excessive Daytime Sleepiness (EDS): Feeling an uncontrollable urge to sleep during the day.
    • Cataplexy: Sudden loss of muscle tone triggered by strong emotions like laughter or surprise.
    • Sleep Paralysis: Temporary inability to move or speak while falling asleep or waking up.
    • Hallucinations: Vivid dreams or sensory experiences while falling asleep or waking up.

    The International Headache Society (IHS) Criteria

    Doctors use these guidelines to diagnose migraines.
    • At least 5 headache episodes
    • Headaches lasting 4-72 hours

    At least two of these features:

    • Pain on one side of your head
    • Pulsing or throbbing pain
    • Moderate to severe pain intensity
    • Pain that gets worse with physical activity

    At least one of these symptoms:

    • Nausea or vomiting
    • Sensitivity to light and sound

    Types of Migraines

    1. Episodic Migraines

    • Occur less than 15 days per month
    • May be infrequent (less than once a month) or frequent (several times a month)

    2.Chronic Migraines

    • Headaches occur 15 or more days per month
    • At least 8 of these headaches have migraine features
    • Can significantly impact quality of life

    3.Migraine with Aura

    • Visual symptoms like flashing lights or blind spots before the headache
    • Can also include numbness, tingling, or difficulty speaking

    4.Migraine without Aura

    • The most common type
    • Occurs without the warning signs seen in migraine with aura

    5.Vestibular Migraine

    • Includes dizziness and balance problems
    • May or may not include headache pain

    6.Menstrual Migraine

    • Occurs in relation to the menstrual cycle
    • Often more severe and harder to treat than other migraines

    7.Hemiplegic Migraine

    • Rare type that includes temporary weakness on one side of the body
    • Can mimic stroke symptoms

    8.Migraine equivalent

    • Only neurological symptoms occur and a headache never appears.

    Common Symptoms of Migraines

    • Throbbing or pulsing pain, often on one side of the head
    • Sensitivity to light (photophobia)
    • Sensitivity to sound (phonophobia)
    • Nausea and sometimes vomiting
    • Dizziness or feeling off-balance
    • Visual disturbances (aura) in some people

    Assess Your Migraine Severity: The MIDAS Score

    To better understand how migraines affect your life, doctors often use a tool called the Migraine Disability Assessment (MIDAS) questionnaire.

    What is the MIDAS Score?

    • A simple questionnaire that measures the impact of migraines on your daily activities
    • Helps you and your doctor understand how much migraines are affecting your life
    • Can be useful in deciding on treatment plans

    How it works

    • You answer five questions about how migraines have affected your activities over the last 3 months
    • Questions cover missed days of work/school, household work, and social activities
    • Your answers are added up to give a total score

    What the scores mean

    • 0-5: Little or no disability
    • 6-10: Mild disability
    • 11-20: Moderate disability
    • 21+: Severe disability

    Why it's helpful

    • Provides a clear measure of migraine impact
    • Helps track changes in your condition over time
    • Assists your doctor in choosing the most appropriate treatments

    EEG Monitoring Internship

    Brain and Spine Center and Nuronz would like to offer students an opportunity to work from home for a neurology clinic and learn basic and advanced EEG monitoring.

    EEG is a tool used to monitor brain activity in patients with neurological diseases such as confusion, dementia, and seizures. This is a wonderful opportunity for introduction into the world of neuroscience, as brain wave activity is the building block of wakefulness, sleep, and its role in patients with dementia and seizures. This will also help meet the goals for clinical hours required for graduate and medical school applications.

    Internship Details:

    • At least 6 months to 1-year commitment.
    • Work from home. HIPAA compliant environment will be provided.
    • We will provide training on basic EEG learning and its application in remote monitoring.
    • Applicants will learn normal and abnormal EEG activity. Applicants will be taught to recognize wave patterns during normal awake, sleep and in patients with neurological disease.
    • The work would entail a shift work of 6 hours with a commitment of 1-3 shifts/week.
    • Shift work (all in AZ time): 12:00 AM—6:00 AM, 6:00 AM—12:00 PM, 12:00 PM—6:00 PM, 6:00 PM—12:00 AM
    • Priority will be given to those who can work overnight shift 12:00 AM—6:00 AM AZ time (3:00 AM—9:00 AM ET)
    • During the shift work, live support will be provided by a registered EEG Technician.

    Hemant Pandey

    Anjanette Kibby

    Simon Parkinson,
    FNP-C

    About

    Simon grew up in North Wales before moving to London where he trained as a nurse. He moved to Phoenix, Arizona in 1999, to work in field of neurosurgery at the Barrow Neurologic Institute. He worked there between 1999 and 2005 when he graduated as a Family Nurse Practitioner from the University Phoenix.
    Simon has been a nurse practitioner in family practice and neurosurgery, where he developed an interest in the care and treatment of patients with neck pain, back pain, neuropathy, as well as fostering a specific interest in the treatment and prevention of headaches. He is currently a member of the American Academy of Neuroscience Nursing and holds his CNRN certification.

    Types of Seizures

    1. Classification by Cause:

    • Primary (Epileptic) Seizures: Seizures that occur without a clear trigger, often due to genetic or developmental causes. These are associated with epilepsy.
    • Secondary (Symptomatic) Seizures: Caused by an identifiable condition, such as a brain injury, infection, stroke, or metabolic imbalances.

    2. Classification by Symptoms and Area of Brain Involvement:

    Focal Seizures (Partial Seizures):

    Focal Onset Aware (Simple Partial Seizures):

    • Occur in one part of the brain.
    • Consciousness is not impaired.
    • Symptoms: Twitching, unusual smells/tastes, visual distortions, or tingling sensations in limbs.

