Author: Integrated Neurology Services

Happy (Stress-Free) Holidays

happy holidaysThe holidays season is an exciting time of year. The chance to see family, friends, celebrate good cheer, and, of course, gifts! But it can also be a very stressful time. Finding and buying gifts, holiday gatherings, multiple events in one day. We can end up stretching ourselves thin during this season and sometimes we start to lose sight of what’s important—spending time with our loved ones. Here are some tips to help manage your stress and enjoy your time this season because after a hard year’s work we deserve to enjoy it.

  1. Write everything down. You’ll definitely want to start off with writing every event, task, or thing you’re supposed to do. If you don’t use a planner it may be a good time to start, even just using the calendar app on your phone can make a huge difference. Once everything is set in your planner or calendar then you can take a breath from, “wasn’t I supposed to do something next week?” and end up double booking yourself. Keeping track of duties and events like this is a great way to stay on task and make the most of your time. Productivity and efficiency are important during busy periods.
  2. It’s OK to say no. It’s really hard to turn someone down but it’s OK to think about what is best for you. If you’re already engaged in two things tomorrow, you don’t have to do that third event. If you’re not going to have fun and it’s not a priority then just gently let them know, “thank you, but I can’t make it.” It might be a bummer but your stress-levels will thank you later.
  3. Enjoy the moment. Remember to stop and take in your surroundings. Feel the moment and really be present for what is happening around you. You don’t want to be worrying about the next thing you need to do when you should be more focused on enjoying where you’re at now. These are the opportunities to create the memories you’ll look back fondly at later on.
  4. Sleep. This one may seem tricky but it’s ever so important. Sleep really is the pinnacle of everything. It will recharge you for the next day so you’re ready to go at full capacity. You don’t want to zombie through a holiday party or nodding off during your child’s recital. Remember to get as much sleep as you can each night. The American Sleep Association recommends the average person get 8 hours of sleep (some people can function fully with less and others need more). Take some time before bed by creating a nighttime routine to prepare your mind and body for sleep. It can include meditation, bathtime, reading, or planning your next day. Anything that will relax and get you in the mindset to sleep.
  5. Eat. Properly. The holidays are notorious for overindulging but sometimes we can get too busy to even remember to eat. Strike a balance. Yes, you probably have a million things happening so stock up on some protein bars or healthy snacks to keep you going through the day. A clear, not-hungry mind is important for staying on task, staying alert, and not being cranky. At holiday events, be mindful of what you are eating and how much. This isn’t a time to necessarily be stingy to your taste buds but you don’t want to do anything you’ll regret later. Small portions, like at a buffet-style dinner, allows you get try a variety of things and leave opportunity for a second plate of your favorites. If you want to eat the cake, by all means, eat the cake but think about the serving size that is appropriate for you. While cutting yourself off from certain foods works for some people, it can make others binge so figuring out a method that works for you is important.

The important thing to remember is that the holiday season is a great time to see friends, family,  and even enjoying some time to yourself. We hope the end of the year brings you cheer and the start of 2019 is a joyous one.

Happy Holidays!

Epilepsy – A Growing Condition

brain electricty

Epilepsy is a broad-term neurological condition that causes seizures. It affects people of all ages, genders, races, and status.

  • Epilepsy affects 65 million people globally — 3.4 million are in the US.
  • 1 in 26 people will develop epilepsy during their lifetime in the US.
  • There are 150,000 new cases of epilepsy in the US every year.
  • More people now live with epilepsy than ever before.

Types of Epilepsy

There are several types of epilepsy that a person can suffer from and the type of epilepsy can change over time. It’s important to remember that all forms of epilepsy are seizures but not all seizures are epileptic. In 2017, the International League Against Epilepsy (ILAE) changed the name and categorization of seizures so you may see the same seizure as different names. Epilepsy can be divided into two categories- generalized and focal – and each has their own breakdowns.  

Generalized –

This type of seizure affects both of the left and right sides of the brain at the same time.

Tonic-Clonic: Once called “grand mal” these are what are often depicted in Hollywood. This may cause you to lose control of your body. You may cry out, seize up, spasm, and lose consciousness. If the seizure lasts for more than three minutes, call 911, as this can lead to breathing problems and increase the risk of biting the tongue or cheek.

