NATIONAL MEDICAL COMMISSION

Postgraduate Medical Education Board

D 11011/1/22/AC/Guidelines/28 Date: 30-12-2022

GUIDELINES FOR COMPETENCY

BASED
POSTGRADUATE TRAINING
PROGRAMME FOR DM IN
NEUROLOGY

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 GUIDELINES FOR COMPETENCY BASED
POSTGRADUATE SUPER-SPECIALTY TRAINING
PROGRAMME FOR DM IN NEUROLOGY

1. Preamble
The aim of the DM Programme is to impart advanced training in neurology to produce
competent super-specialists who can provide clinical care of the highest order to patients with
neurological diseases and serve as future teachers, trainers, researchers, and leaders in the
field of neurology. After successfully completing the course, they would work as productive
members of interdisciplinary teams consisting of physicians, neurosurgeons, geriatric
specialists, psychiatrists, psychologists, rehabilitation experts, and other specialists, nurses,
and other healthcare functionaries providing care to the patients with various neurological
disorders in any setting of the health care system. This document has been prepared by
subject-content specialists of the National Medical Commission. The Expert Group of the
National Medical Commission had attempted to render uniformity without compromise to the
purpose and content of the document. Compromise in purity of syntax has been made in order
to preserve the purpose and content. This has necessitated retention of “domains of learning”
under the heading “competencies.

SUBJECT SPECIFIC OBJECTIVES

The training program is designed to facilitate the ‘acquisition of learning’ by the postgraduate
student in the following three domains of learning:
• Cognitive (knowledge),
• Affective (communication),
• Psychomotor (practice).

1.1Predominant in Cognitive domain (Knowledge)

The student should:
 Understand the basic sciences (embryology, anatomy, physiology, biochemistry,
pharmaco-therapeutics, etc.) related to the field of neurology.
 Be conversant with the etiology, pathophysiology, diagnosis, and management of
common neurological problems.
 Should understand the importance of providing acute care with the goal of ‘full
recovery of function’.

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 Know the common problems in Neurology, the acute, life threatening conditions
which require redressal in a “time sensitive” manner as well as the transdisciplinary
acute medial and surgical conditins which requires team work of different specialities.
 Know the chronic problems encountered in the out patiens clinics of Neurology and
Medicine including specific neurological disorders and neurological complaints in
various systemic diseases spanning a host of medical and surgical conditions. This
includes all ages and also certain age specific neurological diseases involving post
delivery, neonatal, infantile., genetic and inherited conditions, adolescence, adult and
elderly age specific neurological diseases and syndromes.
 Be able to analyze neonatal health problems and develop preventive strategies to
decrease neurological morbidity and mortlity at hospital and community level
including National programs.
 Know neurological end of life care and bereavement follow up.

Group/team approach:
At the end of the course, the postgraduate student should be able to:
• Recognize the role of multi-disciplinary and interdisciplinary approaches in
managing various neurological disorders and recognize the importance of
family, society, and socio-cultural environment in treating the sick patient.
• Function as a part of a team, co-operate with colleagues, and interact with the
neonate’s family to provide optimal medical care.

Evidence-based approach:
At the end of the course, the postgraduate student should be able to critically appraise
medical literature in order to provide evidence-based care.

Research Methodology:
The postgraduate student should acquire:
(a) basic knowledge of research methodology and biostatistics,
(b) familiarity and participation in clinical and experimental research studies, and
(c) knowledge in scientific presentation and publication.

Skills:
At the end of the course, the postgraduate student should acquire (a) skills necessary
for neurological patient care. He/She should be able to undertake preparation of oral

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 presentation, medical documents, professional opinion in interaction with patients,
caretakers, peers, and paramedical staff - both for clinical care and medical teaching.
Effective communication with the patient/caretakers regarding the nature and extent
of disease, treatment options, realistic outcomes, and optimal management is
essential.

1.2 Predominant in Affective domain (Communication )

The PG student should:

 Acquire adequate communication skills to counsel and support the parents and
families of the neurological patients. Regular clinical rounds and academic
presentations during the teaching program should help the trainees to develop patient-
centric and family-centric attitudes, knowledge, and communication skills.
 Establish effective communication with the patient's caregivers, including appropriate
counseling for sickness, terminal illness, and bereavement care.
 Interact professionally and obtain relevant specialist/ancillary 'services' consultation
where appropriate.
 Ensure effective communication and teamwork while teaching others, including
undergraduates in a clinical care unit.
 Be able to communicate and work effectively with a multi-disciplinary team and
understand the role of other team members, including nurses, physiotherapists,
dieticians, psychologists, and others.
 Inculcate ethical principles in all aspects of neurological, pediatric and adult, medical
and surgical care/research (professional honesty and integrity, humility, moderation,
informed consent, counseling, awareness of 'patients' rights and privileges) and be a
role model for other health care team members and respect patient confidentiality.
 Maintain proper etiquette in dealings with patients, caretakers, and other health
personnel, including due attention to the 'patient's right to information, consent, and
second opinion. Maintain professional integrity while dealing with patients,
colleagues, seniors, pharmaceutical companies, and equipment manufacturers.
 Take rational decisions in the face of ethical dilemmas in neurological practice.
 Develop a communication style - both verbal and written, to ensure that the content is
accurately understood by the audience.

