Internships

Internship Programs

Learn, Observe, Advance

The internship programs provide a unique opportunity for Undergraduate students interested in Neuroscience. It allows them to gain hands-on experience in neuroscience, and direct patient care. With a focus on education, mentorship, and professional development, our programs empower students to explore cutting-edge technologies, such as EEG monitoring, and engage in critical aspects of medical documentation in clinic.

Guided by experienced professionals, interns develop practical skills, deepen their understanding of neurological diseases, and build a strong foundation for careers in healthcare fostering curiosity and excellence in a supportive and innovative environment.

Our graduating scribes have successfully pursued MD and DO programs at prestigious institutions nationwide.

Internships we Offer

EEG Internship

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Scribe Internship

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How to Apply?

Please submit an application to nshakir@brainandspineaz.com.
Include the following:

01

Select an Internship

02

Upload Resume

03

Upload Cover letter

04

Upload Transcript

Training for Scribe

Download Manual to Know More

Testimonials

Cary Nelson

“Brain and Spine Center is probably the most automated of all the medical offices I visit. That's kinda cool and seems to be efficient. The staff are all very kind and friendly. Dr Parkinson is never in a hurry but always taking the time needed to answer questions and explain everything very thoroughly. I feel heard and well cared for. I wouldn't hesitate to recommend them.”

Judy Kahler

“I love the staff at Brain and Spine Center.They are kind and genuinely seem happy to be there. Try very hard to answer their calls promptly, and when it's not possible they are super helpful when they do get back to you. I have seen several of the practitioners, and have genuinely felt they were very knowledgeable and really cared about my situation. I would recommend them to anyone who needed them.”

Shelley Petersen

“My appointment at the Brain & Spine Center went very good. I was called back shortly after checking in. The nurse came in and took vitals. Dr. Simon Parkinson was good & is always very caring. He explained my biopsy results and adjusted my medications after listening to how they make me feel. I appreciated that he adjusted instead of just keeping me on them. I would highly recommend Doctor Simon Parkinson he is awesome!”

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

Professional Memberships

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.

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

Professional Memberships

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.

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.

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.

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.

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.

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.

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.

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.

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).

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).

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.

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).

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.

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

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.

Jan Levine

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Ted Etling,
PsyD

Karen Garcia,
DNP, APRN, FNP- C

Diala Manfoukh,
PA-C

Dr. Hemant Pandey,
MD

Anjanette Kibby,
FNP-C

Jan Levine,
RN, MSN, FNP-BC