Tonic: These seizures that cause the arms, legs, and body to tense are often less than 20 seconds long. They usually occur during sleep but can cause a person to fall if they are standing. This is common in Lennox-Gastaut, a syndrome of epilepsy.

Clonic: These can last several minutes and are when the muscles spasms causing the face, neck, and arms to jerk rhythmically.

Myoclonic: Almost as if receiving a shock, the muscles will jerk suddenly during this type of seizure.  

Atonic: Instead of tensing up, the muscles go limp in this type of seizure. You may drop things or fall during these episodes. Though these are often short – 15 seconds – a person may have multiple in a row. This is often seen in people with Lennox-Gastaut and Dravet syndromes.

Absence seizures: Sometimes referred to as “petit mal”. During this type of seizure, you may stare blankly and become disconnected from the world around you. These last only moments and it’s common to not remember having one. This is found often in children younger than 14 years old.

This is a fascinating article about a young boy who suffers from epilepsy and his family’s journey of managing it through diet after medications failed to work. He has had epilepsy since a young age and it has changed through his time with it. His twin sister also suffers from epilepsy but with more success with conventional methods, showing that each person’s condition and needs are very unique

Focal –

This was called partial seizures and is localized in just one area of one hemisphere.

Simple focal seizures: This can affect your senses. You may smell or taste things and you may have twitching in your limbs. You may feel hot, cold, dizzy, or other sensations but you are typically aware and likely to remain conscious.

Complex focal seizures: You might lose consciousness but seem awake. This focuses more on the emotion and memory parts of your brain and can cause you to cry, laugh, or simple physical motions like lip smacking. It can take several minutes to come out of an episode.

Secondary generalized seizures: This seizure starts in one part of the brain and then spreads to both sides.

Epilepsy goes beyond just the types, different groups of factors that play a role in the condition can be specified even more as a syndrome as part of the diagnosis.

When to call 911

Not every seizure is an emergency so it’s important to distinguish when to call for help especially since they are not so uncommon. 1 in 10 people have seizures so one day you may be in a position help someone during theirs.

Call 911 if:

  • The seizure lasts more than 5 minutes
  • It is their first seizure
  • There is a second seizure in close succession to the first
  • They have trouble breathing or waking when the seizure is over
  • The person gets hurt during the seizure or it happens in water
  • They are pregnant or has a medical condition like diabetes or heart disease

For most seizures, it is helpful to:

  • Check for a medical bracelet or other information
  • Keep the environment and others around them calm
  • Comfort and speak to them in a normal calming voice
  • Stay with them until the seizure is over and they are fully conscious. Keep them in a safe place to sit and tell them what happened.
  • Offer to call for a taxi or a person to see them home safely

Tonic-Clonic seizures may need a little extra care because of the nature of the seizure. They may cry out, jerk, or fall. Because of this, it is best to ease them to the floor and turn them to one side. Place something soft and flat under their head like a folded sweater and remove anything dangerous away. Remove any glasses and jewelry that may restrict breathing. Remember to time the seizure and if it lasts longer than 5 minutes to call 911. It is unnecessary to hold a person down during their seizure, just make sure the area around them is clear, and do not put anything into their mouth. CPR is usually unnecessary as the person will breathe normally again once the seizure is over. Food and water is not recommended until they are fully awake and conscious.

The Red Cross has an app that offers step-by-step first aid and advice including information about epilepsy and seizures. You can find more information about it and their other apps here.

Do You CPAP?

cpap-machineWhat is a CPAP?

CPAP is an acronym for continuous positive airway pressure. It’s a small machine that blows air through a tube and mask that allows for your airways to stay open so you can breathe. The strength of the pressure depends on the severity of the sleep apnea.

Newer models of CPAP machines are smaller, lighter, and quieter making it easier to live with. There are also more mask options than before. It’s important to find one that fits you so work with your CPAP provider to find one that makes you happy.

Why is a CPAP important?

If you suffer from sleep apnea that means that while you are sleeping you stop breathing for a duration of time, and likely multiple times a night. Specifically obstructive sleep apnea (OSA) is when there is a pause in breathing of at least 10 seconds due to the softening of the upper airway tissues like the tongue or uvula and getting in the way. OSA is the most common form of sleep apnea so we will focus on this type but be aware there are other types.