    Focal Onset Impaired Awareness (Complex Partial Seizures):

    • Start in one part of the brain but impair consciousness.
    • Symptoms: Staring, repetitive movements (chewing, hand movements), and confusion after the event.

    Generalized Seizures:

    Absence Seizures (Petit Mal):

    • Brief periods of staring or "spacing out" that last a few seconds.
    • More common in children.

    Tonic-Clonic Seizures (Grand Mal):

    • Loss of consciousness with stiffening of muscles (tonic phase) followed by rhythmic jerking (clonic phase).
    • Can last several minutes and may involve loss of bladder control and tongue biting.

    Myoclonic Seizures:

    • Sudden, brief jerks or twitches of the arms or legs.
    • Usually no loss of consciousness.

    Atonic Seizures (Drop Attacks):

    • Sudden loss of muscle tone, causing the person to collapse.
    • Brief, but high risk of injury due to falls.

    Tonic Seizures:

    • Sudden stiffening of muscles, often in the arms, legs, or trunk, leading to falls.

    Clonic Seizures:

    • Rhythmic jerking movements, typically affecting the arms, neck, and face.

    Unknown Onset Seizures:

    • Seizures where it is unclear whether they are focal or generalized, often due to insufficient data (e.g., no witness, or it happens during sleep).

    Types

    1. Postural Orthostatic Tachycardia Syndrome (POTS):

    • Characterized by increased heart rate (>30 bpm in adults, >40 bpm in adolescents) within 10 minutes of standing without significant blood pressure drop.
    • Symptoms: Fatigue, dizziness, brain fog, nausea, and exercise intolerance.

    2. Neurocardiogenic Syncope (Vasovagal Syncope):

    • Sudden fainting due to a temporary drop in heart rate and blood pressure.
    • Symptoms: Dizziness, nausea, and loss of consciousness triggered by prolonged standing, stress, or pain.

    3. Multiple System Atrophy (MSA):

    • A progressive neurodegenerative disorder affecting autonomic function and motor control.
    • Symptoms: Severe orthostatic hypotension, urinary incontinence, and parkinsonian or cerebellar features.

    4. Familial Dysautonomia (Riley-Day Syndrome):

    • A rare genetic condition primarily affecting Ashkenazi Jewish populations.
    • Symptoms: Altered pain perception, orthostatic hypotension, and gastrointestinal dysmotility.

    5. Pure Autonomic Failure (PAF):

    • A disorder marked by gradual loss of autonomic nerve function.
    • Symptoms: Orthostatic hypotension, anhidrosis, and bladder dysfunction.

    ASU | Pre-Health Internship Program (PHIP) Scribes

    Working as a scribe in a neuroscience office provides a wealth of opportunities to delve into the current landscape of neuroscience. This field is not limited to medical care but also encompasses brain wave activities, research, and its interplay with artificial intelligence.
    Our clinic occupies a unique position, offering incoming students a comprehensive understanding of disease processes, patient interactions, and the documentation tasks typically associated with scribing.

    At the Brain and Spine Center, you will get the opportunity to:

    • Document medical histories, examinations, and present illnesses
    • Chart prep for providers to gain familiarity with electronic medical records
    • Learn the rationale behind assessments, the intricacies of neurological examinations, history taking, and the disease process
    • Understand imaging and lab findings and how they are implicated in basic neurological diseases
    • Shadow providers during patient visits and minor procedures
    • Potential opportunities to participate in research, aid in publishing case reports or other findings

    We are looking for students who have:

    • Commitment of 6 months to 1 year minimum
    • Reliable transportation to our offices in Chandler or Casa Grande
    • Proficient typing and computer skills
    • Fast learning ability
    • Proficient in oral and written communication

    Prolonged EEG with Intermittent Monitoring (pEEG)

    Indication

    Prolonged EEG with intermittent monitoring is used for patients requiring extended brain activity observation. It is commonly indicated for:
    • Detecting intermittent or rare seizures that may not appear on routine EEG
    • Assessing patients with unexplained altered consciousness or encephalopathy
    • Monitoring brain activity in patients at risk of non-convulsive status epilepticus

    Process

    • Electrodes are attached to the patient’s scalp and remain in place for an extended period, typically 24-72 hours.
    • Brain activity is recorded continuously while intermittent monitoring is performed by trained technologists or neurologists.
    • The patient’s activity (e.g., sleeping, eating, or specific triggers) may be logged to correlate events with brain wave patterns.
    • The recorded data is reviewed for abnormalities, including seizures or other electrical disturbances.

    Instructions for Patients

    Before the Procedure:

    • Wash your hair the night before and avoid applying conditioner, hair spray, or gels.
    • Continue taking prescribed medications unless instructed otherwise.
    • Avoid caffeine for at least 8 hours before the test.

    During the Procedure:

    • Wear loose, comfortable clothing.
    • Bring items to keep yourself entertained, as the test may require staying in one location for prolonged periods.
    • Avoid disconnecting or tampering with the electrodes or wires.

    Benefits

    • Captures rare or infrequent seizure events missed on shorter EEG studies.
    • Provides a comprehensive evaluation of brain activity over time.
    • Helps guide diagnosis and treatment adjustments in complex cases.

    Side Effects

    • Mild skin irritation or discomfort from electrode placement
    • Temporary inconvenience due to the extended duration of monitoring
    Discuss with your neurologist to determine if prolonged EEG with intermittent monitoring is suitable for your condition.