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2.3 Predominant in Psychomotor domain (Practice)

The PG student should:

 Evaluate a patient thoroughly (history, clinical examination), order relevant
investigations, and interpret them to reach a diagnosis and plan of management.
 Plan and carry out simple investigations/procedures (bedside, laboratory, imaging)
independently.
 Plan and carry out Neurointerventions such as Digital Substraction Angiography
( DSA) procedures though femoral route and assist in diagnostic asnd therapeutic
procedures such as Mechanical Thrombectomy in acute ischemic stroke with large
vessel occlusion ( AIS with LVO).
 Provide Basic and Advanced Life Support services in emergencies.
 Acquire familiarity with and provide critical care of post neurosurgery and
neurointervention patients, including airway support, ventilation, central vascular
access.
 Prepare a patient for an elective/emergency surgery and provide specific post-
operative care.
 Provide counseling to the patient and primary caretakers for the smooth dispensation
of medical care.
 Acquire skills in neurological procedures (including but not limited to invasive and
non-invasive respiratory support, peripheral and central venous access, resuscitation,
bladder catheterization, DSA, interpretation of acute stroke imaging, ( ASPECTS etc),
planning and preparation of nutrition ( swallowing test, Tube feeds etc), insertion of
chest tubes, sepsis workup, suprapubic urine sampling for culture, lumbar puncture,
use of medical equipment such as ventilators, including high-frequency ventilation,
exchange transfusion, therapeutic hypothermia, etc.).
 Monitor and manage patients in the standard ward / high dependency unit / and in the
intensive care setting.
 Provide specific and relevant advice to the patient and family at discharge time for
proper domiciliary care, hospital reporting in an emergency, and routine follow-up.

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 SUBJECT-SPECIFIC COMPETENCIES

3.1 Predominant in Cognitive (knowledge) domain:

After completing the DM (Neurology) course, the student be able to :
1. Know and analyze neurological health problems scientifically, considering the
biological basis and socio-behavioral epidemiology of the neurological disease,
and be able to advise and implement strategies to prevent neurological morbidity
and mortality.
2. Acquire knowledge on providing evidence-based primary, secondary, and tertiary
care of highest quality, including intensive care of the highest standard to the
critically sick patients with neurological diseases using advanced therapeutic and
supportive modalities and skills.
3. Acquire knowledge on developmental assessment of sensory and motor function
of pediatric patiens with neurological diseases and coordinate post discharge
comprehensive follow up.
4. Acquire knowledge to be be able to take rational decisions in the face of ethical
dilemma in neurological practice.
5. Plan and carry out research in neurological/brain health in the clinical,
community, and laboratory settings.
6. Teach basics and critical/mandatory information on common neurological
diseases and neurological emergenices to the medical and the nursing students and
other paramedical/community health functionaries, and develop learning resource
materials.
7. Plan, establish, and manage acute stroke, acute epilepsy, and other acute
neurological emergency units independently.
8. Contribute toward the development and adaptation of neurological care
technologies.
9. Organize stroke, epilepsy, dementia care in the community and at the secondary
health system level and play the assigned role in the national programs aimed at
the non – communicable diseases.
10. Work as a focal point for a multi-disciplinary endeavor for clinical care,
education, research, and community action with other stakeholders and partners.

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 11. Seek and analyze new literature and information on neurology, update concepts,
and practice evidence-based neurology.
12. Lead development of quality improvement projects & develop standard care
practices/ protocols for the unit.
13. Develop skills to train nurses in key components of essential neurological care.

3.2 Predominant in Affective domain (communication and values)

During the course of three years, the postgraduate student is expected to attend
instructive courses that facilitate proficiency relevant to this domain (eg.,
communication skills, biomedical ethics, patient counseling).
After completing the DM (Neurology) course, the student should be able to do the
following:

 Have empathy for patients and their family and should address them as worthy
human beings.
 Discuss options, including the advantages and disadvantages of each investigation
and treatment. She/he should be able to discuss medical issues with them in
‘layperson's language’.
 Become confident communicator and well-accomplished professional.
 Acquire communication skills to be able to debate & deliver a scientific lecture
and participate in panel discussions, hold group discussions and be able to deliver
the knowledge received by him/her during the course.
 Be able to function as a part of a team, develop an attitude of cooperation with
colleagues, and interact with the patient and the clinician or other colleagues to
provide the best possible diagnosis or opinion.
 Always adopt ethical principles and maintain proper etiquette in dealing with
patients, relatives, and other health personnel and respect the patient's rights,
including the right to information and second opinion.
 Acquire communication skills of a high order to write reports, interact with peers,
and paramedical staff, and with students for effective teaching.
 Demonstrate humane and compassionate attributes befitting a caring
neonatologist.

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 Acquire communication skills to give a professional opinion and interact with
patients and relatives in a caring manner.

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3.3 Predominant in Psychomotor domain (skills)
A. At the end of the course, the student should acquire the following skills (table 1):
Table 1:Must know, desirable to know and observed skills
Must know skills Desirable skills Observed skills
These are mandatory skills. The student These are good to know skills. These are mandatory
should be able to perform the following The student should be able to skills but need to be
procedures independently: perform the following ONLY observed
procedures independently or
as a part of a team and/or
interpret the results of:
Common neurological procedures to be 1. Assessment Tools: 1. Observe neurological
performed: NIHSS/MRS surgery
1. Lumbar puncture: 15 ADL Scores 2. Observe Epilepsy
2. Muscle and nerve biopsy: 5 UPDRS surgery
3. CSF tap test for NPH: 5 Cognitive Scales 3. Observe DBS
4. Nerve conduction studies and EDSS 4. Observe house-
interpretation: 100 keeping protocols and
5. EMG and interpretation: 100 2. Botulinum Toxin injection asepsis routines of
6. EEG and interpretation: 250 for Spasticity, Vocal cord individual units.
7. Interpretation of VEEG: 75 dystonia, other rarer
8. Interpretation of PSG and Sleep titration: conditions
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9. Endotracheal intubation: 50
10. Peform Digital Substraction
Angiography: 10
11. Oro/nasogastic tube insertion: 75
12. Central venous line insertion: 75
13. Interpretation of VEP/BAER/SSEP: 250
14. Interpretation of acute stroke imaging:
150
15. Interpretation of cerebral angiogram: 100
16. Botulinum Toxin injection for Movement
Disorders such as Blepharospasm, Hemi
facial Spasm, Meigs Syndrome: 50
17. Application of CPAP: 20
18. Intravenous cannulation: 100
19. Peripheral arterial cannulation: 200
20. Arterial stab sampling: 50
21. TCD for stroke patients : 50
Laboratory investigations
22. Perform the following basic tests in the
side lab: microscopy of CSF and
peripheral smear, point of care screening
tests. and blood gas analysis.