While an apnea has to be more than 10 seconds some people stop breathing for minutes and, in serious cases, interruptions can happen more than 30 times an hour!

Can you imagine the consequences of multiple pauses in breathing? Even just a few times can cause oxygen saturation to lower which can have drastic consequences.

If you’re not breathing, your body will wake you up so you can catch a breath which means not only is your breathing interrupted but so is your sleep. Sleep apnea sufferers tend to also experience daytime sleepiness and fatigue. We all know being tired during the day is no fun. It may also be a contributing factor to memory problems, mood issues, and performance issues. Cognitive abilities, as well as reaction time, have been known to suffer from sleep problems and it can’t help if your brain is working on lower oxygen.

Untreated sleep apnea can also lead to a whole host of health complications, even be premature death. Sleep apnea has been strongly linked with type 2 diabetes and obesity. High blood pressure and cardiovascular disease also have strong ties to untreated sleep apnea. Overall, if the body isn’t getting enough sleep or oxygen it has a hard time of taking care of itself.

OK, I’ll get a CPAP. What’s next?

Use your CPAP every night. Some insurance plans require a certain amount of compliance to continue to cover your treatment. Ask your doctor what your insurance requires. CPAP compliance is important though for you to see improvement in your condition.

Lifestyle adjustments can help with your treatment as well. Losing weight, exercise, eating well, and avoiding drinking and smoking can improve your condition. Some people are able to lower their CPAP pressure or get away from it completely by getting to a proper weight and a healthy lifestyle.

Don’t forget to clean your CPAP equipment. Since it is blowing air directly into your body, you’ll want to make sure everything is clean to avoid any mold or bacteria exposure. It should be done at least weekly and can be done with some mild soap and water.

What if I don’t like using my CPAP?

CPAP isn’t for everyone but it is the gold standard for treating sleep apnea and most people benefit from using it. If you’re finding that you’re struggling with the CPAP speak with your doctor about some solutions before abandoning it completely. It may just be a mask change or pressure adjustment. As stated before, consider working in healthier lifestyle options while you’re using the CPAP. You may be able to lower your pressure or even stop using it. 

If you really can’t get behind the CPAP ask your doctor what your other options are. A newer solution includes the Inspire. It is implanted in the body and signals your muscles to open the airway without disturbing your sleep. A specially fitted dental device is also an option as well as surgery.


Regardless of the treatment option you choose, it is important to choose one that works for you. Your healthcare provider can help in advising your best course of action.


Alzheimer’s Disease Facts

Alzheimer's as a puzzle with pieces missing

This September is the 7th World Alzheimer’s Month, a campaign created every September to raise international awareness. A goal for the campaign is to increase an understanding of dementia globally and fight stigmas that may surround it by the unaware and misinformed.

The difference between Alzheimer’s Disease and Dementia
Alzheimer’s disease and dementia are not one in the same. Dementia is used to refer to a group of symptoms that affect memory while Alzheimer’s is a disease that progressively hinders cognitive function and memory. Most simply put, dementia is an umbrella term and Alzheimer’s disease is one type of dementia.

The Facts

Alzheimer’s disease is the most common form of dementia both in the US and globally.

Alzheimer’s Disease in the US

  • An estimated 5.7 million Americans are living with Alzheimer’s disease
  • By 2050, that number is estimated to grow to almost 14 million people. By 2025, every state is expected to see at least a 14% increase.
  • Roughly two-thirds of those with Alzheimer’s are women
  • Up to 5% are younger than 65 and have early-onset Alzheimer’s disease
  • Someone develops Alzheimer’s disease every 65 seconds in the U.S.
  • Alzheimer’s disease is the 6th leading cause of death in the U.S. and the only one in the top 10 that cannot be prevented, slowed, or cured.
  • 1 in 10 Americans that are 65 or older has Alzheimer’s disease and 1 in 3 seniors die from some type of dementia
  • Alzheimer’s kills more people than breast cancer and prostate cancer combined
  • From 2000 to 2014, there was an 89% increase in Alzheimer’s related deaths
  • Around 16 million Americans provide unpaid care for dementia patients. In 2017, it is estimated over 18.2 billion hours of care was given and is valued at over $230 billion.
  • In 2017, the disease cost the nation $259 billion. 2018’s cost of Alzheimer’s disease and dementia to the country is an estimated $277 billion and by 2050 it could be almost $1.1 trillion.
  • Up to $7.9 trillion in medical costs could be saved with an early and accurate diagnosis.  

