Office-Based Neurology

“What does ‘Office-Based Neurology’ mean”? When first approached to serve as Guest Editor of this issue, this was my first thought. It was initially not entirely clear to me what the primary focus of an issue dedicated to “Office-Based Neurology” should be. Because the types of problems encountered in a neurology office practice span nearly the entire realm of clinical neurology, paring down the myriad neurologic disorders into a single issue was a seemingly impossible task. Initially, I reminisced to the first year following my neurology training in which I worked in a large private practice neurology group. I recalled the variety of patients and neurologic disorders that I encountered as the “first-line” neurologist, which was a somewhat novel work environment after having spent 4 years training in a large, tertiary care institution.

There is little objective data available that accurately assesses the frequency of different types of disorders encountered in an outpatient neurology practice. One review of all patient encounters by a single physician during a 3-year neurology residency program found that the five most common types of “outpatient” neurologic disorders encountered were epilepsy, Parkinson's disease, radiculopathy, peripheral neuropathy, and headache.[1] However, compared with data compiled nearly a decade earlier, all of these types of disorders, with the exception of headache, were overrepresented during the residency.[1] In the 2009 American Academy of Neurology demographic membership survey, 54% of responders indicated that their primary practice focus was general neurology.[2] Although the survey did not inquire about the types of problems encountered, the “general neurology” practice focus implies that most neurologists evaluate and treat the gamut of neurologic diseases in their practice. Following general neurology, the three most common outpatient-related specialty practice focuses were headache, epilepsy, and dementia. Despite these attempts to determine the prevalence of certain neurologic conditions, factors such as the types of neurology practices (e.g., solo vs. large multispecialty group), practice settings (e.g., small rural vs. large urban), and the particular focus of individual practices certainly influence the referrals to that practice and impacts the types of problems encountered.

Following my inaugural year of practice, I returned to an academic setting where my practice evolved into a subspecialty focus in neuromuscular diseases. I wondered how I as a “neuromuscular subspecialist” could serve as a Guest Editor for a Seminars in Neurology issue related to general office-based neurology. The answer was obvious. Although my primary area of expertise currently lies in neuromuscular diseases, my continued daily involvement in the practice of “general neurology,” both with my own patients as well as through regular supervision and teaching of our neurology residents, requires ongoing and updated knowledge of the entire realm of clinical neurology. To that extent, and to stay abreast of the current advances and practices in each subspecialty of neurology, an issue dedicated to a review of the important aspects of the evaluation and management of common outpatient neurologic conditions would be a valuable reference.

In this issue of Seminars in Neurology, a group of expert authors and colleagues provide current and up-to-date information related to the approach to evaluating and managing common neurologic symptoms that are encountered in a general outpatient neurology practice. The intent of this issue is not to provide intricate details of the myriad disorders that could cause each symptom, but to provide a concise overview of the approach to these problems. In using the available data regarding the prevalence of specific neurologic conditions, we chose to focus on the more commonly encountered neurologic problems. The issue is therefore divided into several common, symptom-based clinical complaints that prompt referral to a neurologist.

One of the most common neurologic referrals is for headaches. In the first article, Drs. Mathew and Garza carefully review the diagnostic criteria and the treatment of the common primary headache syndromes, but also discuss the important red flags and diagnostic tests needed to exclude more serious causes of headache. The article on cognition by Dr. Woodruff provides a symptom-based approach to the differential diagnosis for patients presenting with cognitive disorders, divided according to the primary cognitive domains involved, and reviews the approach to the evaluation and management of the more common cognitive disorders. Dizziness is a nonspecific but common complaint in neurologic practice, and the third article focuses on methods to clarify the description of “dizziness” and outlines the types of conditions that should be considered in patients with vertigo, lightheadedness, and imbalance. The article on the “sleepy” patient by Drs. Bodkin and Manchanda provides a concise overview of the approach to evaluating patients with common sleep disorders and offers some treatment strategies for several conditions. Dr. Noe's article on seizures discusses the evaluation and a variety of management issues related to patients with chronic seizure disorders.

Movement disorders are a common presenting symptom in the outpatient neurology setting and two articles nicely focus on an approach to the evaluation of patients with two types of movement-related symptoms – tremor and gait disturbances. Drs. Puschmann and Wszolek provide clear descriptions and review causes of a variety of different types of tremor. Dr. Van Gerpen takes a unique approach to evaluating gait disorders, focusing on problems in each of the different components of the gait cycle to determine the potential causes of the gait abnormality.

Another common, “bread-and-butter” outpatient neurologic complaint is limb or spine pain. Although the causes of these symptoms are vast, Dr. Watson provides an excellent, systematic clinical approach toward the evaluation of these types of problems and importantly reviews identifying conditions that require more urgent evaluation. Finally, the articles on peripheral neuropathy and weakness by Drs. Vavra and Dimberg provide a concise yet thorough review of the diagnostic approaches to the more common neuromuscular disorders encountered in an office-based neurology practice.

Our goal and hope is that the articles in this issue will provide a means for neurologists to improve and update their approaches toward evaluating and treating these common neurologic disorders in the outpatient setting. I would like to thank each of the contributing authors who provided these excellent reviews that have enlightened me and improved my knowledge in a variety of areas. I would also like to thank Karen Roos, M.D. for her gracious invitation to serve as Guest Editor as well as her excellent and thoughtful guidance and support throughout the project.

REFERENCES

• 1 D'Esposito M. Profile of a neurology residency.  Arch Neurol. 1995;  52 (11) 1123-1126
• 2 American Academy of Neurology. Neurologists 2009. AAN Member Demographics. St. Paul, MN: American Academy of Neurology; 2009