    Ted Etling,
    PsyD

    About

    Licensed psychologist specializing in clinical neuropsychology and has extensive knowledge and training in brain behavior/cognitive functioning. He assesses the cognitive impact of dementia, Parkinson’s and Multiple Sclerosis, traumatic brain injuries and stroke as well as seizure activity. Dr. Etling received his masters and doctorate degrees from Illinois School of Professional Psychology in Schaumberg, Illinois after obtaining a 4 -year undergraduate degree from Azusa Pacific University in Azusa, California. His predoctoral training was completed at Wright State University/Miami Valley Hospital in Dayton, Ohio. A 2-year post-doctorate training position in neuropsychology/cognitive rehabilitation was completed at JFK Medical Center/Center for Head Injuries and Brain Trauma Unit in Edison, NJ. He is licensed to practice in the State of Arizona. He also completed additional residency training at Arizona Neuropsychological Services focused on testing and diagnosing dementias.

    Karen Garcia,
    DNP, APRN, FNP- C

    About

    Karen Garcia’s journey in healthcare has been shaped by her commitment to understanding the complexities of the human body and mind. Her academic pursuit began with a Bachelor’s degree in Psychology from the University of Texas at San Antonio, followed by a Master’s degree from St. Mary’s University in Texas. These foundational years fueled her fascination with the intricate connection between mental health and physical well-being, which would later guide her career path.
    After completing her studies in psychology, Karen sought to apply her knowledge directly to patient care. This aspiration led her to pursue a nursing degree at Arizona State University, where she honed her clinical skills and developed a deep passion for patient advocacy and hands-on care. She built a strong foundation as a cardiac nurse for four years and an orthopedic nurse for six years. Her desire to bridge her psychology background with advanced healthcare practice led her to enroll in the Doctor of Nursing Practice (DNP) program at the University of Arizona. There, she refined her leadership abilities and clinical expertise, empowering her to drive positive change in healthcare.
    Karen’s primary focus in healthcare has evolved into a specialization in neurology, particularly neuropathy and sleep medicine. She is deeply passionate about the role of sleep in overall health and is currently dedicated to expanding the sleep program at the Brain and Spine Center. Karen believes that improving sleep quality is a critical component of both neurological and overall health, and she is enthusiastic about working with a team committed to advancing this field.
    Karen’s upbringing as an Army ‘brat’ has taken her to Germany (twice), Virginia, Kansas, and Texas, with Texas remaining her home until she moved to Arizona in 2005. She fell in love with Arizona when her husband, an Air Force member, was stationed there. In her spare time, Karen enjoys traveling, reading true crime and mystery novels, playing board games, skiing, hiking, riding rollercoasters, shopping, and spending time with her husband, daughter, and two fur babies. She dreams of spending more time at the beach, traveling, and exploring new languages and cultures.

    Awards and Recognitions

    • Two Daisy Award Nominations for compassionate and high-quality nursing practice.
    • Volunteer service with the Banner University Wound and Ostomy Team.
    • Active member of the Unit Safety Council, contributing to healthcare standards and patient safety.

    Professional Memberships

    • American Academy of Neurology.
    • American Academy of Sleep Medicine.

    Diala Manfoukh,
    PA-C

    About

    Diala Manfoukh earned her Master of Science in Physician Assistant Studies from A.T. Still University in Mesa, Arizona, graduating in September 2023. She previously completed her Bachelor of Science at Arizona State University, staying true to her Arizona roots.
    Diala chose neurology because it is an exciting and fast-growing field that translates skills in science, technology, medicine, and engineering into real-life solutions that help everyday people. She finds studying the brain especially rewarding, as it allows her to contribute to building the future and expanding our understanding of ourselves and our society. Her passion for neurology was further solidified during her four years as a medical scribe at Brain and Spine, where she developed strong connections with patients at both the Chandler and Casa Grande locations.
    In recognition of her professionalism and positive attitude throughout PA school, Diala was honored with the DPAS Professionalism Award from A.T. Still University in September 2023. She is also a certified Physician Assistant through the National Commission on Certification of Physician Assistants (NCCPA).
    Diala is deeply committed to community service. She volunteers with various Arizona Muslim organizations, focusing on youth mentorship, and has contributed to global humanitarian efforts through organizations like Helping Hand for Relief and Development.
    At home, Diala cherishes the time she spends with her close-knit family, which includes her supportive parents and her younger brother and sister. Outside of work, she is a passionate crafter who finds joy in exploring different art forms. Whether painting vibrant canvases, knitting cozy creations, or designing unique jewelry, she loves bringing her ideas to life.
    In her dream scenario, Diala would embark on a journey to explore every corner of the globe, immersing herself in diverse cultures, cuisines, and traditions. After fulfilling her wanderlust, she envisions opening a cozy coffee shop that doubles as a petting zoo—a place where people can relax, connect with animals, and experience simple joys in a welcoming environment. Beyond these personal aspirations, Diala is deeply passionate about advocating for peace and improving humanity on a global scale. She dreams of working at a legislative level to champion causes that promote equality, justice, and a better future for all.

    Dr. Hemant Pandey,
    MD

    About

    – Championing Dementia Care, Biomarker Research, and Community Engagement

    Clinical Expertise

    • Board-certified neurologist specializing in Cognitive Neurology, Clinical Neurophysiology, Vascular Neurology, and Sleep Medicine.
    • Expertise in advanced diagnostics and therapies, including EEG, ambulatory EEG, EMG, Botox injections for migraine and dystonia, Deep Brain Stimulation for Parkinson’s disease, and Vagus Nerve Stimulation for epilepsy.
    • Founder and CEO of the Brain & Spine Center in Chandler, Arizona.

    Dementia and Biomarker Research

    • Over 15 years of dedicated experience in dementia care and Alzheimer’s disease research.
    • Early adopter of plasma biomarkers, including p-tau 217, for the early detection of Alzheimer’s disease and disease stratification.
    • Principal investigator in over 25 clinical trials, including studies on Alzheimer’s disease, neuropathy, migraine, and neurological disorders.
    • Collaborated with leading biomarker companies to implement cutting-edge diagnostic tools in clinical practice.

