About The Practice

Serving Texas Children's Concerns about Neurology, Epilepsy Developmental & Sleep Disorders. Advanced spasticity management.

The Houston Area ( Bellaire Katy Sugar Land Richmond Missouri City Cypress The Woodlands Lake Jackson)

The Greater San Antonio Area ( New Braunfels Seguin Central Texas)

Dr Joshua Rotenberg. Board Certified in Neurology with Special Qualifications in Child Neurology.

Dr. Rotenberg has added subspecialty board certification in epilepsy AND sleep disorders (American Board of Psychiatry & Neurology-Child Neurology).

Member - American Epilepsy Society

Member - American Academy of Cerebral Palsy & Developmental Medicine

Texas Medical & Sleep Specialists - Children & Adults Welcome. WWW.TXMSS.COM 713-464-4107

Wednesday, October 22, 2014

Concussions in the U.S. - Some helpful information on brain injury

This article explains all about concussion in the U.S., how to treat them, and common misconceptions about concussions.

Concussion, sometimes referred to as mild traumatic brain injury, is one of the most commonly encountered sports injuries. Studies vary but rates are estimated at two million sport related concussions per year in the United States. It is also commonly believed that these are under reported injuries due to lack of recognition of the concussion and the desire of athletes to not miss time from their activity.

Research has led to change in our approach to treatment of the injuries. New guidelines do not use a set time away from activity and emphasize a gradual return to play. While concussions often occur from direct contact to the head or face, they may also occur from rotational forces without contact such as a tumbling fall. Although research continues to help understand what happens to the brain in a concussion, it appears that the neurons (brain cells) sustain a small injury that creates an "energy crisis." This generally lasts 7-10 days and physical or cognitive activity during this time period may worsen symptoms and prolong recovery. ...

Collision sports (football, hockey, etc.) generally have the highest overall rates of concussion; however, they can be seen in all sporting activity. Fortunately, the overall rates of concussions are relatively low even in collision sports. Certain risk factors are associated with an increased risk of concussion or prolonged recovery. Genetics, gender, playing position, migraines, history of multiple concussions and mental disorders (depression, anxiety and ADHD) all may play a role in how an athlete is affected by a concussive injury.
However it is still unclear how much influence each of these factors has on an individual athlete's risk. The diagnosis of a concussion can be complex as the signs and symptoms of concussions can be found in many other conditions and there is not a singular test we can use to determine if a concussion has occurred. Sometimes the diagnosis is very straight forward, for example when there has been a brief loss of consciousness, but many times the changes seen in the athlete are very subtle. The diagnosis of a concussion is mainly based on the history and physical examination. Symptoms of a concussion may include headache, dizziness, nausea/vomiting, amnesia, brief loss of consciousness and inability to concentrate. These symptoms may last for several days to a few weeks.
Imaging, CT scan or MRI, rarely indicate concussions, unless there is a finding on examination that suggests a structural injury ( e.g. bleeding or swelling). Newer computerized tests may add value in some cases, but these tests are not used to diagnose concussions and it is unclear if using these tests improve the outcomes of concussed athletes. Previous grading scales used symptoms at the time of the concussion to determine the severity of the concussion. New guidelines now suggest that we not grade concussions at all and that we only determine that a concussion has occurred. The reasoning for this lies in newer research that shows symptoms at the time of the initial injury do not correlate with the severity of the injury and recovery time. Additionally, grading does not change our treatments as resting until symptoms have resolved is the initial treatment regardless of the injury.
When an athlete is suspected of having a concussion, they should be removed immediately from competition. Symptoms should be monitored and the athlete should not be returned to competition until they are evaluated by a qualified medical professional. This evaluation should occur as soon as possible. The athlete should be monitored closely for several hours after a concussion. It is important to stress that both physical and mental rest speed the recovery of concussions. It is okay for the athlete to sleep and should avoid over stimulation such as video games or loud crowded activities. Athletes may need to stay out of school or have modified class schedules.
Ask your health care provider for more specific recommendations. Returning the athlete to play starts when the athlete is symptom free. It will take 3-7 days for full return to sports (depending on the sport) with an athlete gradually increasing their activity level every 24 hrs. Returning to class can occur over the same timeframe and athletes should be monitored as well for any increase or recurrence of symptoms. Activity can surface underlying concussion symptoms and athletes should be instructed to notify their coach, trainer or physician if they redevelop any symptoms during the recovery period. This process allows faster and safer return to sporting activity. Computerized neuropsychological testing is sometimes used to help monitor an athlete's progress but is never used on its own to determine a diagnosis or an athlete's readiness to return to play. There are many common misconceptions about concussive injuries.
The following are several myths about concussion:
Every athlete who sustains a hard hit must have a concussion. Although our knowledge about the forces involved in concussion is improving we still have not found a level of force that definitely causes a concussion. At times high forces do not cause an injury and relatively lower ones may. This means that we should not overact to every head impact but also need to listen to athletes who complain of concussive like symptoms after any head contact. Because there is no known force level for concussion in-helmet devices that are marketed to consumers as "concussion alarms," they are not recommended as they will likely lead to both over and under diagnosis of concussive injuries.
Better helmets and mouth guards will prevent concussions. Unfortunately there is no good scientific evidence that helmets of any type (hard shells, soft-padded or head bands) or mouth guards can prevent or reduce the risk of concussions. Hard helmets can reduce the risk of more serious head injuries (bleeding, skull fractures etc.) and should be worn in high risk sports. Mouth guards can prevent dental injuries and should be worn for sports with a high risk of these injuries. Helmet-add ons additionally are not effective in concussion prevention and using these will generally void any warranties associated with the helmet. Risk reduction may be possible in some settings with rule changes (e.g. no hitting from behind in hockey) and behavior changes (e.g. tackling technique in football).
Once you have a concussion you will always be more susceptible to having another one. While there appears to be an increased risk of recurrence in the first few weeks after a concussive injury it is unclear what factors may influence the risk of another injury in the future. Despite being a commonly held belief there is no evidence to suggest that athletes develop a decreasing force threshold after each injury. A few small studies have found the opposite....
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A Review of : Salivary gland botulinum toxin injections for drooling in children with cerebral palsy and neurodevelopmental disability

