For many years, concussion management didn't play a significant role in the training of future neurologists — or in the practice of most clinical neurologists. Concussions were primarily the purview of the neurosurgeon, because so many patients had trauma such as skull fractures and subdural hematomas, and the neurosurgeons led their surgical care.
“While neurologists might take care of the headaches or seizures that resulted from the concussion, we were not really involved as chief stakeholders who might coordinate care for these patients,” said Joel Morgenlander, MD, professor and interim chair of the neurology department at Duke University.
But in recent years, a confluence of factors has changed that. For example, the growing recognition of the complex and often long-term sequelae of sports concussion — in which surgical management is rarely required — placed traumatic brain injury (TBI) in a different context.
“Over time, neurosurgeons became less active in medical management of the patients, and it has fallen to a potpourri of interested parties,” said Dr. Morgenlander. “The prevalence of concussion and the seriousness of both its acute and chronic effects have become more obvious to those taking care of patients.”
Approximately four years ago, the AAN formed its Sports Neurology Section, chaired by Anthony Alessi, MD, an associate clinical professor of neurology at the University of Connecticut. The Section now has nearly 500 members, and recently formed a Sports Neurology Education Working Group specifically focused on improving resident education regarding traumatic brain injury and sports concussion.
GAPS IN TRAINING
“Around the same time that we began moving forward with this effort around sports neurology and getting neurologists more comfortable with the care of those patients, there came a change in the neurology residency training format,” said Dr. Morgenlander. The adoption of competency-based residency training by the Accreditation Council for Graduate Medical Education (ACGME) in 2013 — known as “The Milestone Project” — underscored the gaps in concussion management training.
“When the milestone list for neurology came out, sports concussion and TBI weren't listed,” said Dr. Morgenlander.
So an initial mission of the Sports Neurology Education Working Group became to spur change in the neurology milestones. “Our first effort was to work with Steve Lewis, MD, [associate chair of the department of neurological sciences at Rush University in Chicago and vice-chair of the Resident Review Committee (RRC) of the ACGME] and his group, who were writing the neurology milestone list for residents, to see if we could get TBI included.”
A revised version of the milestone list now includes TBI within the cognitive section, but the milestones still do not include a specific mention of sports concussion.
NEUROLOGY OF SPORTS CONCUSSION
Although sports concussion doesn't rate milestone inclusion, Dr. Morgenlander hopes that the TBI emphasis will help to encourage residency program directors to incorporate some of the training that the working group is now developing, which will include the growing body of work in neurology surrounding sports concussion.
“Neurology residents frequently see inpatients who have had TBI as a result of motor vehicle accidents, falls, or other trauma,” he said. “But sports concussion is mainly an outpatient disorder, so unless someone in the faculty practice where the residents are training is involved in the care of these patients in some way — and the residents happen to be in clinic with them — they could conceivably get through residency without seeing many of these patients.”
Dr. Morgenlander and his working group — which also includes Andrew Russman, DO, from the Cleveland Clinic; Kevin Crutchfield, MD, of Baltimore's Sinai Neurology Associates; Gary Stobbe, MD, from Seattle Children's Hospital; and New York University Langone's Brian Hainline, MD, the National Collegiate Athletic Association's first chief medical officer — plan to work with the AAN to aggregate the existing body of work around sports concussion education into modules for residency training.
“We'd like to combine the materials that are already accessible, such as lectures given at the AAN annual meeting, and make those available in a batch way to residency programs. At every meeting, there are probably about 10 sessions scattered throughout the week that are pertinent to folks interested in sports neurology and concussion, and that could be utilized in training,” said Dr. Morgenlander. “What we'd also really like to do is put together a video of the appropriate exam for a patient who has just had a sports concussion, demonstrating the things you want to be able to do to assess the patient in your office, in the clinic, or on the sidelines.”
The Sports Neurology Section meeting at this year's AAN meeting will include a discussion of how to put such content together, Dr. Morgenlander said, adding, “that's only part of what we hope to do.” This July, in Chicago, the AAN will hold its first Sports Concussion Conference, which will include a number of presentations from Section and Working Group members.
With this issue, Neurology Today introduces this new column, Inside the AAN Sections, which will feature the subspecialty issues, concerns, and priorities of the AAN Sections. For more information about the AAN Sections, see http://bit.ly/OyzjkQ.