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 Skills Training and Simulation (All medical colleges are mandated to have
simulation labs by NMC )
The postgraduate students are encouraged to utilize low and hi-fidelity mannequins;
individual task trainers are to be made available in the department for skill practice.
Sessions in workshop mode are specially organized for new trainees to teach
interventional procedures such as cerebral angiography, interpretation of
neuroimaging mandatory for treamtnet of acute stroke; intractable epilepsy work up,
electrophysiological procedures, and Botulinum toxin injections etc.
Simulation sessions on team training and communication also must be organized.

B. Should be able to interpret the results of the following procedures and take
necessary action:
Biophysical profile, interpretation of genetic tests, interpret metabolic
screen/diagnosis.
Interpretation of cranial CT scan (both NCCT and CECT), MRI (T1 weighted, T2-
weighted, DWI and flair); basic interpretation of FDG-L-dopa PET-CT scan
interpretation of electrophysiological tests (BERA, VEP, aEEG); use of wide-angle
cameras to image retina for ROP.
Participate in morbidity and mortality review (death audits).

C. The student should be able to observe or perform under supervision the following
procedures –desirable skills:
 Community-based death surveillance and audit
 Partnership with IT for newer and simpler LMIC specific technology innovation
 Systematic reviews

TRAINING OBJECTIVES OF POST-GRADUATE TRAINING

EXPECTED FROM STUDENTS AT THE END OF POST GRADUATE
TRAINING AS RECOMMENDED BY THE NMC

1: Acquire comprehensive knowledge of the basics of Neurology including all

allied specialities related to Neurology like Neuroanatomy,

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 Neurophysiology, Neurochemistry, Neuropharmacology, Neuroimaging,
Neuropathology, Neuroinfections, Neuroimmunology, Preventive
Neurology, Neuroepidemiology, Paediatric Neurology and Neurosurgery.
SKILLS
2: Possess complete Clinical Diagnostic Skills for the recognition of common
Nervous system diseases.
3: Possess a complete knowledge of all the commonly used Neurophysiological
diagnostic Tests like Electroencephalography, Electroneurography,
Electromyography, Cerebral evoked potentials.
4: Acquire skills in the performance and interpretation of special investigations
such as Polysomnography, Video EEG monitoring, EEG-Telemetry,
autonomic function tests, Transcranil Doppler tests
5: Acquire skills in interpretation of common neuroimaging investigations such
as CT scanning, MRI scanning, MR and Digital subtraction angiography,
Myelography, MR spectroscopy and Single Photon Emission Computerised
Tomography.
6. Acquire skills in invasive procedures such as lumbar puncture, intrathecal
drug administration, CSF manometry; performing digital subtraction
angiography, intra venous and intraarterial thrombolysis; assisting in
endovascular thrombectomy in acute ischemic stroke, and Nerve and muscle
biopsy and their interpretation of relevant histopathology;
7. Acquire exposure in sophisticated neuromodulation procedures such as
planning of deep brain stmulation, vagal nerve stimulation;.
8. Able to apply sound clinical judgement and recommend rational cost
effective investigations for the diagnosis and management of Neurology
cases in the OPD, Wards, Emergency Room and Intensive Care unit.

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 SYLLABUS
Course contents
AIM:
To produce specialists with necessary skills, judgement and sense of dedication
to tackle all major and minor cardiac problems. The candidates will be trained
in all aspects of Neurology starting from Basic Sciences to recent advances.

PAPER I: BASIC SCIENCES RELATED TO NEUROLOGY

NEUROANATOMY

The Neuroanatomy with special emphasis on development of:

 Neuroaxis (brain, spinal cord and neurons and glia),

 Autonomic nervous system and their maturation process in the post-natal,
childhood and adolescent states;
 Location and significance of stem cells,
 CSF pathways,
 Blood supply and sino venous drainage of brain and spinal cord, the
meninges,
 Skull and vertebral column, the cranial nerves, spinal roots, plexuses, and
their relation to neighboring structures;
 Anatomy of peripheral nerves,
 Neuromuscular junction and muscles;
 Histology of cerebrum, cerebellum, pituitary gland, brain stem and
spinal cord, nerves and neuromuscular junction and muscle.
 Functional anatomy of lobes of cerebrum and white matter tracts of brain
and spinal cord, craniovertebral junction, conus and epiconus and cauda
equina, brachial and lumbosacral plexuses, cavernous and other venous
sinuses;

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  New developments in understanding of:
o Ultrastructural anatomy of neurons,
o axonal transport,
o neural networks and synapses and nerve cell function at molecular
level.

NEUROPHYSIOLOGY
 Neurophysiology will cover all the physiological changes in the nervous
system during its normal function with special reference to nerve impulse
transmission along myelinated fibers,
 neuromuscular junction and synaptic transmission,
 muscle contraction;
 visual, auditory and somatosensory and cognitive evoked potentials;
 Regulation of secretions by glands, neural control of viscera such as
heart, respiration, GI tract, bladder and sexual function; sleep-wake
cycles;
 Maintenance of consciousness,
 special senses,
 control of functions of (a) pituitary, (b) autonomic system (c) cerebellum,
(d) and extrapyramidal functions,
 reflexes,
 upper and lower motor neuron concepts and sensory system.

MOLECULAR BIOLOGY

Brain is the one structure where maximum genes are expressed in the human
body. The topics include:
 Principles of molecular biology including Gene Structure, Expression and
regulation;

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 Recombinant DNA Technology;
 PCR Techniques,
 Molecular basis for neuronal and glial function,
 Molecular and cellular biology of the membranes and ion-channels,
 Mitochondrial genome,
 Role of RNA in normal neuronal growth and functional expression,
 Receptors of neurotransmitters,
 Molecular and cellular biology of muscles and neuromuscular junction,
etc.
 The Human Genome and its future implications for Neurology including
developmental and neurogenetic disorders,
 bioethical implications and genetic counselling,
 Nerve growth and other trophic factors and neuroprotectors,
 Neural Tissue modification by genetic approaches including Gene
Transfer, stem cell therapy etc.
 Molecular Development of neural tissue in peripheral nerve repair

NEUROCHEMISTRY

 All aspects of normal and abnormal patterns of neurochemistry including:

 Neurotransmitters associated with different anatomical and functional
areas of brain and spinal cord, especially with respect to dopaminergic,
serotoninergic, adrenergic and cholinergic systems,
 Opioids,
 Excitatory and inhibitory amino acids and their role in pathogenesis of
Parkinsonism, depression, migraine, dementia, epilepsy,
 Neuromuscular junction and muscle contractions,
 Carbohydrate, amino acid and lipid metabolism,

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  Neural expression of disorders of their metabolism,
 Electrolytes and their effect on encephalopathies,
 Muscle membrane function, storage disorders,
 Porphyria.