    Publications and Research Contributions

    • Authored over 15 posters and peer-reviewed publications.
    • Presented research at prestigious conferences, including the American Academy of Neurology, AANEM, AAES, and Southern Medical Assembly.

    Community Service and Education

    • Partnered with Memory Cafes, residential facilities, and local support organizations to provide resources for dementia patients and their families.
    • Actively engages in public and physician education through talks and workshops on dementia care and plasma biomarkers.
    • Developed teaching programs for medical students, nurse practitioners, and high school interns, fostering future healthcare professionals.
    • Organized rotations and mentorships in neurology for students from AT Still University, the FAST-TRACK program, and the University of Arizona College of Nursing.

    Research Trials

    • Led pivotal studies on Alzheimer’s treatments, including:
    • Anti-amyloid drugs for early symptomatic Alzheimer’s disease.
    • Monoclonal antibodies targeting tau protein for cognitive and functional decline prevention.
    • Studies on agitation and psychosis in Alzheimer’s patients.
    • Principal investigator for migraine prevention trials, diabetic neuropathy treatment, and neurodegenerative disease interventions.

    Speaker and Advocate

    • Speaker for Eisai and Lilly, promoting advancements in Alzheimer’s treatments and biomarker utilization.
    • Advocate for integrating plasma biomarker testing into primary care for early Alzheimer’s detection. Working with emerging plasma Biomarker companies.

    Awards and Leadership

    • Former Stroke Director at Chandler Regional Medical Center, where he developed comprehensive stroke protocols and trained multidisciplinary teams.
    • Recognized for his leadership in neurology and dedication to advancing dementia care in the community.
    • Top Doc Phoenix award for 2018, 2019, and 2024
    • Featured as ‘Men of Chandler’ in Chandler Magazine.

    Personal Life and Interests Awards and Leadership

    • Married to a musculoskeletal radiologist and proud father of three boys, the oldest of whom is an Eagle Scout.
    • Active participant in his sons' Scouting journeys, fostering leadership and outdoor skills.
    • A dedicated teacher at Chinmaya School, where he introduces students to Indian philosophy and values.
    • Host of large Indian festivities, celebrating culture and fostering community connections.
    • Actively practices and teaches non-dualist philosophy, inspiring others as a Sunday School teacher.
    • Enjoys family time with his golden retriever.

    Anjanette Kibby,
    FNP-C

    About

    Anjanette Kibby holds a BA in Psychology from the University of Texas San Antonio, a BS in Nursing from the University of Texas Arlington, and a Master of Nursing as a Family Nurse Practitioner from the University of Phoenix.
    Anjanette’s career in healthcare has been marked by her dedication to providing exceptional care and her passion for neurology. She has been with the Brain and Spine Center since 2021, where she continues to be fascinated by the brain’s role in governing thoughts, emotions, movement, and consciousness. She enjoys the diversity of neurological conditions but holds a special interest in movement disorders. These conditions often present unique challenges and complexities, making their management both demanding and rewarding. Despite the lack of cures for many movement disorders, Anjanette finds the field’s ongoing innovation and progress inspiring, and she takes pride in implementing cutting-edge advancements into patient care.
    Throughout her career, Anjanette has built meaningful relationships with her patients and their families. She treasures the long-term nature of neurological care, allowing her to develop deep connections that often feel like an extension of her own family. She considers it a profound privilege to provide care in such an impactful way.
    Outside of her professional life, Anjanette has served on the Fairview Heights Library Board and volunteered at the Fairview Heights Food Pantry and local church refugee triage events. Her family has also hosted BE THE MATCH bone marrow screening drives in St. Louis, Atlanta, and Phoenix. During her undergraduate studies, she worked at Jim Cullum’s Landing, a jazz club on the San Antonio River Walk, where she fell in love with jazz music and met her husband, David. Married for 30 years, Anjanette and David have three sons and a daughter and are now enjoying the empty-nesting and grandparenting stage of life. They enjoy golf, pickleball, and chasing their grandchildren around playgrounds. If time and money were no object, Anjanette would love to cruise frequently, spending her days immersed in fiction by her favorite authors, Ken Follett and Brandon Sanderson, and evenings watching ocean waves.

    Awards and Recognitions

    • Recipient of The Daisy Award for Extraordinary Nurses.
    • Certifications: Certified Critical Care Nurse (CCRN) and Progressive Care Certified Nurse (PCCN) while working in the ICU at Chandler Regional Medical Center.

    Professional Memberships

    • American Association of Nurse Practitioners.
    • International Parkinson and Movement Disorder Society.
    • American Academy of Neurology.
    • The Association of Movement Disorder Advanced Practice Providers.

    Jan Levine,
    RN, MSN, FNP-BC

    About

    Jan Levine is a Clinical Research Investigator at MD First Research Chandler, with a distinguished career in neurology and clinical research. Born and raised in Arizona, Jan graduated from Arizona State University in 1999 and began her medical career as a CV/Trauma/Surgical ICU nurse, a role she excelled in for 10 years.
    In 2009, Jan earned her Master of Science in Nursing and Family Nurse Practitioner degree from Grand Canyon University. She subsequently spent a decade in private neurology practice, providing comprehensive care for patients at her office and at institutions like Banner University Hospital and Abrazo Heart Hospital. Her expertise encompassed neuromuscular disorders, neurodegenerative diseases, epilepsy, movement disorders, headaches, and spinal conditions.
    During her last five years in practice, Jan specialized in headache syndromes, treating conditions such as migraines, cluster headaches, and trigeminal neuralgia. She administered neurotoxin injections with Botox, Dysport, and Xeomin for migraines, blepharospasm, cervical dystonia, and limb spasticity.
    Her skills also included lumbar punctures, skin biopsies, deep brain stimulation (DBS) programming, vagus nerve stimulation (VNS), and nerve blocks. An advocate for advancing neurological care, she contributed to research studies on neuromuscular and neurodegenerative diseases and migraines. Her work has been presented at the American Academy of Neurology and published in medical journals.
    For the past five years, Jan has worked with CND Life Sciences, where her research has focused on diagnostic skin biopsy testing for synucleinopathies such as Parkinson’s disease, Lewy Body Dementia, Pure Autonomic Failure, Multiple System Atrophy, and REM Sleep Behavior Disorder.
    Jan resides in Paradise Valley with her two dogs. Outside of her professional commitments, she enjoys staying active at the gym, hiking, playing tennis, traveling, and spending time with her dogs. She is also passionate about cooking and baking.