This treatment provides rapid relief and can help kids avoid added medications. With sedation or without, kids tolerate this procedure.  - JR

 2012 Nov;54(11):977-87. doi: 10.1111/j.1469-8749.2012.04370.x. Epub 2012 Sep 5.

Salivary gland botulinum toxin injections for drooling in children with cerebral palsy and neurodevelopmental disability

: a systematic review.



The aim of this paper was to systematically review the efficacy and safety of botulinum toxin (BoNT) injections to the salivary glands to treat drooling in children with cerebral palsy and neurodevelopmental disability.


A systematic search of The Cochrane Central Register of Controlled Trials, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, and the Physiotherapy Evidence Database (PEDro) was conducted (up to 1 October 2011). Data sources included published randomized controlled trials (RCTs) and prospective studies.


Sixteen studies met inclusion criteria. Three outcome measures support the effectiveness of BoNT for drooling. One RCT found an almost 30% reduction in the impact of drooling on patients' lives, as measured by the Drooling Impact Scale (mean difference -27.45; 95% confidence interval [CI] -35.28 to -19.62). There were sufficient data to pool results on one outcome measure, the Drooling Frequency and Severity Scale, which supports this result (mean difference -2.71; 95% CI -4.82 to -0.60; p<0 .001="" 2="" 41="" a="" adverse="" because="" bibs="" but="" day.="" early="" events.="" events="" from="" in="" incidence="" inconsistently="" number="" observed="" of="" one="" p="" per="" ranged="" reduction="" reported.="" required="" significant="" terminated="" the="" there="" to="" trial="" was="">


BoNT is an effective, temporary treatment for sialorrhoea in children with cerebral palsy. Benefits need to be weighed against the potential for serious adverse events. More studies are needed to address the safety of BoNT and to compare BoNT with other treatment options for drooling.

Monday, October 20, 2014

Seizures after Vaccine are Not due to the Vaccine...it might be worse.

Etiologies for Seizures Around the Time of Vaccination found in 65%!!

