Neurology

Neurology (from Greek νεῦρον, neuron, "nerve"; and -λογία, -logia) is a medical specialty dealing with disorders of the nervous system. Specifically, it deals with the diagnosis and treatment of all categories of disease involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue, such as muscle.[1] The corresponding surgical specialty is neurosurgery. A neurologist is a physician who specializes in neurology, and is trained to investigate, or diagnose and treat neurological disorders. Pediatric neurologists treat neurological disease in children. Neurologists may also be involved in clinical research, clinical trials, as well as basic research and translational research.

Qualifications

In the United States and Canada, neurologists are physicians who have completed postgraduate training in neurology after graduation from medical school. Neurologists complete, on average, at least 10-12 years of college education and clinical training. This training includes obtaining a four-year undergraduate degree, a medical degree, which is an additional four years, and then completing a three or four-year residency in neurology. The four-year residency consists of one year of internal medicine training followed by three years of training in neurology. One and two year fellowships are available following completion of the neurology residency if desired.

Many neurologists also have additional subspecialty training (fellowships) after completing their residency in one area of neurology such as stroke or vascular neurology, interventional neurology, epilepsy, neuromuscular, neurorehabilitation, behavioral neurology, sleep medicine, pain management, neuroimmunology, clinical neurophysiology, or movement disorders. In Germany, a compulsory year of psychiatry must be done to complete a residency of neurology.

In the United Kingdom and Ireland, neurology is a subspecialty of general (internal) medicine. After five to nine years of medical school and a year as a pre-registration house officer (or two years on the Foundation Programme) a neurologist must pass the examination for Membership of the Royal College of Physicians (or the Irish equivalent) before entering specialist training in neurology. A generation ago some neurologists would also spend a couple of years working in psychiatric units and obtain a Diploma in Psychological Medicine, but that became uncommon and now that a basic psychiatric qualification takes three years to obtain it is no longer practical. A period of research is essential, and obtaining a higher degree aids career progression: many found it was eased after an attachment to the Institute of Neurology at Queen Square in London. Some neurologists enter the field of rehabilitation medicine (known as physiatry in the US) to specialise in neurological rehabilitation, which may include stroke medicine as well as brain injuries.

Testing examinations

During a neurological examination, the neurologist reviews the patient's health history with special attention to the current condition. The patient then takes a neurological exam. Typically, the exam tests mental status, function of the cranial nerves (including vision), strength, coordination, reflexes and sensation. This information helps the neurologist determine if the problem exists in the nervous system and the clinical localization. Localization of the pathology is the key process by which neurologists develop their differential diagnosis. Further tests may be needed to confirm a diagnosis and ultimately guide therapy and appropriate management.

Many symptoms that may occur would involve: tension, sleep loss, headaches and anger.

Clinical tasks

General caseload

Neurologists are responsible for the diagnosis, treatment, and management of all the above conditions. When surgical intervention is required, the neurologist may refer the patient to a neurosurgeon. In some countries, additional legal responsibilities of a neurologist may include making a finding of brain death when it is suspected that a patient is deceased. Neurologists frequently care for people with hereditary (genetic) diseases when the major manifestations are neurological, as is frequently the case. Lumbar punctures are frequently performed by neurologists. Some neurologists may develop an interest in particular subfields, such as dementia, movement disorders, headaches, epilepsy, sleep disorders, chronic pain management, multiple sclerosis or neuromuscular diseases.

Overlapping areas

There is some overlap with other specialties, varying from country to country and even within a local geographic area. Acute head trauma is most often treated by neurosurgeons, whereas sequelae of head trauma may be treated by neurologists or specialists in rehabilitation medicine. Although stroke cases have been traditionally managed by internal medicine or hospitalists, the emergence of vascular neurology and interventional neurologists has created a demand for stroke specialists. The establishment of JCAHO certified stroke centers has increased the role of neurologists in stroke care in many primary as well as tertiary hospitals. Some cases of nervous system infectious diseases are treated by infectious disease specialists. Most cases of headache are diagnosed and treated primarily by general practitioners, at least the less severe cases. Similarly, most cases of sciatica and other mechanical radiculopathies are treated by general practitioners, though they may be referred to neurologists or a surgeon (neurosurgeons or orthopedic surgeons). Sleep disorders are also treated by pulmonologists and psychiatrists. Cerebral palsy is initially treated by pediatricians, but care may be transferred to an adult neurologist after the patient reaches a certain age. In the United Kingdom and other countries, many of the conditions encountered by older patients such as movement disorders including Parkinson's Disease, stroke, dementia or gait disorders are managed predominantly by specialists in geriatric medicine.

Clinical neuropsychologists are often called upon to evaluate brain-behavior relationships for the purpose of assisting with differential diagnosis, planning rehabilitation strategies, documenting cognitive strengths and weaknesses, and measuring change over time (e.g., for identifying abnormal aging or tracking the progression of a dementia).

Relationship to clinical neurophysiology

In some countries, e.g. USA and Germany, neurologists may specialize in clinical neurophysiology, the field responsible for EEG, nerve conduction studies, EMG and evoked potentials. In other countries, this is an autonomous specialty (e.g. United Kingdom, Sweden).

Overlap with psychiatry

Further information: Psychoneuroimmunology and Neuropsychiatry Although many mental illnesses are believed to be neurological disorders affecting the central nervous system, traditionally they are classified separately, and treated by psychiatrists. In a 2002 review article in the American Journal of Psychiatry, Professor Joseph B. Martin, Dean of Harvard Medical School and a neurologist by training, wrote that the separation of the two categories is arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain and mind are one makes the separation artificial anyway.

There are strong indications[citation needed] that neurochemical mechanisms play an important role in the development of, for instance, bipolar disorder and schizophrenia. Also, "neurological" diseases often have "psychiatric" manifestations, such as post-stroke depression, depression and dementia associated with Parkinson's disease, mood and cognitive dysfunctions in Alzheimer's disease and Huntington disease, to name a few. Hence, there is no sharp distinction between neurology and psychiatry on a biological basis – this distinction has mainly practical reasoning and strong historical roots (such as the dominance of Freud's psychoanalytic theory in the first three quarters of the 20th century – which has since then been largely replaced by the focus on neurosciences – aided by the tremendous advances in genetics and neuroimaging.)

Readings

Readings with discussion.

Wikipedia

Salvia divinorum - What effect does salvia divinorum have on neurology and the brain?