    Inspire Sleep Device

    Indication

    The Inspire sleep device is used for patients with:
    • Obstructive sleep apnea (OSA) who cannot tolerate CPAP therapy
    • Moderate to severe OSA confirmed by sleep studies

    Process:

    Pre-Procedure:

    • The device is implanted during a minimally invasive outpatient surgery.
    • The system includes a small generator, a sensing lead, and a stimulation lead.

    How It Works:

    • The device monitors breathing patterns during sleep.
    • It gently stimulates the hypoglossal nerve, keeping the airway open.

    Follow-Up:

    • Patients activate the device using a remote control before sleep.
    • Regular follow-ups ensure the device settings are optimized.

    Insurance Verification

    • Insurance coverage will be verified before the procedure.

    Instructions for Patients

    Before Surgery:

    • Fast as instructed and arrange transportation.

    After Surgery:

    • Avoid heavy lifting or strenuous activities for a few weeks.
    • Follow up with the sleep specialist for adjustments.

    Benefits

    • Improves sleep quality and reduces snoring.
    • Non-invasive, long-term management of OSA.
    • Enhances overall quality of life.

    Side Effects

    • Mild discomfort at the implantation site
    • Temporary tongue or throat soreness

    Video Nystagmography (VNG)

    Indication

    Video Nystagmography is a diagnostic test used to evaluate:
    • Balance disorders
    • Dizziness and vertigo
    • Unexplained falls or unsteadiness
    • Inner ear dysfunction

    Process:

    Preparation

    • The patient wears special goggles with cameras to track eye movements.
    • The test room is darkened for accurate recordings.

    Tests Performed:

    • Ocular Motility Test: Patient follows moving targets with their eyes.
    • Positional Testing: Head and body are moved to assess changes in eye movement.
    • Caloric Testing: Warm and cool air or water is introduced into the ear canal to stimulate the inner ear.

    Duration:

    • The test takes 60-90 minutes and is non-invasive.

    Insurance Verification

    • Insurance coverage will be verified prior to the procedure.

    Instructions for Patients

    • Before the Procedure:
    • Avoid caffeine, alcohol, and medications affecting balance 24 hours before the test.
    • Wear comfortable clothing and avoid heavy makeup.

    After the Procedure:

    • You may feel mild dizziness; it should resolve within minutes.

    Benefits

    • Identifies the root cause of balance and dizziness issues.
    • Helps tailor treatment for vestibular disorders.

    Side Effects

    • Temporary dizziness or nausea during the test

    Follow-Up

    • Results will be reviewed and discussed during your follow-up appointment.

    Nutrition Therapy for Dementia: The MIND Diet

    Indication

    Nutrition therapy, specifically the MIND diet, supports brain health and is recommended for:
    • Individuals at risk of cognitive decline
    • Patients with mild cognitive impairment (MCI) or dementia
    • Older adults aiming to maintain brain health

    Dietary Components

    Brain-Healthy Foods:

    • Green leafy vegetables: Spinach, kale, and collard greens (6+ servings per week)
    • Berries: Blueberries and strawberries (2+ servings per week)
    • Nuts: Almonds, walnuts, or cashews (daily handful)
    • Whole grains: Brown rice, quinoa, oats (3 servings daily)
    • Fish: Salmon, mackerel, or sardines (at least once a week)
    • Poultry: Chicken or turkey (2 servings per week)
    • Olive oil: As a primary cooking fat

    Foods to Limit:

    • Butter, margarine, and trans fats
    • Red meat (limit to fewer than 4 servings per week)
    • Fried foods and sweets

    Insurance Verification

    • Insurance coverage will be verified for any related consultations or interventions.

    Instructions for Patients

    • Plan meals ahead using brain-healthy recipes.
    • Incorporate a variety of colorful fruits and vegetables.
    • Stay hydrated and avoid excessive salt and sugar.

    Benefits

    • May slow cognitive decline
    • Improves cardiovascular health, which supports brain function
    • Offers a structured approach to healthy eating

    Follow-Up

    • Patients will meet with a nutritionist to discuss tailored recommendations. Progress and outcomes will be reviewed during follow-up visits.

    Cognitive Therapy for Patients with Dementia or Alzheimer’s Disease

    Indication

    Cognitive therapy is a non-pharmacological approach to support brain function and emotional well-being in patients with dementia or Alzheimer’s disease. It is indicated for:
    • Early to moderate stages of Alzheimer’s disease
    • Patients experiencing memory loss, confusion, or difficulty with daily activities
    • Improving quality of life and maintaining cognitive abilities

    Goals of Therapy

    • Stimulate brain function through structured mental exercises
    • Enhance memory, attention, and problem-solving skills
    • Improve communication and emotional well-being
    • Maintain independence in daily activities for as long as possible

    Process

    Initial Assessment:

    • A therapist evaluates the patient’s cognitive strengths, challenges, and daily routines.

    Therapy Sessions:

    • Conducted individually or in small groups, sessions involve tasks such as:
    • Memory exercises (e.g., recalling recent events or familiar names).
    • Problem-solving activities like puzzles or sequencing tasks.
    • Orientation exercises to help with time, place, and personal details.
    • Reminiscence therapy using photos or music to evoke positive memories.

