JWM Neurology Welcomes Saju Abraham, MD

Neurologist Saju Abraham, MD has joined JWM Neurology.

Dr. Abraham received his medical degree from St. James School of Medicine in Bonaire, Netherland Antilles. He completed his Neurology Residency at the University of Illinois in Chicago and his Epilepsy Fellowship at the University of Michigan in Ann Arbor.

He sees patients with all types of neurological conditions.

His areas of expertise include:

• Epilepsy and seizures


• EEG and Video EEG


• Stroke


• Multiple Sclerosis


• Brain and spinal cord injuries


• Parkinson's disease and movement disorders


• Neck, back and arm pain


• Headaches


• Alzheimer's disease

Tourette Syndrome: What Makes Some Brains Tic?

Keith R. Ridel, MD
JWM Pediatric Neurologist

Tics are a symptom of Tourette Syndrome. Tourette Syndrome is a disorder where a person has at least one vocal and at least two movement tics for more than one year, usually beginning before puberty. Not every person who has tics has Tourette Syndrome. If the tics last less than one year, the diagnosis is Transient Tic Disorder. Persons with other neurologic or psychiatric disorders may also have tics.

Tics are usually brief movements or sounds. They may be simple actions that we all do, such as blinking or humming, done too often. The tic should look or sound the same each time, at least for a while. Usually, in Tourette’s, tics move to different locations over time. Also, tics may become more complex, such as repeating a certain word or tapping a certain way. Young children may not be aware of their tics, but older children and adults often feel a sensation inside, an urge to tic. Holding a tic in may cause stress; letting it out may relieve it.

No one knows for sure what is different about the brain of a person who has Tourette’s. The brain contains 10 billion neurons that communicate with one another in complex ways, controlling thoughts, emotions, movements, and body functions. Studying a living brain to see why it behaves as it does is challenging for neuroscientists, but there are some new clues about why some brains tic.

Information travels to our brain through nerves in our faces, bodies, arms, and legs.

• For example, information that a bug is sitting on my arm must travel from the skin on my arm, up my arm to my spinal cord, then up to my brain.


• Then it must travel to the cortex, the surface of my brain, so I can become conscious of the location of the sensation (left forearm), the meaning of the sensation (a hungry mosquito), and perhaps some emotions associated with the sensation (fear, irritation).


• Then my cortex will form a plan (rotate left arm gently, swat mosquito with right hand) and issue a command to execute the action (rapid movement of flattened right hand onto mosquito on left forearm).

Beneath the brain’s surface are some important structures that communicate within the brain in complex circuits. These areas affect how the information about the mosquito gets to the surface of the brain. These areas also affect how we move in response to sensations. One of these areas that seems to be important in Tourette’s is called the Striatum (rhymes with “I ate ‘em”). The striatum is part of many important brain circuits. Although the striatum looks pretty much the same in people who tic and people who don’t (you can’t diagnose Tourette Syndrome with a brain MRI), there are some new research brain scans that show that areas of the striatum “light up” when someone tics, or tries to hold their tics in. In Tourette’s, it may be that the striatum works differently, in how it regulates sensory information coming in, in how it affects urges to respond to those sensations, or both.

Certain brain chemicals called neurotransmitters (used by neurons to communicate with each other) also appear to be abnormal in the brains of persons with Tourette’s. These include dopamine, which is involved in many movement disorders, and serotonin, which is involved in many mood disorders, such as depression and obsessive compulsive disorder. Currently, these chemical differences are difficult to measure. However, for many persons with Tourette’s, medicines, which block dopamine or increase serotonin can be helpful.

Tourette’s is an area of active research. New studies should increase our knowledge of what makes some people tic. Children with tics are often sent to child neurologists for evaluation and management.

Pediatric Neurologist Dr. Keith Ridel Joins JWM Neurology

Pediatric Neurologist, Keith Ridel MD, has joined JWM Neurology.

Dr. Ridel received his medical degree from the University of Cincinnati College of Medicine in Cincinnati, Ohio. He completed his Pediatric residency and Child Neurology fellowship at Cincinnati Children’s Hospital Medical Center in Cincinnati, Ohio.

Dr. Ridel sees infants, children and teenagers with general neurology problems.

His areas of expertise include:
• Seizure
• Headache
• Sleep disorders
• Seizures
• Tics and movement disorders
• Neuromuscular disorders
• Neck, back and arm pain
• Brain and spinal cord injuries
• Genetic neurological disorders
• EEG/Video EEG testing

Dr. Adam Fisch Joins JWM Neurology

Dr. Adam Fisch joined JWM Neurology and is a board certified neurologist and sleep disorders medicine physician.

He has special interests in sleep medicine/EEG/EMG. Dr. Fisch is originally from Indianapolis and received his medical degree from Indiana University School of Medicine. He completed his neurology residency and sleep medicine fellowship at Washington University School of Medicine in St. Louis, Missouri.