NEUROPHARMACOLOGY
 Application of neuropharmacology in medical therapy of epilepsy,
Parkinsonism, movement disorders, neuropsychiatric syndromes,
spasticity, pain syndromes, disorders of sleep and dysautonomia
syndromes.
 Antiepileptic drugs, usage during disorders of renal, hepatic function and
in dementia.
 Adverse drug reactions of common drugs used in Neurological disorders
including antiepileptic drugs, antiplatelets, anticoagulants etc.

NEUROPATHOLOGY

 Pathological changes in various neurological diseases with special

reference to vascular, immune-mediated, demyelinating and
dysmyelinating, metabolic and nutritional, genetic and developmental,
infectious and iatrogenic and neoplastic etiologies and clinical
correlation.
 Pathological changes in nerve and muscle in neuropathies and
myopathies.
 Ultrastructural pathology such as apoptosis, ubiquitinopathies,
mitochondrial diseases, channelopathies, peroxisomal disorders, inclusion
bodies, prion diseases, disorders mediated by antibodies against various
cell and nuclear components, paraneoplastic disorders etc.

NEUROMICROBIOLOGY
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Microbiological aspects of infectious neurologic diseases including:

 Encephalitis, meningitis, brain abscess, granulomas, myelitis, cold

abscess, cerebral malaria, parasitic cysts of nervous system, rhino cerebral
mycoses, leprous neuritis, neuro leptospirosis, primary and secondary
Neuro HIV infections, congenital TORCH infections of brain, slow virus
infections such as CJD and SSPE.
 Neurological complications of viral infections such as Polio, EBV,
Chickenpox, Rabies, Herpes, Japanese encephalitis and other epidemic
viral infections.

NEUROTOXICOLOGY

Diagnosis and effective therapy of:

 Organophosphorus poisoning,
 hydrocarbon poisoning,
 lead, arsenic, botulinum toxin and tetanus toxicity,
 snake, scorpion, spider, wasp and beestings.

NEUROGENETICS AND PROTEOMICS:

 Autosomal dominant and recessive and X-linked inheritance patterns,

 disorders of chromosomal anomalies,
 Gene mutations, trinucleotide repeats, dysregulation of gene expressions,
 Enzyme deficiency syndromes,
 Storage disorders,
 Disorders of polygenic inheritance,
 Proteomics in health and disease.

NEUROEPIDEMIOLOGY:

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  Basic methodology in community and hospital based neuro-
epidemiological studies such as systematic data collection, analysis,
derivation of logical conclusions,
 Concepts of case-control and cohort studies, correlations,
 Regressions and survival analysis,
 Basic principles of clinical trials.

PAPER II: CLINICAL NEUROLOGY INCLUDING PEDIATRIC

NEUROLOGY and NEUROPSYCHIATRY.

GENERAL EVALUATION OF THE PATIENT

 The science and art of history taking,

 Physical examination including elements of accurate history taking,
symptoms associated with neurological disease,
 Physical examination of adults, children, infants and neonates, syndromes
associated with congenital and acquired neurological disease, cutaneous
markers,
 Examination of unconscious patients,
 Examination of higher mental functions, cranial nerves, the ocular
fundus,
 Examination of tone, power of muscles,
 Proper elicitation of superficial and deep reflexes including alternate
techniques,
 Neonatal and released reflexes,
 Neurodevelopmental assessment of children, sensory system, peripheral
nerves, signs of Meningeal irritation, skull and spine examination

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 including measurement of head circumference, shortness of neck and
carotid pulsations .and vertebral bruits.
DISTURBANCES OF SENSORIUM

 Pathophysiology and diagnosis of COMA,

 Diagnosis and management of coma, delirium and acute confusional
states, reversible and irreversible causes,
 Persistent vegetative states and brain death,
 Neurophysiological evaluation and confirmation of these states,
 Mechanical ventilation and other supportive measures of comatose
patient,
 Prevention of complications of prolonged coma,
 The significance of timely brain death in organ donation and ICU
resource utilization.

SEIZURES and EPILEPSY and SYNCOPE

 Diagnosis of seizures, epilepsy and epileptic syndromes,

 Recognition, clinical assessment and management of seizures especially
their electrodiagnosis, video monitoring with emphasize on
phenomenology and their correlation with EEG,
 Structural and functional brain imaging such as CT and MRI and fMRI
and SPECT scan,
 Special situations such as epilepsy in pregnant and nursing mothers,
driving, risky occupations, its social stigmas differentiation from pseudo
seizures,
 Use of conventional and newer antiepileptic drugs, their drug interactions
and adverse effects etc.,
 Modern lines of management of intractable epilepsies, such as ketogenic
diet, vagal nerve stimulation, epilepsy surgery,

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  Pre-surgical evaluation of patients,
 Management of status epilepticus and refractory status epilepticus,
 Differentiation of seizures from syncope, drop attacks, cataplexy, startles
etc.

HEADACHES and OTHER CRANIAL NEURALGIAS

 Acquisition of skills in analysis of headaches of various causes such as

those from raised intracranial pressures, migraines, cranial neuralgias,
vascular malformations,
 Meningeal irritation, Psychogenic etc. and their proper pharmacologic
management.