    Family Involvement:

    • Caregivers may be trained to support activities at home and create a structured, calming environment.

    Instructions for Patients and Caregivers

    • Maintain a consistent routine to reduce confusion and anxiety.
    • Encourage participation in therapy sessions and follow-up activities.
    • Use visual aids, labels, or reminders to assist with orientation.
    • Foster a supportive environment with patience and reassurance.

    Benefits

    • Helps delay cognitive decline and improve daily functioning.
    • Reduces anxiety and frustration related to memory loss.
    • Enhances social interaction and emotional health.

    Side Effects

    • None directly, though therapy may be mentally tiring at times.
    Discuss with your neurologist or therapist to determine if cognitive therapy is suitable for your condition or your loved one’s care.

    Autonomic Testing

    Indication

    Autonomic testing evaluates the function of the autonomic nervous system, which controls involuntary bodily functions like heart rate, blood pressure, and digestion. It is commonly indicated for:
    • Diagnosing autonomic neuropathy in conditions like diabetes or Parkinson’s disease
    • Evaluating unexplained fainting, dizziness, or lightheadedness (syncope)
    • Assessing blood pressure regulation issues such as orthostatic hypotension or POTS (Postural Orthostatic Tachycardia Syndrome)
    • Monitoring progression of autonomic disorders

    Process

    1. Heart Rate and Blood Pressure Tests:

    • Measures changes in heart rate and blood pressure in response to breathing exercises or positional changes.

    2. Tilt Table Test:

    • Evaluates how blood pressure and heart rate respond when the patient transitions from lying down to an upright position.

    3. Sudomotor Tests:

    • Assesses sweat gland function to detect nerve damage affecting sweating.

    4. Other Tests:

    • Valsalva maneuver or specialized breathing tests to evaluate autonomic responses.
    The procedure is non-invasive, typically lasting 60-90 minutes, and is customized based on symptoms.

    Instructions for Patients

    Before the Procedure:

    • Avoid caffeine, nicotine, and alcohol for at least 24 hours before the test.
    • Do not eat a heavy meal within 2-3 hours before testing.
    • Wear comfortable clothing and bring any medications for review by the doctor.

    During the Procedure:

    • Follow instructions to perform specific tasks such as deep breathing or lying in different positions.
    • Notify the technologist if you feel discomfort or dizziness.

    Benefits

    • Provides detailed insights into autonomic nervous system function.
    • Helps diagnose and manage conditions like dysautonomia, POTS, and neuropathy.
    • Guides treatment strategies to improve symptoms and quality of life.

    Side Effects

    • Temporary dizziness or lightheadedness during positional changes
    • Rarely, mild discomfort during specific tests
    Discuss with your neurologist to determine if autonomic testing is appropriate for your condition.

    Causes

    1. Primary Causes:

    • Postural Orthostatic Tachycardia Syndrome (POTS).
    • Familial Dysautonomia (Riley-Day Syndrome).
    • Multiple System Atrophy (MSA).

    2. Secondary Causes:

    • Diabetes Mellitus: Affects peripheral nerves and autonomic function.
    • Autoimmune Diseases: Sjögren’s syndrome, lupus, and others can target autonomic nerves.
    • Connective Tissue Disorders: EDS and related conditions impact vascular stability.
    • Infections: Lyme disease, Epstein-Barr virus, or COVID-19-associated dysautonomia.
    • Toxicity: Chemotherapy, heavy metals, or alcohol abuse.

    Botox for Migraine

    Botox (onabotulinumtoxinA) is an FDA-approved treatment for chronic migraine, defined as headaches occurring 15 or more days per month with at least 8 migraine days. It helps prevent migraines by relaxing specific muscle groups and blocking the release of chemicals involved in pain transmission.

    Benefits

    • Reduces the frequency, duration, and severity of migraines
    • Improves quality of life
    • Minimizes reliance on daily medications

    Frequency

    • Injections are typically administered every 12 weeks.

    Side Effects

    • Mild pain or swelling at injection sites
    • Temporary muscle weakness
    • Rare side effects include eyelid drooping or neck pain
    Talk to your neurologist to determine if Botox is suitable for you.

    Ring Device for Home Sleep Study

    Indication

    The ring device is a revolutionary tool for assessing sleep quality and identifying sleep-related disorders. Unlike traditional home sleep studies, it does not require nasal cannulas or chest belts. It is commonly indicated for:
    • Screening for obstructive sleep apnea (OSA)
    • Evaluating snoring and breathing disturbances during sleep
    • Monitoring treatment efficacy for CPAP or other sleep therapies
    • Assessing unexplained fatigue or poor sleep quality

    Process

    • The device is worn as a ring on your finger overnight.

    It monitors key physiological signals, including:

    • Heart rate and heart rate variability
    • Breathing patterns and oxygen levels
    • Body movements during sleep
    • The data is automatically uploaded to a secure platform through a smartphone or provided interface.
    • A sleep report is generated and reviewed by a specialist to provide a diagnosis or further recommendations.

    Instructions for Patients

    Before the Test:

    • Ensure the device is fully charged and synced with the provided app or platform.
    • Avoid caffeine, alcohol, and heavy meals close to bedtime.
    • Prepare for uninterrupted sleep to ensure accurate results.

    During the Test:

    • Wear the ring snugly on your finger as directed.
    • Sleep comfortably with no nasal cannulas or other intrusive sensors.
    • Contact your provider if you encounter any issues with the setup or device.

    Benefits

    • Non-invasive design—just a ring on your finger.
    • No need for nasal cannulas, belts, or other traditional equipment.
    • Accurate and detailed data on sleep quality and breathing patterns.
    • Convenient and easy to use at home.