Its important to have an expedited evaluation by an epilepsy specialist. JR

Post-immunization epilepsy likely not related to vaccine: study

Reuters: HealthSeptember 17, 2014
(Reuters Health) - Children who start having seizures soon after a vaccination and go on to develop epilepsy usually turn out to have an underlying cause of the seizure disorder, according to a new study published in Pediatrics.
"It's reassuring to hear that with follow-up testing, the vast majority of these cases can be identified as coming from a different cause," Dr. Shannon MacDonald told Reuters Health.
In the days after receiving a vaccine, compared to other times, children are two to five times more likely to have a febrile seizure, according to the authors of the new study.
"When a child has its first seizure shortly after a vaccination, and continues to have seizures thereafter, parents may think the vaccination has caused the epilepsy. However, in our study the majority of children who developed epilepsy after a vaccination, had a genetic or structural cause of the epilepsy," Dr. Nienke Verbeek, a clinical geneticist at University Medical Centre Utrecht in The Netherlands, told Reuters Health.
"In these children, the vaccination should only be considered a trigger for the first seizure that thereby unmasks the child’s underlying susceptibility for epilepsy," Verbeek added.
Roughly one in every 100 healthy, normally developing children will develop epilepsy after a febrile seizure, according to NINDS, but children with certain conditions, including cerebral palsy and developmental delay, are at greater risk.
To better understand the relationship between febrile seizures and epilepsy, the researchers looked at nearly a thousand children who had a first seizure within several days of being vaccinated. Twenty-six of the children were later diagnosed with epilepsy, and the researchers were able to follow up with 23 of them.
Eight of the children had Dravet syndrome, a rare genetic condition in which seizures may be brought on by fever, infectious disease, or vaccination. Three of the children had developmental delays and structural brain defects that could cause epilepsy. Four other children had gene mutations that could cause epilepsy, brain malformations, or a family history of the disease.
"Although no underlying cause was detected in one-third of children with epilepsy with vaccination-related onset, a genetic basis of epilepsy in these children is still possible: genetic analyses were incomplete, some children had positive family histories for seizures, and molecular defects underlying many genetically determined epilepsies have yet to be discovered," Verbeek and her colleagues write.
"For parents it is important to understand that a genetic cause (a so called DNA-mutation) for epilepsy cannot be induced by vaccinations," Verbeek told Reuters Health. " These mutations are already present in the child before it is born. They may have been transmitted by one of the parents, but more commonly have occurred spontaneously around the time of conception."
The findings “provide a pretty strong case that this was not caused by the vaccination,” Dr. Jorn Olsen told Reuters Health in a telephone interview.
SOURCE: Pediatrics, online September 15, 2014.
OBJECTIVES: This study was an assessment of the incidence, course, and etiology of epilepsy with vaccination-related seizure onset in a population-based cohort of children.
METHODS: The medical data of 990 children with seizures after vaccination in the first 2 years of life, reported to the National Institute for Public Health and Environment in the Netherlands in 1997 through 2006, were reviewed. Follow-up data were obtained of children who were subsequently diagnosed with epilepsy and had had seizure onset within 24 hours after administration of an inactivated vaccine or 5 to 12 days after a live attenuated vaccine.
RESULTS: Follow-up was available for 23 of 26 children (median age: 10.6 years) with epilepsy onset after vaccination. Twelve children developed epileptic encephalopathy, 8 had benign epilepsy, and 3 had encephalopathy before seizure onset. Underlying causes were identified in 15 children (65%) and included SCN1A–related Dravet syndrome (formerly severe myoclonic epilepsy of infancy) or genetic epilepsy with febrile seizures plus syndrome (n = 8 and n= 1, respectively), a protocadherin 19 mutation, a 1qter microdeletion, neuronal migration disorders (n = 2), and other monogenic familial epilepsy (n= 2).
CONCLUSIONS: Our results suggest that in most cases, genetic or structural defects are the underlying cause of epilepsy with onset after vaccination, including both cases with preexistent encephalopathy or benign epilepsy with good outcome. These results have significant added value in counseling of parents of children with vaccination-related first seizures, and they might help to support public faith in vaccination programs.

Sunday, October 19, 2014

The impact of migraines on the whole family

This article discusses the impact that migraine headaches have on the entire family.

Most Migraine sufferers will tell you that their migraines are worsened by stress. Stress can come from a number of sources, but the ones that seem to be on the top of the list are school, or work, and family. Though all three are tremendously significant, it is infinitely easier to change a classroom, school or even job than it is to change one’s family.
Whether it be marital discord, money concerns, or parent – teen conflict, families issues have a tremendous impact on the migraineur and ignoring this is likely to result in less than successful migraine therapy.
On the flip side, having a supportive, understanding family can be an enormous help to the migraine sufferer…to an extent. Unfortunately, we find that very often with our adolescent patients, the parents are too focused on the migraine; so called “helicopter parents” who are hovering over their teen with repeated inquiries about their pain. In my clinic I had one parent ask her 16 year old son how he was feeling 4 times in a 15 minute visit. This kind of attention only serves to increase the focus on a problem that we are trying to minimize.
Often, having the whole family involved in the therapeutic process is the answer. It may mean scheduling visits at a time that spouses or parents are available, and it may involve family counseling. People often find the prospect of family counseling threatening. It really should not be viewed as such. Seldom do people take classes on being a spouse or a parent before having to be one. Processes that seem right and become family habit sometimes are detrimental in ways not obvious to those involved.
Making the effort to work on sources of family stress and how the family responds to them; learning to be supportive without being overbearing can be the key to improving the life not only of the migraineur, but the whole family.