Alzheimer’s Disease GloballyAn older lady out on her own

  • Over 44 million people worldwide have Alzheimer’s disease or dementia
  • Every 3 seconds there is a new case of dementia
  • Only 1 in 4 people with Alzheimer’s disease are actually diagnosed
  • Alzheimer’s and dementia are most prevalent in Western Europe (with North America a close second) and least found in Sub-Saharan Africa.
  • The top cause for disability in later life is Alzheimer’s and other dementias.
  • The total cost of Alzheimer’s and dementia worldwide is estimated to be over $605 billion — which equals 1% of the world’s GDP–, with some estimates as high as $808 billion.
  • If it were a country, it would be the 18th largest economy and if it were a company, it would be the largest in the world, even beating Apple and Google,  by annual revenue

Early Signs

Early detection can help with treatment and care, so contact a doctor if you think you may be developing Alzheimer’s or other dementia.

  • Memory loss
  • Trouble planning or solving problems
  • Issues completing familiar tasks
  • Challenges with remembering times, dates, and seasons
  • Vision problems and judging spacial relations
  • Difficulty with conversations or words when speaking or writing
  • Misplacing items and unable to retrace steps
  • Issues with making decisions and an increase of poor judgment
  • Withdrawal from activities
  • Mood changes

While some of these may seem like normal aging-related problems, the frequency and severity of an issue should be considered. Sometimes forgetting may not be an alarming factor, but if it’s happening often or disrupting daily life it may be a sign to seek help.

Don’t Wait To Treat Psoriatic Arthritis


Psoriasis is a skin condition that forms red patchy scales that are itchy and can be painful. The lifecycle of kin cells is sped up causing them to build up rapidly on the surface. This is a chronic disease with no cure that can come and go. Management through lifestyle habits such as moisturizing, reducing stress, and quitting smoking may help alleviate symptoms. 

Psoriasis affects males and females at equal rates and is likely to first appear sometime between 15-35 years of age. According to the American Academy of Dermatology, 7.5 million people in the United States are affected and by the International Federation of Psoriasis Associations roughly 3% of the world has some type of psoriasis.

Psoriatic Arthritis

A type of psoriasis that affects the joints. Almost 30% of those with psoriasis later develop psoriatic arthritis but joint problems can begin prior to the appearance of surface lesions. It can cause stiffness, swelling, and joint pain anywhere from the fingertips to the spine and range from mild to severe pain. Like psoriasis, this may alternate between periods of flares and remission.

PsA that is considered mild can also be called oligoarticular, which means that no more than four joints are affected. Polyarticular, a more severe form, means that four or more joints are affected. Different classifications are dependent on which joints are affected. The spinal column, which includes the neck, lower back, and sacroiliac joints is called spondylitis and tends to co-exist with other forms of psoriatic arthritis. Enthesitis is the inflammation of where tendons or ligaments insert into the bones. Tissues in these areas can become solid (calcification or ossification) or ropey (fibrosis). Dactylitis, sometimes called “sausage digits”, is the swelling/inflammation of a whole toe or finger. It often affects multiple digits unevenly on the body.


  • Pain in the back (upper and lower) and neck
  • Tender, swollen joints
  • Stiffness (especially in the morning)
  • Swollen toes and fingers
  • Plaques (red, scaly patches of skin)
  • Pitting or separation from the nail bed
  • Fatigue


While there is no cure for PsA, there are treatment options to help manage the symptoms. Each person’s treatment plan is unique to their condition, so speak with your doctor about what your best options are. Treatment for psoriatic arthritis is important as studies have shown that delaying even just six months can cause permanent damage to joints.

There are various drug options to help manage symptoms:

    • NSAIDs (non-steroidal anti-inflammatory drugs) inhibit your body from creating the chemicals that cause inflammation. Over the counter (ibuprofen, aspirin, etc) and prescription options are available but can have undesired side effects.
    • DMARDs and Biologics are for when NSAIDs don’t work well or the condition is more severe. They are stronger and can have a delayed effect but may help stop or slow joint and tissue damage, swelling, and pain. Common DMARDs include Cyclosporine, Methotrexate, Sulfasalazine, Leflunomide. Biologics are a newer type of DMARD that block the protein that sources inflammation. These include Etanercept, Golimumab, and Infliximab to name a few.