    Limitations

    • May not diagnose all types of sleep disorders requiring in-lab testing.
    • Requires proper device setup and syncing for accurate results.

    Side Effects

    • None expected; mild discomfort may occur for some due to wearing the device overnight.
    Discuss with your sleep specialist to determine if the ring device is right for your sleep study needs.

    Neuropsychological Testing

    Indication

    Neuropsychological testing is used to assess cognitive, emotional, and behavioral functioning. It is commonly indicated for:
    • Evaluating memory loss, attention issues, or learning difficulties
    • Diagnosing dementia, traumatic brain injury (TBI), or stroke-related cognitive deficits
    • Monitoring cognitive changes in neurological conditions like Parkinson’s disease or multiple sclerosis
    • Assessing psychological factors impacting cognitive performance

    Process

    • A trained neuropsychologist conducts the evaluation, which may last several hours.
    • The testing involves paper-and-pencil tasks, computer-based assessments, and structured questionnaires.
    • Areas tested include memory, problem-solving, language, attention, motor skills, and emotional state.
    • Results are analyzed to create a comprehensive report, identifying strengths and weaknesses.

    Instructions for Patients

    Before the Test:

    • Get a good night’s sleep and eat a healthy meal.
    • Bring any necessary aids like glasses or hearing devices.
    • Notify the provider of medications or conditions that may affect performance.

    During the Test:

    • Be honest and do your best; there are no right or wrong answers.
    • Expect breaks during longer sessions.

    Benefits

    • Provides detailed insights into cognitive strengths and challenges.
    • Aids in accurate diagnosis and treatment planning.
    • Helps track changes in cognitive function over time.

    Side Effects

    • None directly, but the testing process may feel mentally tiring.

    Discuss with your neurologist if neuropsychological testing is appropriate for your condition.

    Plasma Biomarkers for Alzheimer’s Disease

    Indication

    Plasma biomarkers are advanced blood tests used to detect and monitor Alzheimer’s disease and related neurodegenerative conditions. They are commonly indicated for:
    • Identifying early signs of Alzheimer’s disease in patients with mild cognitive impairment (MCI) or memory concerns
    • Supporting clinical diagnosis of Alzheimer’s disease alongside imaging and other diagnostic tools
    • Monitoring disease progression and treatment response in diagnosed patients

    Key Biomarkers

    • Amyloid Beta (Aβ42/Aβ40 Ratio): Indicates the presence of amyloid plaques, a hallmark of Alzheimer’s disease.
    • Phosphorylated Tau (pTau-181 or pTau-217): Reflects tau pathology associated with neurofibrillary tangles.

    Process

    • A small blood sample is drawn during a routine office visit.
    • The sample is sent to a specialized laboratory for analysis using high-sensitivity testing techniques.
    • Results are typically available within a few days and are interpreted by your neurologist.

    Instructions for Patients

    • No special preparation is needed before the blood draw.
    • Inform your doctor about any medications or supplements you are taking.
    • Discuss your family history of dementia or memory disorders with your provider.

    Benefits

    • Non-invasive and accessible compared to traditional diagnostic methods like lumbar punctures or PET scans.
    • Provides early and accurate detection of Alzheimer’s-related pathology.
    • Helps guide treatment decisions and enrollment in clinical trials.
    • Facilitates monitoring of disease progression over time.

    Limitations

    • Not a standalone diagnostic tool; used in conjunction with clinical evaluation and imaging.
    • May not fully distinguish Alzheimer’s from other neurodegenerative diseases.

    Side Effects

    • None directly related to the test; mild discomfort may occur at the blood draw site.
    Discuss with your neurologist to determine if plasma biomarker testing is appropriate for you or your loved one.

    Electroencephalogram (EEG)

    Indication

    An Electroencephalogram (EEG) is a diagnostic test used to measure the electrical activity of the brain. It is commonly used for the following:
    • Diagnosing seizures and seizure disorders
    • Evaluating memory loss and confusion
    • Assessing changes in mental status or unexplained altered consciousness

    Process

    • The patient lies or sits in a comfortable position.
    • Small metal discs (electrodes) are attached to the scalp using a special adhesive or cap.
    • The electrodes record brain waves while the patient is at rest, performing tasks, or under specific conditions.
    • The test is non-invasive and usually takes 20-60 minutes, though longer recordings may be needed for certain conditions.
    • The recorded data is analyzed by a neurologist to identify patterns or abnormalities.

    Instructions for Patients

    • Wash your hair the night before the test to remove oils, but avoid applying conditioner, hair spray, or gels.
    • Avoid consuming caffeine (coffee, tea, energy drinks) for at least 8 hours before the test.
    • Continue taking prescribed medications unless instructed otherwise by your doctor.
    • For a sleep EEG, follow your doctor’s specific instructions about sleep deprivation.
    • Wear comfortable clothing, but avoid items like earrings or hairstyles that may interfere with electrode placement.

    Nerve Conduction Study (NCS) and Electromyography (EMG)

    Indication

    NCS and EMG are diagnostic tests used to evaluate nerve and muscle function. They are commonly indicated for:
    • Diagnosing nerve injuries, such as carpal tunnel syndrome or sciatica
    • Assessing muscle weakness or disorders, including myopathy
    • Identifying nerve disorders, such as neuropathy or radiculopathy

    Process

    1. Nerve Conduction Study (NCS):

    • Electrodes are placed on the skin over specific nerves and muscles.
    • A mild electrical pulse is applied to stimulate the nerve, and its response is measured
    • This evaluates how well nerves send signals to muscles.