CEREBROVASCULAR DISEASES

 Vascular anatomy of brain and spinal cord,

 Various causes and types of cerebrovascular syndromes, ischemic and
hemorrhagic types, arterial and venous types, anterior and posterior
circulation strokes,
 OCSP and TOAST classifications,
 Investigation of strokes including neuroimaging using Dopplers,
 CT and MR imaging and angiography, acute stroke therapy including
thrombolytic therapy,
 Interventional therapy of cerebrovascular diseases,
 Principles of management of subarachnoid hemorrhage etc.
 Special situations like strokes in the young, strategies for primary and
secondary prevention of stroke.

DEMENTIAS

 Concept of minimal cognitive impairment,

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  Reversible and irreversible dementias, causes such as Alzheimer’s and
other neurodegenerative diseases and vascular and nutritional and
infectious dementias, their impact on individual, family and in society.
 Genetic and familial syndromes.
 Pharmacotherapy of dementias, potential role of cognitive rehabilitation
and special care of the disabled.

PARKINSONISM AND MOVEMENT DISORDERS

 Disorders of extrapyramidal system such as Parkinsonism, chorea,

dystonia, athetosis, tics, their diagnosis and management,
 Pharmacotherapy of Parkinsonism and its complications,
 management of complications of Parkinsonism therapy, including
principles of deep brain stimulation and lesion surgeries.
 Use of EMG guided botulinum toxin therapy,
 Management of spasticity using intrathecal baclofen and TENS.

ATAXIC SYNDROMES:

 Para infectious demyelination, cerebellar tumors, hereditary ataxias,

vestibular disorders,
 Diagnosis and management of brainstem disorders,
 Axial and extra-axial differentiation.

CRANIAL NEUROPATHIES:

 Disorders of smell, vision, visual pathways, pupillary pathways and

reflexes,
 Internuclear and supranuclear ophthalmoplegia,
 Other oculomotor disorders,
 Trigeminal nerve testing,
 Bell’s palsy,
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  Differentiation from UMN facial lesions,
 Brain stem reflexes,
 Investigations of vertigo and dizziness,
 Differentiation between central and peripheral vertigo,
 Differential diagnosis of nystagmus,
 Investigations of deafness, bulbar and pseudobulbar syndromes.

CNS INFECTIONS:

 Diagnosis and management of viral encephalitis, meningitis bacterial,

tuberculous, fungal, parasitic infections such as cysticercosis, cerebral
malaria, SSPE, Neuro HIV primary and secondary infections with
exposure to gram stain and cultures, bac tec, QBC, ELISA and PCR
technologies.

NEUROIMMUNOLOGIC DISEASES

 Diagnosis and management of CNS conditions such as Multiple

Sclerosis, PNS conditions such as GBS, CIDP, Myasthenia gravis,
polymyositis.

NEUROGENETIC DISORDERS

 Various chromosomal diseases,

 Single gene mutations such as enzyme deficiencies,
 Autosomal dominant and recessive conditions and X-linked disorders,
trinucleotide repeats,
 Disorders of DNA repair. Genetics of Huntington’s disease, familial
dementias, other storage disorders, hereditary ataxias,
 Hereditary spastic paraplegias, HMSN, muscular dystrophies,
mitochondrial inheritance disorders.

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DEVELOPMENTAL DISORDERS OF NERVOUS SYSTEM

 Neuronal migration disorders,

 Craniovertebral junction diseases,
 Spinal dysraphism,
 Phacomatoses and other neurocutaneous syndromes- their recognition
and management.

MYELOPATHIES

 Clinical diagnosis of distinction between compressive and non-

compressive myelopathies,
 Spinal syndromes such as anterior cord, subacute combined degeneration,
 Central cord syndrome,
 Brown-Sequard syndrome,
 Tabetic syndrome,
 Ellsberg phenomenon.
 Diagnosis of spinal cord and root compression syndromes,
 CV junction lesions,
 Syringomyelia, conus cauda lesions,
 Spinal AVMs,
 tropical and hereditary spastic paraplegias,
 Fluorosis.

PERIPHERAL NEUROPATHIES

 Immune mediated, hereditary, toxic, nutritional and infectious type

peripheral neuropathies; their clinical and electrophysiological diagnosis.

MYOPATHIES AND NEUROMUSCULAR JUNCTION DISORDERS

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  Clinical evaluation of patients with known or suspected muscle diseases
aided by EMG,
 Muscle pathology, histochemistry, immunopathology and genetic studies,
 Dystrophies, polymyositis, channnelopathies, congenital and
mitochondrial myopathies,
 Neuromuscular junction disorders such as myasthenia, botulism, Eaton-
lambert syndrome,
 Snake and organophosphorus poisoning, their electrophysiological
diagnosis and management.
 Myotonia, stiff person syndrome.

PAEDITRIC NEUROLOGY:

 Normal development of motor and mental milestones in a child, Cerebral

palsy,
 Attention deficit disorder,
 Autism,
 Developmental dyslexia,
 Intrauterine TORCH infections,
 Storage disorders,
 Inborn errors of metabolism affecting nervous system,
 Developmental malformations,
 Child hood seizures and epilepsies,
 Neurodegenerative diseases.

COGNITIVE NEUROLOGY AND NEUROPSYCHIATRY:

 Detailed techniques of higher mental functions evaluation,

22
  Basics of primary and secondary neuropsychiatric conditions such as
anxiety, depression, schizophrenia, acute psychosis, acute confusional
reactions (delirium), organic brain syndrome,
 Primary and secondary dementias, differentiation from pseudodementia.

TROPICAL NEUROLOGY

Conditions which are specifically found in the tropics like to be taught in detail;

 Neuro-cysticercosis,
 Cerebral malaria,
 Tropical spastic paraplegia,
 Snake/scorpion/ Chandipura
 Encephalitis,
 Madras Motor Neuron disease etc.