Remicade®, an Infliximab biologic medication, has shown in clinical studies that it can help with pain, swelling, and stiffness, stop joint damage, and improve skin conditions. Integrated Neurology Services offer Remicade administration, among other infusion medicines.

  • Enzyme Inhibitors are new and for chronic inflammation. It also works in blocking a specific type of protein.
  • Steroids, specifically corticosteroids, help serious swelling and pain.
  • Surgery is typically the last resort option if nothing else works. Most PsA patients won’t need surgery but it is an option of treatment.

Again, a doctor will help with deciding on the best treatment plan for each individual’s condition.

Integrated Neurology Services’ Infusion Suite offers a comfortable location to receive prescribed infusion medications. Our facility includes cozy leather chairs, refrigerator, microwave, and free WiFi. Let us know how we can help in your infusion treatment options for psoriatic arthritis or any other condition that may need IV therapy.

FLUENT Study Enrollment Closing — Act Now!

The FLUENT study will be closing enrollment at the end of the month, on June 30, 2018! Those diagnosed with Multiple Sclerosis (MS) who are interested in trying Gilenya (fingolimod) for the first time may be eligible to participate. The study simply asks for a few questionnaires and a blood draw at baseline and at the standard 1m, 3m, 6m, and 12m follow-up office visits to help learn more about how this medicine affects the immune system.

Neurology Advisor reports patients who have previously tried one or more injectable therapy (iDMTs) may still see improvement with a switch to a Gilenya pill once a day! Read it here.

Need more information? Check out this website or this one to learn more about these studies. 

If you or anyone you know are interested in learning more about this trial, feel free to call our Research Director, Lindsay, at 703-313-9111 ext. 107, or email her at


Julie- Best of Luck!

a picture with our med student intern.


We had the honor and privilege of having Julie work with us for two weeks for her neurology rotation. We wish her the best of luck in her pursuit of higher education and know that she will be an amazing doctor. We will miss you and hope you’ll come to visit us! 



Dear Dr. Fishman,

Let me start out by saying what a fantastic 2 weeks I had with you! With sincere honesty, out of all 3rd and 4th year clinicals, this was by far my favorite rotation. I certainly had an interest in neurology coming in but your passion for the specialty and dedication to your patients, along with your teaching, were really inspiring. As you noted, a preceptor can shape a student’s perspective….and I am now thinking about possibly pursuing neurology further. 

Thank you for being such a wonderful role model. You are talented when it comes to teaching–your passion and great degree of knowledge were so impressive to me. But perhaps what was even more impressive was your respect for and commitment to your patients. (Having a brother with MS, this especially hit home.) I enjoyed partaking in your interactions with them in that you demonstrated the kind of relationship, a therapeutic alliance, that I hope to one day have with my patients. You not only shared your expertise but also listened compassionately each time to their thoughts and concerns–something that makes a great physician. When the pre-med student came in concerned his headaches represented a malignancy, for example, you put him at ease with reassurance and ordering of a scan.

I feel truly privileged to have had these 2 weeks with you. I have a tremendous level of respect for you and the amazing work you do every day. Thank you for all that you have taught me–whether it be neurology or just clinical pearls of medicine. 

I look forward to staying in touch, and will certainly send your way all those I know in search of a great neurologist.


Ps. Thank you for my FAVORITE new tool–my reflex hammer! I have been testing all the reflexes in my household and will now (at least look like I) know what I am doing on my neuro rotation at UVA…! 🙂

Safety Awareness


wear a helmet

Every year National Safety Awareness is observed in June to minimize injury and death on the road, at home, and at work. Injuries are the leading cause of death for Americans ages 1 to 40. The good news? Everyone can get involved to help prevent injuries. 

This June, we encourage you to learn more about important safety issues like preventing poisonings, transportation safety, and slips, trips, and falls.

  • Poisonings: Nine out of 10 poisonings happen right at home. You can be poisoned by many things, like cleaning products or another person’s medicine.
  • Transportation safety: Doing other activities while driving – like texting or eating – distracts you and increases your chance of crashing. Almost 1 in 6 crashes (15%) where someone is injured involves distracted driving.
  • Slips, trips, and falls: One in 4 older adults falls each year. Many falls lead to broken bones or a head injury.

