Archive for August, 2013

Stricter Guidelines Direct Assessment and Recovery of Concussions

A greater awareness of the lasting impact that concussions can have on a person’s cognitive and neurobehavioral function has resulted in stricter guidelines in the way we assess and recover from concussions in recreational and professional sports.



“The grading scales that used to be utilized have fallen out of favor, as have the return to play guidelines that used to be associated with them,” says Harris Frankel, MD, neurologist at The Nebraska Medical Center. “There is no magic number that determines whether or not one should return to play following a concussion. Because of individual variability, it is difficult to predict when “the next blow” might be catastrophic and/or result in serious neurologic impairment, especially if one is not allowed to recover completely from the previous concussive injury.”

We need to be especially careful of children knowing that their brains take longer to recover than that of an adult. As such, the consequences in children and adolescents can be more severe. Relying on the physical symptoms reported by the athlete may not be reliable enough. In addition, a concussion does not have to involve a loss of consciousness. Any athlete that suffers head trauma during a sporting event and appears momentarily dazed, should be removed from the field until he or she has had a thorough evaluation by a trained professional.

Assessment of a concussion has also changed. “Concussions are a functional disturbance, not a structural injury per se and therefore, CTs and MRIs cannot be used to diagnose concussions,” notes Dr. Frankel. Imaging studies such as CT and MRI may be indicated to look for structural injuries such as bleeding and/or swelling in the brain that can occur following head trauma.”

Dr. Frankel strongly encourages all athletes participating in contact sports to undergo some form of baseline neurocognitive function testing prior to beginning a sport/activity. In the event an individual suffers a concussion, repeat testing is advisable to compare with the initial/baseline test. This can assist medical professionals in determining when it might be safe to “return to play.” These tests can be taken at most Omaha schools or at a doctor’s office with providers certified to administer the tests.

The Nebraska Medical Center is a credentialed ImPACT provider. ImPACT is just one of the neurocognitive tests that are used to help determine the cognitive recovery following a concussion. “If a physician is provided with an ImPACT test and isn’t sure how to interpret the test, they can call us and our credentialed physicians will be happy to confer with them,” says Dr. Frankel.

“Prior to returning to competition, athletes should go through a gradual return to play progression,” explains Rusty McKune, certified athletic trainer at The Nebraska Medical Center. “Should an athlete exhibit or develop any signs or symptoms, he or she needs to stop this progression and consult with a medical professional. Providing the brain adequate time to heal may not only include refraining from sports but may initially include refraining from school and things like TV, texting and video games until symptoms subside.”

Once a child suffers a concussion, they are at higher risk of sustaining a second concussion, which can invoke more serious complications than the first, says Dr. Frankel. Multiple concussions over time can result in long-term side effects such as chronic headaches, fatigue, sleep difficulties, dizziness, personality changes, sensitivity to light and noise, as well as deficits in short-term memory, problem-solving and intellectual functioning. Athletes should not be allowed to return to play until they are asymptomatic at both rest and exertion. The presence of symptoms indicates that the brain is still suffering from the effects of the previous injury. If a subsequent injury occurs before the first injury is completely resolved (as is evident by any persistent symptoms), a catastrophic and potentially deadly condition known as second impact syndrome can occur.


Relief for the Most Chronic Pain Sufferers

More than 100 million Americans live with chronic pain and can’t find relief with traditional modalities.

Chronic pain that is not treated successfully can become physically disabling, leading to depression, loss of sleep, missed workdays and decreased physical functioning, says Angie Rakes, M.D., medical director of the Pain Management Program at The Nebraska Medical Center. These issues often complicate a patient’s condition and make it necessary to use a combination of modalities to treat the patient’s pain effectively.


In fact, approximately 25 percent of patients with chronic pain have chronic pain syndrome – a complex of psychosocial issues that interfere with the successful management of their pain.

The Pain Management Program uses an individualized approach for each patient that addresses both physical and psychosocial factors and has been successful in providing effective relief to many patients, says Dr. Rakes. The program treats all types of chronic pain, including pain associated with many types of conditions such as headaches, back pain, fibromyalgia, arthritis or complex regional pain syndrome.