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A parent's thoughts on concussions can hinder treatment and recovery

A study shows that a parent's misconceptions about concussions and treatment hinders treatment and recovery.

With football season in full swing, there's no shortage of talk about young players -- from high school down to the pee wee levels -- suffering from concussions. Yet many parents may lack knowledge about this mild traumatic brain injury, according to two studies to be presented Oct. 10 at a pre-conference symposium on pediatric sports medicine at the American Academy of Pediatrics (AAP) National Conference & Exhibition in San Diego.
Nearly 175,000 children are treated in U.S. emergency rooms each year for concussions due to sports-related activities, according to the Centers for Disease Control and Prevention. Parental knowledge of the signs and symptoms of concussion and recognizing that this is a brain injury is important to ensure children are diagnosed in a timely manner and get appropriate treatment.
Two separate studies looked at parents' knowledge of concussion and common misconceptions. They will be presented as part of the Peds21 symposium, "1, 2, 3, Go! Sports in the World of Pediatrics -- Playing it Safe and Making it Fun!" in the San Diego Convention Center.
For the first abstract, titled "Parental Knowledge of Concussion," 511 parents of children ages 5-18 years who sought care at a pediatric emergency department within two weeks of their child suffering a head injury filled out a 24-item survey. They were asked questions about their demographics, their child's head injury, and general questions related to their knowledge of concussion and its treatment.
Results showed about half of parents correctly identified a concussion as a brain injury that could lead to symptoms such as headache or difficulty concentrating. No parental demographics (age, sex, education or prior history of sports participation) significantly predicted parents' knowledge about concussions.
The survey also indicated that almost all parents (92 percent) were aware that they should stop their child from playing and see a physician if they suspected a concussion. Yet only 26 percent were aware of guidelines on when their child could return to sports and school work.
"Our study showed that the vast majority of parents knew what to do if they suspected a concussion in their child and in most cases understood the clinical importance of this injury as a brain injury," said lead author Kirstin D. Weerdenburg, MD, FAAP, pediatric emergency medicine fellow at Hospital for Sick Children, Toronto, Ontario, Canada.
"The study also highlights that a physician visit shortly after the injury is important to confirm the diagnosis for parents and to inform parents of return to play/learn guidelines to ensure a proper recovery and prevent a second concussion while the brain is still healing," Dr. Weerdenburg said.
The authors of the second abstract, "Parental Misconceptions Regarding Sports-Related Concussion," also surveyed parents to assess their knowledge of concussions. The online survey was completed by two groups -- 214 parents whose children were evaluated at a sports medicine clinic for musculoskeletal or mild traumatic brain injuries (group 1) and 250 parents of students at a local private school (group 2).
The survey included questions that gauged their knowledge of and attitudes about concussions as well as demographic information.
The majority of parents in both groups did well overall but had several misconceptions:
  • About 70 percent in group 1 and 49 percent in group 2 incorrectly believed that brain imaging (CT/MRI scans) can be used to diagnose concussion.
  • About 55 percent in group 1 and 52 percent in group 2 did not know that "bell ringer or ding" is synonymous with concussion.
  • Reduced breathing rate was incorrectly identified as a symptom by 25 percent and 29 percent, respectively.
  • Difficulty speaking was incorrectly identified as a symptom by 75 percent and 79 percent, respectively.
"Our study highlights the fact that many parents are still in need of education regarding concussion identification and post-injury evaluation. Even those highly educated parents were prone to misconceptions," said senior author Tracy Zaslow, MD, FAAP, medical director of the sports medicine and concussion program at Children's Orthopaedic Center, Children's Hospital Los Angeles. "False perceptions such as the ones pinpointed by our study may impact when medical care is sought after concussion and lead to less than optimal home care."
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Insomnia in older adults affects sleep quality

A study showed that older adults who have insomnia have their sleep quality affected, but not their sleep duration.