Dr. Fisch is an avid educator and has lectured to medical students, rehabilitation therapists and neurology residents at many different universities. He also recently authored a book titled Neuroanatomy: Draw it to Know It, published by Oxford University Press, for which he won the “2009 Washington University in St. Louis Leonard Berg Prize for Research During Residency” Award. He has since created neuroanatomy tutorials available on http://www.drawittoknowit.com/.

Dr. Fisch sees patients with general neurology problems and sleep disorders.

Free Women's Sleep Disorders Seminar

JWM Neurology & Holder Mattress Factory Present a FREE Seminar:

"Common Treatable Sleep Disorders in Women"

Having trouble sleeping? You’re not alone! In this free seminar, Meredith Cousin, MD, a neurologist and sleep disorders specialist with JWM Neurology will talk about conditions that
influence sleep patterns and keep you from waking up rested. From sleep apnea and Restless Legs Syndrome to insomnia and hormone/pregnancy-related sleep issues, you’ll learn about common sleep disorders that can be treated.

Holder Mattress experts will demonstrate the correlation between a properly constructed mattress and a good night's sleep.

• Thursday, May 21st
• 6:00 p.m.
• Holder Mattress Factory:
1422 S. Rangeline Rd., Carmel, IN
(116th St. and Rangeline Road)

Space is limited so please R.S.V.P.

• Holder Mattress 317-848-2939
• JWM Neurology 317-308-2828, ext. 1604

Refreshments will be served.

Common Questions About CPAP

If you’ve been diagnosed with sleep apnea, chances are good that you have been told to wear a CPAP mask while you sleep in order to treat the condition. CPAP is an acronym that stands for Continuous Positive Airway Pressure. Typically, a face mask is connected to a pump and forces air into the nasal passages to stimulate proper breathing.

Here are some common questions our sleep disorders physicians are asked about CPAP along with their answers. If you are having trouble with your CPAP be sure to speak to your physician. Many sleep disorders labs have regularly scheduled CPAP clinics where patients can go and get their problems worked out.

My CPAP mask is uncomfortable and does not fit properly. What should I do?
Often times, patients have to try out a few different masks before they get a proper fit. Masks can also be individually adjusted to fit comfortably. If you are having problems contact your health care provider to see what can be done.

Is there one CPAP mask that fits all people?
No, unfortunately there is not. Everyone’s facial shape and features are different, therefore there are a variety of masks available. It’s important you find the right one with the proper fit to ensure you are able to wear your CPAP consistently.

Do I need to wear my CPAP every night?
Consistency is the key in treating disorders such as sleep apnea. Therefore, it’s important to wear your mask every night. The more you wear it, the more you’ll get used to sleeping comfortably. Sleep apnea actually causes you to stop breathing several times during sleep and is therefore a very dangerous condition. It can cause stroke or heart attack if left untreated.

My throat gets dry when I use my CPAP. Is this normal?
Yes, this is a common complaint. Many CPAP machines come with a humidifier control which helps control dry mouth. If your particular model does not have this function, ask your health care provider about upgrading or trading in your machine.

How long will it take my CPAP to become effective?
Everyone is different, however, it can range from several weeks to a few months. It all depends on your diagnosis. The key is to wear your CPAP every night (or day if you are a shift worker) once you’re fitted. It will be uncomfortable and awkward at first, but once patients get into the habit, it becomes a routine part of sleep hygiene.

Pregnancy and Sleep

Pregnant and sleeping for two or more? If so, your sleep quality may change – especially by your third trimester.

Increased sleep complaints during pregnancy are often due to endocrine and physiologic changes in the body. The increase in progesterone that accompanies pregnancy naturally increases fatigue, raises body temperature, increases respiratory rate and intensifies the need for frequent urination. Physical changes such as the increase in abdominal mass and vascular load all lead to poor sleep quality.

Often during the first trimester, there is an increase in total sleep time and the need for naps; however, sleep quality can be poor due to frequent awakenings during the night.

Initial changes in sleep patterns typically occur in the first 12 weeks of pregnancy and then increase during the third trimester and early postpartum weeks. Be aware of:

• slight decreases in Rapid Eye Movement (REM) sleep
• decrease in deep sleep
• decrease in sleep efficiency
• increased awakenings after initially falling asleep

Women who have never before snored may begin to do so when pregnant. Snoring in expectant mothers is caused from inflammation in the nasal passages. This can lead to Obstructive Sleep Apnea, caused by a blockage in the airway, which is a very dangerous condition. It can cause death if not treated.

A condition known as Restless Legs (RLS) can also develop during the third trimester of pregnancy which causes an uncontrolled urge to move the legs. A contributing factor often may be iron or folic acid deficiency, so be sure to tell your doctor if you have these symptoms.

The best tips for a good night’s sleep when expecting: learn to relax utilizing breathing and other relaxation techniques. A warm shower or bath may also be helpful.