Raising awareness about safety issues can reduce the risk of injuries by being better prepared. Check out some of these resources to learn more about safety preparedness:

Take some classes to learn skills like CPR and first aid

Get downloadable material about safety awareness

Stroke—You Have To Act FAST

Learning the signs and symptoms of a stroke and knowing how to act FAST can be life-saving. This month is marked by National Stroke Awareness month.

Here are the numbers:

  • About 800,000 people have a new or recurrent stroke every year.
  • That comes down to a person having a stroke about every 40 seconds.
  • It’s the 5th leading cause of death in the US.
  • Every 4 minutes someone dies from a stroke.
  • Up to 80% of strokes can be prevented.
  • It is the leading cause of adult disability in the US.

What is a stroke?

A stroke is either caused by a weakened vein leaking blood or a blocked artery. In either case, blood – and therefore oxygen – are not getting to the brain. These are called hemorrhagic and ischemic strokes, respectively. A temporary block of blood flow is called a transient ischemic attack (TIA) but is also referred to as a mini-stroke. That should not dampen the potential severity of what it is, attention should be sought immediately as a full stroke is likely to occur soon.

What is FAST?

FAST is a simple acronym for signs to be on the look-out for if you suspect a person is having a stroke.

Face drooping – Ask the person to smile and observe if the face droops.

Arms weak – See if the person is able to lift both arms overhead. Does an arm drift down or do they have trouble raising one?

Speech difficulty- Have the person repeat a person phrase. Pay attention to see if they slur or sound odd. They may have some confusion and trouble understanding you.

Time to call 9-1-1 (or your local emergency number) – Call 911 immediately if you observe any of these signs.

Other symptoms include:

  • trouble walking
  • a sudden and severe headache that may be joined with vomiting or dizziness
  • trouble seeing in one or both eyes

Why is it that so important?

In the case of many medical emergencies, stroke included, time is of the essence. Once a person starts having a stroke, it only takes a matter of minutes before brain damage can start to occur. Depending on where and the severity of the stroke, the type of damage can vary but often temporary or permanent disability can be expected. Two-thirds of survivors have some type of disability. These can include:

  • A difficulty with talking and swallowing: sometimes people can experience problems with swallowing, eating, and language due to trouble controlling muscles in your throat and nose. This can include difficulty communicating by talking, reading, and writing. Working with a therapist may help.
  • New sensations may occur in parts of the body affected by the stroke. This could be pain, tingling, or numbness. New sensitivities like to temperature changes could develop.
  • After a stroke, you may lose control of parts of your body or be paralyzed on one side like a side of your face or a leg. Physical therapy may help to return to activities like dressing, walking, and eating.
  • Some memory loss is common as well as changes to your cognitive ability like reasoning and judgment.
  • Emotional problems or depression could manifest after experiencing a stroke.
  • A person may experience behavior changes and their ability for self-care. They may become withdrawn and need help with chores, grooming, and dressing.

The success of treating these complications varies on the person and their situation.

Risk factors

Below are some risk factors that increase a person’s chance of having a stroke. While some of these are unavoidable, working on the ones that are changeable can help lower your risk level and possibly increase your quality of life.

  • Age – being over the age of 55 increases your risk of a stroke
  • Sex – men are more likely than women to have a stroke but women are older when they have one and are more likely to die of a stroke.
  • Race – African-Americans have a higher risk of stroke.
  • Hormones – estrogen-based therapies,  use of birth control, and the higher levels of estrogen during pregnancy and after childbirth increase the risk of stroke.
  • Physical inactivity
  • Heavy drinking
  • Obesity
  • Illicit drugs (cocaine, methamphetamines, etc)
  • Smoking and secondhand smoke
  • Diabetes
  • High cholesterol
  • High blood pressure
  • Cardiovascular disease (abnormal heartbeat, heart failure, defects, and infection)
  • Obstructive sleep apnea
  • A family history of stroke, TIA, or heart attack


Implementing simple lifestyle changes can help lower your risk but if you are concerned about your risk, speak to a healthcare professional. If you or someone know has been affected by stroke, therapy may be able to help increase one’s quality of life. Remember, if you suspect someone is having a stroke, act FAST.