Reports of insomnia are common among the elderly, but a new study finds that sleep problems may stem from the quality of rest and other health concerns more than the overall amount of sleep that patients get.
An estimated 30 percent of adults report having some symptoms of insomnia, which includes difficulty falling asleep, staying asleep or waking up too early and then not feeling well rested during the daytime. Prior studies suggest that nearly half of older adults report at least one insomnia symptom and that lack of restorative sleep might be linked to heart disease, falls, and declines in cognitive and daytime functioning.
The new study found discrepancies between self-reported insomnia and outcomes recorded on a sleep-monitoring device. Older adults' perception of sleep does not always match what's actually happening when a more objective assessment is used to monitor sleep patterns and behaviors.
A study, published online by Journals of Gerontology: Medical Sciences, used data from 727 participants in the National Social Life, Health and Aging Project who were randomly invited to participate in an "Activity and Sleep Study." The activity and sleep study had two components: a self-administered sleep booklet, which included questions about the person's sleep experience, (e.g., "how often do you feel really rested when you wake up in the morning?") and 72-hours of wrist actigraphy, which is a wristwatch-like sensor that monitors sleep patterns and movements.
An author on the study, Linda Waite, the University of Chicago Lucy Flower Professor in Urban Sociology and the director of the Center on Aging at NORC at UChicago, said the researchers wanted to objectively evaluate several aspects of older adults' sleep characteristics, which is why they used the actigraphs in addition to the survey questions.
"Older adults may complain of waking up too early and not feeling rested despite accumulating substantial hours of sleep," Waite said.
The actigraph measurements showed that most of the older adults got sufficient amounts of sleep.
Even though reported sleep problems are common among older individuals, according to the survey only about 13 percent of older adults in the study said that they rarely or never feel rested when waking up in the morning. About 12 percent reported often having trouble falling asleep, 30 percent indicated they regularly had problems with waking up during the night and 13 percent reported problems with waking up too early and not being able to fall asleep again most of the time.
The actigraph provided data that showed the average duration of sleep period among the study participants was 7.9 hours and the average total sleep time was 7.25 hours. Waite said this indicates that the majority of older adults are getting the recommended amount of sleep and usually not having common sleep problems.
One other unexpected finding for the researchers was that respondents who reported waking up more frequently during the night had more total sleep time. "This suggests that a question about feeling rested may tap into other aspects of older adults' everyday health or psychological experience," said Waite.
"Our findings suggest that reports of what seem like specific sleep problems from survey questions may be more accurately viewed as indicators of general problems or dissatisfaction with sleep that may be due to other issues in their lives affecting their overall well-being. These survey questions and actigraphy may measure different aspects of sleep experience."
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When to go to the hospital for a migraine

This article explains when it is appropriate to go to the hospital for a migraine headache.

Headache is one of the most common reasons for an emergency room visit. Some people go due chronic headache or Migraine problems that do not go away with treatment, and in other cases, headache is a symptom of another medical problem.
The best reason for an ER visit is for unusual symptoms that are new to you. You may seek attention to make sure there is no chance of another problem such as aneurysm or meningitis. A severe headache that starts very suddenly (within a second or two) can mean another disorder such as stroke. New symptoms such as a fever, weakness, vision loss or double vision, or confusion are some of most concerning symptoms. If you have a new symptom and serious, life-threatening medical problems such as liver, heart or kidney disease, are pregnant, or have a disorder which affects your immune system such as HIV infection, an ER visit may be more essential.
For many patients, an ER visit for headache or Migraine happens after a long period of severe headache lasting days or weeks. After long time of experiencing severe headache, you may reach the "last straw" and no longer be able to deal with the problem. ER doctors are not specialists in headache and Migraine, and their goals are to make sure there is no serious life-threatening problem and help reduce suffering. Different ER doctors have different ways to treat acute headache and Migraine: there is no universal protocol for emergency treatment of headache disorders.
When going to the ER, be sure to mention:
  • your symptoms, including any that are new or unusual for you;
  • any medications you have taken, especially in the last few days; and
  • if you have had good results from a particular medication regimen, that can be helpful to the ER.
Often ER doctors will want to order tests such as a CT scan of the head or spinal tap to make sure there is no bleeding in the brain, large stroke or meningitis. If you are having your typical severe headache or Migraine, and no new symptoms, the chance these tests will be helpful are extremely low and you have the right to refuse them. (See 5 Things Migraine and Headache Patients and Doctors Should Question.)
The majority of persons coming to an ER for severe headache or Migraine do not get lasting results from the medications given in the ER, so having a good long-term plan and relationship with an outpatient doctor who treats your headache disorder is very important. If you have even occasional long-lasting headaches or Migraines, a good preventive plan is very important, and you should have at least one rescue medication to prevent future ER visits.
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