Now in its 40th year, the program is the second largest pain center in the country. The Pain Management Program is unique in that it uses an interdisciplinary team of health care professionals, including physicians, nurses, physical therapists, neurosurgeons and psychologists, who specialize in pain. These health care professionals work together to develop an effective pain management program that incorporates psychological management of pain, as well as techniques such as manual physical therapy, biofeedback, meditation, relaxation, nutritional counseling and exercise such as tai chi and yoga. The program also teaches patients coping skills to help them better manage pain throughout their daily lives so that they may return to activities associated with family, school or work.

Individuals recommended for the program include those who have not had success with conventional pain management therapies, those taking opioid medications that are interfering with daily functioning and those experiencing opioid-induced hyperalgesia. Physicians can refer patients directly into the program.

“Getting help early is an important factor in providing the most effective pain relief, says Dr. Rakes. “The longer you wait to seek treatment, the more difficult it becomes to treat pain as it allows the body to generate a map to pain that is difficult to break.”

The Pain Management Program offers three or four-week treatment options that meets daily for eight hours. “Chronic pain is a multi-faceted problem that can’t always be resolved with a single approach such as a medication or an injection,” says Rex Schmidt, PsyD, clinical psychologist with the Pain Management Program. “Treating pain requires changing the central nervous system. We’ve found that by combining all of these therapies into an intense daily program that are done simultaneously, we are able to change the course of pain pathways to the central nervous system that results in a variety of positive outcomes.”

Data tracking patient outcomes has shown that the majority of patients leaving the program have:

  • pain reduction of 36 percent
  • 50 percent reduction of depression
  • return to work rate of up to 75 percent
  • pain medication reliance reduction of 68 percent


“We see patients who come in hopeless and are able to reclaim their lives again when they leave. Some people leave our program completely pain-free,” says Dr. Schmidt.



Seizure Freedom is Possible for Most Patients

With the right diagnosis and treatment, today epilepsy is more treatable than ever before.

“Seizure freedom is no longer the exception, but the expectation,” says Deepak Madhavan, MD, epileptologist and medical director of the Nebraska Epilepsy Center at The Nebraska Medical Center. “The landscape has changed dramatically over the last 15 years due to newer medications, more advanced diagnostic tests and more precise surgical techniques. Through medications, surgery or a combination of the two, we can reduce or completely eliminate seizures in many patients.”

The Nebraska Epilepsy Center, the only comprehensive epilepsy center of its type in the region, diagnoses and treats epilepsy patients from children to adults using some of the most advanced diagnostic and treatment tools available.

One of these tools is the MEG scanner, which is available at The Nebraska Medical Center and only a few other large epilepsy centers nationally. The MEG uses magnetic fields generated by the brain’s neuronal activity to detect brain activity with greater detail and accuracy than previous testing tools. By allowing doctors to identify exactly where the brain is malfunctioning, the MEG improves the ability to diagnose and treat the disorder with the appropriate medications and provides greater surgical precision when removing the lesion becomes necessary.

While the treatment of epilepsy has seen great strides, awareness of this unpredictable and misunderstood disease has not kept pace.

Individuals who continue to experience seizures despite treatment are probably being treated with some of the older medications, which also carry a lot of chronic side effects, notes Dr. Madhavan. The type and combination of drugs prescribed for each individual depends on the specific type of epilepsy and its point of origination in the brain.

“With our experience and advanced diagnostic tools, we can evaluate these patients, do specialized testing if necessary and make sure they are taking the appropriate medications,” he says. Dr. Madhavan and partner Najib Murr, MD, are two of just three epilepsy-trained physicians in the state.

“Using the appropriate medications can make a significant difference in managing their seizures,” notes Dr. Madhavan. “Sixty to 70 percent of patients can become seizure-free on the proper medications. The remaining 35 percent will need surgery combined with medications. Approximately 10 percent of surgery patients will see significant improvement but may still experience some seizures.”