PAPER III: DIAGNOSTIC and INTERVENTIONAL NEUROLOGY

INCLUDING NEUROLOGICAL INSTRUMENTATION, DIAGNOSTIC
NEUROLOGY

 Performing and interpreting Digital Electroneurogram, Electromyogram,

 Evoked potentials, Electroencephalography,
 Interpretation of skull and spine X-rays,
 Computerized tomography of brain and spine,
 Magnetic resonance images of brain including correct identification of
various sequences, angiograms, MR spectroscopy,
 Basics of functional MRI,
 Interpretation of digital subtraction imaging, SPECT scans of brain,
subdural EEG recording, transphenoidal electrode EEG techniques for
temporal lobe seizures,

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  video EEG interpretation of phenomenology and EEG-phenomenology
correlations,
 EEG telemetry,
 Transcranial Doppler diagnosis and monitoring of acute ischemic stroke,
 Subarachnoid hemorrhage,
 Detection of right-to-left shunts etc;
 Color duplex scanning in Carotid and vertebral extracranial segment
screening.

NEUROINSTRUMENTATIONS

Acquire skills in procedures like:

 Intrathecal administration of antispasticity drugs, beta interferons in

demyelination, opiates in intractable pain etc.,
 EMG guided Botox therapy for dystonia,
 Subcutaneous administration of antimigraine and antiparkinsonian drugs,
 Intraarterial thrombolysis in extended windows of thrombolysis in
ischemic strokes,
 Transcranial Ultrasound clot-bust intervention in a registry in acute stroke
care unit,
 Planning in deep brain stimulation therapy in uncontrolled dyskinesias
and on-off phenomena in long standing Parkinsonism,
 Planning in vagal nerve stimulation in intractable epilepsy.

PAPER IV:
RECENT ADVANCES IN NEUROLOGY:

ADVANCES INNEUROIMAGING TECHNIQUES, BIONICS IN

NEURAL PROSTHESIS and REHABILITATION,

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NEUROPROTEOMICS and NEUROGENETICS, STEM CELL and
GENE THERAPY
ADVANCES IN NEUROIMAGING TECHNIQUES:

 Integration of CT, MR, SPECT, and PET images with each other and
with EEG.
 EVOKED potentials based brain maps in structural and functional
localization in neurological phenomena and diseases.
 DSA interpretation and diagnosis.

BIONICS IN NEURAL PROSTHESIS AND REHABILITATION:

 Advanced techniques in neuro-rehabilitation such as TENS, principles of
man-machine interphase devices in cord, nerve and plexus injuries,
cochlear implants, artificial vision.

NEUROPROTEOMICS AND NEUROGENETICS:

Brain functions are regulated by proteomics and genomics linked to

variousproteins and genes relevant to the brain, body’s maximum number of
proteins and genes being expressed in brain as neurotransmitters or channel
proteins and predisposing brain to a number of disorders of abnormal
functioning of these proteins.

STEM CELL AND GENE THERAPY:

 Principles of ongoing experiments on stem cell therapy for nervous

system disorders such as foetal brain tissue transplants in parkinsonism;
intrathecal marrow transplants in MND,MS, Spinal trauma; myoblasts
infusion therapy in dystrophies.

NEUROEPIDEMIOLOGICAL STUDIES AND CLINICAL TRIALS:

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The students of the DM course will be trained in conducting sound Neuro-
epidemiology studies on regionally and nationally important neurological
conditions as well as on diseases of scientific and research interest to the
department. They will also be trained in principles of clinical trials.

Essential Practical Knowledge

1. Online certification in Research Methodology Course

o 2. Certification of NIHSS, MRS, mBI, EDSS
o 3. Interpretation of acute stroke imaging
o 4. Performance of cerebral angiography and interpretation of DSA
o 5. Performance of TCD
o 6. Performance and interpretation of electrophysiological tests
o
o

TEACHING AND LEARNING METHODS

Postgraduate teaching program
General principles
Acquisition of practical competencies being the keystone of postgraduate medical education,
PG training should be skills-oriented. Learning in PG program should be essentially self-
directed and primarily emanating from clinical and academic work. The formal sessions are
merely meant to supplement this core effort.
Teaching Methodology
The postgraduate student should be given the responsibility of managing and caring for
patients gradually under supervision.
Formal teaching sessions and learning opportunities
A. Intramural activities
Teaching and learning during bedside rounds of various areas, case discussions in NICU,
wards by self-reflection, and follow up clinics are mainstays. Several organized learning
experiences should be provided to the students to facilitate the refinement of knowledge and

26
skills. Students are expected to actively participate in the teaching program of the department
and allied specialties within the department and other departments of the institute. They get
regular opportunities to prepare and make presentations in these teaching programs.
Following formal sessions are recommended in order to facilitate learning* :
 Journal club (once 15 days )
 Perinatal round (once 15 days)
 Seminar (once 15 days)*
 Clinical case discussion (once 15 days )
 Perinatal audit/CPC (once a month)
 Research review (once a month)
 Neonatal surgery (once 3 month)
*In addition, depending on the strength of the institutions, sessions on imaging, pathology,
microbiology, biostatistics/epidemiology, and interdepartmental seminars may be
undertaken.
The list of seminar topics is given in Annexure I.
B. Extramural opportunities
The postgraduate students are encouraged to attend continuing education symposia,
workshops, and academic conferences, including meetings of national and international
societies, workshops.
Learning by Teaching
The students will participate in teaching junior residents, nurses, nursing students, and
trainees from other hospitals coming for observership. They will also be given the exposure
of teaching and training during workshops and CMEs organized by the faculty within the
institution and outreach activities.
 In addition, the student should attend accredited scientific meetings (CME, symposia, and
conferences) once or twice a year.
 A postgraduate student of a postgraduate degree course in super specialties would be
required to present one poster presentation or read one paper at a national/state
conference; should write a research paper from his/her work which should be
published/accepted for publication/sent for publication during the period of his
postgraduate studies.
C. Log Book: During the training period, the postgraduate student should maintain a Log
Book indicating the duration of the postings/work done in Wards, OPDs, and Casualty.

27
 This should indicate the procedures assisted and performed and the teaching sessions
attended. The purpose of the Log Book is to:
a) Help maintain a record of the work done during training,
b) Enable Consultants to have direct information about the work; intervene if
necessary,
c) Use it to assess the experience gained periodically.