    2. Electromyography (EMG):

    • A small needle electrode is inserted into specific muscles.
    • The electrode records electrical activity while the muscle is at rest and during movement.
    • This assesses the electrical function of muscles and nerves.
    The combined procedure typically takes 30-90 minutes and is performed by a neurologist or specialis

    Instructions for Patients

    Before the Procedure:

    • Wear loose, comfortable clothing to allow easy access to test areas.
    • Avoid applying lotions, oils, or creams to the skin on the day of the test.
    • Notify the doctor of any blood-thinning medications, pacemakers, or implanted devices.

    During the Procedure:

    • You may feel mild discomfort from electrical pulses or needle insertions.
    • Relax during the test to ensure accurate results.

    Benefits

    • Provides detailed information on nerve and muscle function.
    • Helps pinpoint the location and severity of nerve or muscle issues.
    • Guides treatment planning for conditions like neuropathy, radiculopathy, or neuromuscular disorders.

    Side Effects

    • Temporary soreness or bruising at the needle insertion sites
    • Mild discomfort during electrical stimulation
    Discuss with your neurologist to determine if NCS and EMG are appropriate for your condition.

    Sphenopalatine Block for Migraine

    The sphenopalatine ganglion (SPG) block is a treatment option for acute and chronic migraines. The SPG is a nerve cluster located behind the nose that plays a role in headache and facial pain. The block involves delivering medication to the SPG to reduce inflammation and interrupt pain signals.

    Benefits

    • Provides rapid relief from migraine pain
    • Reduces migraine frequency and severity
    • Minimally invasive and well-tolerated
    • Can reduce reliance on oral medications

    Indication for Use

    Indicated for patients with acute migraine attacks or chronic migraines not adequately managed with standard treatments.

    Frequency

    The frequency of SPG blocks depends on the patient’s response. It is often used as needed for acute attacks or in a series for chronic migraines.

    Side Effects

    • Temporary nasal discomfort or irritation
    • Mild bleeding or numbness in the treated area
    • Rare side effects include dizziness or lightheadedness
    Discuss with your neurologist to determine if the SPG block is an appropriate treatment option for your migraines.

    Trigger Point Injection for Headache and Neck Pain

    Indication Trigger point injections are used to treat:

    • Chronic tension headaches
    • Neck pain related to muscle spasms or trigger points
    • Myofascial pain syndrome
    • Pain caused by muscle knots that do not relax

    Process

    1. Preparation:

    • The area of pain is identified and marked by the healthcare provider.
    • The skin is cleaned with an antiseptic solution.

    2. Injection:

    • A small needle is used to inject a local anesthetic, often combined with a steroid, into the trigger point.
    • The injection interrupts pain signals and reduces inflammation.

    3. Duration:

    • The procedure typically takes 15-30 minutes and is done in an outpatient setting.

    Instructions for Patients

    Before the Procedure:

    • Wear comfortable clothing that allows access to the injection site.
    • Inform your doctor about any allergies, medications, or blood-thinning agents.

    After the Procedure:

    • Rest the treated area.
    • Apply an ice pack to reduce any swelling or discomfort.

    Benefits

    • Immediate relief from pain and muscle tightness.
    • Improves mobility and reduces tension-related symptoms.
    • Allows patients to participate in physical therapy or exercises more effectively.

    Side Effects

    • Mild soreness at the injection site
    • Temporary numbness or weakness in the area
    • Rarely, infection or bleeding at the injection site
    Discuss with your doctor to determine if trigger point injections are suitable for your condition.

    Types

    1. Large Fiber Neuropathy

    • Affects: Large myelinated fibers (movement, reflexes, proprioception).
    • Symptoms: Muscle weakness, balance problems, loss of vibration/position sense, reduced reflexes.
    • Causes: Diabetes, autoimmune diseases (GBS, CIDP), hereditary neuropathies (e.g., Charcot-Marie-Tooth).

    2. Small Fiber Neuropathy (SFN)

    • Affects: Small, unmyelinated fibers (pain, temperature, autonomic functions).
    • Symptoms: Burning pain, tingling, loss of pain/temperature sensation, autonomic issues (sweating, dry eyes, digestive problems).
    • Causes: Diabetes, autoimmune diseases (e.g., Sjogren's), toxins, idiopathic.

    3. Posterior Column Neuropathy

    • Affects: Nerves in the posterior spinal cord (vibration, proprioception).
    • Symptoms: Loss of vibration sense, balance problems, impaired proprioception.
    • Causes: Vitamin B12 deficiency, Friedreich’s ataxia, multiple sclerosis.

    4. Autonomic Neuropathy

    • Affects: Autonomic nerves (involuntary functions).
    • Symptoms: Orthostatic hypotension, gastrointestinal issues, bladder dysfunction, sexual dysfunction.
    • Causes: Diabetes, autoimmune diseases, infections (HIV, Lyme).

    5. Focal Neuropathy

    • Affects: Specific nerves (usually due to compression or injury).
    • Symptoms: Pain, numbness, weakness in the affected area.
    • Causes: Trauma, nerve entrapment (e.g., carpal tunnel).

    Symptoms

    • Sensory Symptoms: Can be positive (Painful) or negative (Non-painful such as coldness, wetness, tightness)
    • Numbness and Tingling: Common in the hands and feet.
    • Burning Pain (Positive): Sharp, stabbing pain or sensations of heat.
    • Loss of Sensation (Negative): Difficulty feeling textures, temperatures, or pain. Coldness, wetness, tightness, socks crumpled, walking on gravel.

    Motor Symptoms:

    • Muscle Weakness: Difficulty with motor skills like gripping, walking, or moving limbs.
    • Coordination Issues: Problems with balance and fine motor control especially in dark.

    Autonomic Symptoms:

    • Bladder and Bowel Dysfunction: Incontinence or constipation.
    • Blood Pressure Problems: Dizziness or fainting when standing (orthostatic hypotension).
    • Sexual Dysfunction: Erectile dysfunction or decreased sexual response.

    Jan Levine