Early diagnosis and treatment is important to prevent the disease from progressing and causing long-term side effects. Untreated, recurrent seizures can cause progressive changes to the brain and can result in seizures becoming more frequent, more severe and more difficult to treat.

The Nebraska Epilepsy Center is a level four center that sees the most complicated cases in the region. The center follows approximately 3,000 patients and performs about 40 surgeries a year, which places it in the top 10 centers in the country. It is estimated that 30,000 to 35,000 people in Nebraska have epilepsy.


Comprehensive Pancreatobiliary Disorders and Autologous Islet Transplantation Clinic

Diseases of the pancreas and biliary tract are often complex and difficult to manage. A new clinic at The Nebraska Medical Center, the Comprehensive Pancreatobiliary Disorders and Autologous Islet Transplantation Clinic, was developed to provide a full spectrum of diagnostic and therapeutic approaches for a wide variety of non-malignant pancreatic and biliary diseases. The most common conditions treated at the clinic include acute and chronic pancreatitis.

The clinic brings together the expertise of gastroenterologists, endocrinologists, surgeons, pain specialists, nutritionists, nurse coordinators and social workers who collaborate and develop a personalized plan of care for each patient.

“These patients have complex problems and often they get left behind,” says Luciano Vargas, MD, surgeon at The Nebraska Medical Center, who specializes in diseases of the pancreas, liver and kidneys, as well as liver, pancreas and intestinal transplantation.


Together, Dr. Vargas and his colleagues bring a wealth of experience and expertise in diseases of the liver and pancreas that allow them to draw from three distinct perspectives to provide a comprehensive plan of care that is concise, well thought out and employs a very efficient use of the patient’s time.

About 300,000 cases of acute pancreatitis occur annually in the United States. Among gastrointestinal diseases, acute pancreatitis is the most common single reason for hospitalization. The majority of cases of acute pancreatitis are related to gallstones and alcohol use. Most cases of acute pancreatitis will resolve on their own. However, about 20 percent of cases can progress to severe acute pancreatitis. Repeated episodes of acute pancreatitis can lead to scarring in the pancreas and development of chronic pancreatitis.

“Chronic pancreatitis patients often have chronic pain, frequent flare-ups and may need repeated hospitalizations,” says Dr. Vargas. “Some are unable to work due to chronic pain.”

Compounding the problem is the fact that chronic pancreatitis can be difficult to diagnose and is often misdiagnosed and underdiagnosed, says Shailender Singh, MD, gastroenterologist at the clinic, who specializes in diseases of the pancreas. “A CAT scan or MRI can look completely normal and endoscopic ultrasound by itself is a very subjective test that can be difficult to evaluate unless you have a lot of experience.”

Dr. Singh has received specialized fellowship training in endoscopic ultrasound and performs the secretin stimulated endoscopic pancreatic function test. This is considered to be the most accurate and sensitive diagnostic test available for chronic pancreatitis and is available nowhere else in the region.

Management of the condition often involves diet restrictions, the elimination of alcohol and smoking, pancreatic enzyme replacement and narcotics to control the pain. If this does not relieve symptoms, other approaches will be explored including several endoscopic approaches and surgical procedures, all of which are performed by physicians at the clinic. “We offer the entire spectrum of care options,” says Dr. Vargas.

If patients continue to have debilitating pain despite all medical and endoscopic therapies, the patient will be evaluated for total pancreatectomy with auto islet cell transplant, a procedure performed at only a few medical centers in the country.

Dr. Vargas who trained at The Nebraska Medical Center, is one of the early adopters of this transplant procedure. “The procedure can literally change a person’s life,” says Dr. Vargas.

Unfortunately, not all patients end up with total pain relief. “There is no one panacea for most patients,” says Dr. Singh. “Our goal is to help them manage their pain at a level that is tolerable and allows them to function normally. We are a place that these patients can go and know that they are receiving the most advanced treatment options available anywhere. We are in it with them for the rest of their lives.”