The Log Book should be used to aid the internal evaluation of the student. The Logbook
shall be checked and assessed periodically by the faculty members imparting the training.
Candidates will be required to produce the logbook original or copy at the time of
practical examination. It should be signed by the Head of the Department. A proficiency
certificate from the Head of Department regarding the clinical competence and skillful
performance of procedures by the student will be necessary before he/she would be
allowed to appear in the examination. The teaching faculty are referred to the NMC
Logbook Guidelines uploaded on the Website.

E. POSTINGS
Overview
The total period of the DM course is 36 months. Of this, at least 27 months will be spent
in the newborn service, 6 months will be meant for essential rotations in related
specialties, and the rest 3 months will be apportioned for either elective rotations or the
newborn service.

Period of postings in various units, divisions / departments

The trainee will be posted in different specialties as follows :-
- Neurology 2 years
- Neuro-physiology 4-6 months
- Neuro-surgery 1 month
- Neuro-pathology 1 month
- Neuro-radiology 1 month
- Elective posting 2 weeks
The elective posting may consist of posting in the other institutes or own institute
for training in specific fields

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 - Psychiatry 1 month
- Neuro-anaesthesia/ICU 1 months

During Clinical Neurology posting the trainee is required to undertake:-

- Ward work
- Consultations
- Neuro-investigations
- EEG reporting
- Out patient clinics
- Neuro-emergency

The above postings should be for a period of 2-4 months at different times over the training
period. All the patients seen in the OPD by the trainee or on consultation are to be shown by
him/her to the consultants and management planned.

F. Patient safety

During the training programme, patient safety is of paramount importance; therefore,

skills are to be learnt initially on the models, later to be performed under supervision
followed by performing independently. For this purpose, provision of skills laboratories
in medical colleges is mandatory.

ASSESSMENT
FORMATIVE ASSESSMENT, during the training program: Formative assessment should
be continual and should assess medical knowledge, patient care, procedural & academic
skills, interpersonal skills, professionalism, self-directed learning, and ability to practice in
the system.
Periodic Evaluation:
Candidates will be evaluated continuously for their performance in all areas such as clinical
and investigative work, case presentations, seminars, journal clubs, procedures
undertaken/participated in etc. Additional periodic assessment will include theory and
practical assessment mimicking the final examination and should be conducted every 6
months. Such an evaluation will help assessing the progress of the trainees and the quality of

29
the training programme. Evaluation will be communicated to trainees and their feedback
would be taken into consideration for modifications in the training programme.

Internal Assessment should be frequent, cover all domains of learning and used to provide
feedback to improve learning; it should also cover professionalism and communication skills.

Quarterly assessment during the DM training should be based on:

1. Journal based / recent advances learning
2. Patient based /Laboratory or Skill based learning
3. Self-directed learning and teaching
4. Departmental and interdepartmental learning activity
5. External and Outreach Activities / CMEs/Workshops/Conferences
6. Participation/conduct of research project - desirable

Regular internal assessment will be made on day to day work of the trainee which involves
patient’s care, learning, bed side care presentation and research. Grading is done every six
months and final assessment will be made at the end of training period.

In Medical disciplines, the student should be assessed in all aspects of case management
including history taking, physical examination, differential diagnosis, cost effective and
appropriate investigations, treatment plan, monitoring and evaluation, patient and family
counselling and interaction with all the health workers involved in the care of patients and
academic presentations.

Clinical skills and performance, academic performance and personal attributes shall be
graded on a scale of 1 to 5 (5 being the highest). The academic presentations shall be graded
at the time of presentation, by the faculty in-charge. Evaluation on clinical skills shall be
done by the unit/department in-charge at the end of every semester.

The student to be assessed periodically as per categories listed in post graduate student
appraisal form (Annexure II).

SUMMATIVE ASSESSMENT

30
The summative examination would be carried out as per the Rules given in the relevant
POSTGRADUATE MEDICAL EDUCATION REGULATIONS.

Essential pre-requisites for appearing for examination include:

1. Log book of work done during the training period including rotation postings,
departmental presentations, and internal assessment reports should be submitted.
2. At least two presentations at national level conference. At least one research paper
should be published/ accepted in an indexed journal. (It is suggested that the local or
University Review committee assess the work sent for publication).
3. Submission of thesis/ research work (desirable: As per PG Regulations)

1. Theory

There shall be four theory papers:-

Paper I: Basic sciences as related to Neurology (This should include anatomy,
physiology, Pathology, biochemistry, pharmacology and genetics as applicable
to neurology)
Paper II: Clinical Neurology (This should include all aspects of clinical neurology i.e.
diagnosis, management, therapeutics, approach to clinical situations)
Paper III: Investigative Neurology (This should include all the investigative procedures i.e.
electrophysiology, imaging, neuropathology, magneto-encephalography etc)

Paper lV: Recent advances in Neurology (This should include recent advances in
neurosciences including genetics, immunology, therapeutics, pathophysiology
etc)

Theory and Practical/Oral Examinations: Theory and Practical/Oral examinations will be

conducted as per University guidelines. The theory examination shall be held in advance
before the clinical and practical examination, so that the answer books can be assessed
and evaluated before the commencement of the clinical/practical/oral examination.

31
 The practical examination should consist of the following and should be spread over two
days, if the number of candidates appearing is more than five. Oral examination shall be
comprehensive enough to test the student's overall knowledge of the subject.

This will consist of:

1. Up to 10 spotters for Objective Structured Clinical Examination ( OSCE)
pattern
2. Two clinical cases
The candidates shall also be given EEG, Pathology specimens, histology slides and neuro-
radiology for interpretation, followed by Viva Voce.
The clinical examination and viva-voce will last for not less than two days
1. There should be one long or semi-long case which must be on acute care of a sick
neonate. The long case should include: History taking, physical examination,
interpretation of clinical findings, differential diagnosis, investigations, prognosis
and management.
2. Three short cases from various sections of the specialty.
3. The log book of procedures and interventions shall also be assessed in the
practical examination.

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 Annexure I
List of seminars
Following is the list of essential seminars which a postgraduate student is
required to attnd during the three years. Other relevant topics may be included
from time to time:-
 Neuron
 Synapse
 Neuroglia
 Cerebral cortex - anatomy and physiology
 Frontal lobe
 Parietal lobe
 Temporal lobe
 Occipital lobe
 Limbic system
 Thalamus
 Basal Ganglia
 Cerebellum
 C.S.F. formation, composition and dynamics
 Cerebral circulation
 Cerebral oedema
 Cerebral perfusion
 CSF & ICP  physiological considerations
 Spinal cord circulation
 Spasticity – Pathophysiology
 Rigidity – Pathophysiology
 Tremors
 Myoclonus
 Genesis of E.E.G.
 Ontogenesis of E.E.G.

33
 EMG routine, F. wave, H. reflex
 EMG recent advances:
- Evoked potentials – General and Auditory
- Visual and somatosensory evoked response and event related
potentials
- Basic principles and clinical application of computed tomography
- Epilepsy – Pathophysiology
- Epilepsy – Neurochemistry
- Epilepsy – Management
- Temporal lobe epilepsy – theory, recent controversy and
management
- Surgery in epilepsy
- Supra nuclear control of ocular movements
- Nystagmus
- Sleep
- Central speech disorders
- Mechanism of memory
- Dementia – Pathophysiology and approach
- Mechanism and Neurochemistry of pain
- Immunological and immune related disorders of nervous system
- Myasthenia gravis – pathophysiology and treatment
- Slow virus infections of CNS
- Radiotherapy, immunotherapy and chemotherapy of CNS
malignancy
- MRI – Principles and clinical application
- Spinal dysraphism
- PET - Principles and clinical application

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 - Hypertension and brain
- Neurolipidosis – biochemical aspect
- Neurolipidosis – clinical aspect
- Subarachnoid haemorrhage – Presentation and management
- Muscular dystrophies – Current concepts
- Stroke – Current aspect of aetiopathogenesis
- Stroke management – Medical / Surgical
- Wilson’s disease
- Demyelinating diseases in India

 Functional Imaging in Neurology

 Neuromuscular Channellopathies

 Neurology of pain/migraine

 Neurology of emotions

 Neurointervention in Stroke

 Approach to intracranial granulomatous disorders

 Neurology of HIV infection

 Neuroprotection in Stroke – An update

 Update on Aphasias

 Statins in Neurological disorders

 Neuromuscular Junction- Physiology and Pathophysiology

 Stem cells in Neurology

 Epileptogenesis

 Multiple Sclerosis – Pathophysiology

35
 Multiple Sclerosis – Therapeutic update

 Ultrasound in Neurology

 Pathophysiology of Mitochondrial disorders (including genetics)

 Excitotoxicity in Neurological Disorders

 Disorders of sleep (Including parasomnias)

 Parkinsonism – Pathophysiology and treatment

 Peripheral nerve – Biochemistry and Physiology

 Skeletal muscle – Ultra, Structure and Biochemistry

 Surgery in Parkinson’s disease and related disorders

 Visual pathways with pathological correlates

 Non motor functions of the cerebellum

 Approach to Chronic polyneuropathies

 Pathology of Myopathies

 Neuro-radiology of Myopathies

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 ANNEXURE II

Student appraisal form for DM in Neurology

Less than More than
Element Satisfactory Comments
Satisfactory satisfactory
1 2 3 4 5 6 7 8 9
Scholastic Aptitude
1 and Learning
Knowledge appropriate
1.1 for level of training
Participation and
contribution to learning
activity e.g., Journal
Club, Seminars, CME
1.2 etc)
Conduct of research
and other scholarly
activity assigned (e.g
Posters, publications
1.3 etc)
Documentation of
acquisition of
competence
1.4 (eg Log book)
Performance in work
1.5 based assessments
1.6 Self Directed Learning

2 Care of the patient

Ability to provide patient
care appropriate to
2.1 level of training
Ability to work with
other members of the
2.2 health care team
Ability to communicate
appropriately and
empathetically with
patients families and
2.3 care givers
Ability to do procedures
appropriate for the level
of training and assigned
2.4 role
Ability to record and
document work
accurately and
appropriate for level of
2.5 training
Participation and
contribution to health
care quality
2.6 improvement

37
 Professional
3 attributes
Responsibility and
3.1 accountability
Contribution to growth
3.2 of learning of the team
Conduct that is ethical
appropriate and
3.3 respectful at all times
4 Scholarship
Teaching and
mentoring skills
appropriate to level of
4.1 training
Ability to formulate
research questions,
initiate conduct and
complete research
4.2 projects
Ability to review and
use the published
literature appropriately
in care of the patient
4.3 lab or workspace
Ability to provide
consultations to other
specialties as may be
4.4 required

Space for additional

5 comments

6 Disposition
Has this assessment
been discussed with
the trainee? Yes No
If not explain

Name and Signature of

the assesse

Name and Signature of

the assessor
Date

38
Subject Expert Group members for preparation of Guidelines for
competency based postgraduate training programme for DM in Neurology

1. Dr. Padma Srivastava Convener, Expert Group

Professor & Head,
Department of Neurology
Chief, Neurosciences Center
All India Institute of Medical Sciences, New Delhi.

2. Dr. Vivek Lal Member

Director,
Post Graduate Institute of Medical Education & Research
Head, Department of Neurology
PGIMER, Chandigarh.

3. Dr. Debashish Chawdhury Member

Head, Department of Neurology
GB Pant Hospital, New Delhi

4. Dr. U K Misra Member

Professor Emeritus
Sanjay Gandhi Post Graduate Institute of Medical Sciences
Lucknow

5. Dr. Thomas Iype Member

Head, Department of Neurology
Trivandrum Medical College,
Thiruvanthapuram, Kerala

6. Dr. Sanjib Sinha Member

Head, Department of Neurology
National Institute of Mental Health and Neuro-Sciences
Bangalore, Karnataka

39