Making Sense of Low Back Pain
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November 20, 2014

Dr. Hamilton Hall, MD, FRCSC, is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.
Greg McIntosh, MSc, completed his Masters in Epidemiology from the University of Toronto's Faculty of Medicine. He is currently the Director of Clinical Research for CBI Health Group and research consultant to the Canadian Spine Society.

Abstract
This article highlights the myths and misunderstandings surrounding the straight leg raise (SLR) test for sciatica. Unfortunately, neither intra- nor inter-observer reliability of the passive SLR test has ever been agreed upon. In addition, there is poor consensus about what constitutes a positive SLR test in terms of pain location, leg elevation limitation or clinical significance. Until there are stricter performance standards and uniform agreement, researchers and clinicians should interpret the test with caution. We believe a true positive SLR should be the reproduction or exacerbation of the typical leg dominant pain in the affected limb at any degree of passive elevation. Those with only increased back pain or any leg pain other than that presenting as the chief complaint should be regarded as false positives.
Key Words: low back pain, straight leg raise, sciatica, irritative test.

Untitled Document

Dr. Hamilton Hall, MD, FRCSC, is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.

August 27, 2014

1,2Darren M. Roffey PhD; 1Simon Dagenais DC, PhD, MSc; 3Ted Findlay DO, CCFP; 4,5Travis E. Marion MD, MSc; 6Greg McIntosh MSc; 7,8Mohammed F. Shamji MD, PhD, FRCSC; 1,2,4,5Eugene K. Wai MD, MSc, FRCSC

1University of Ottawa Spine Program, The Ottawa Hospital, Ottawa, ON, 2Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON,

3
Department of Family Medicine, University of Calgary, Calgary, AB, 4Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, 5Department of Surgery, Faculty of Medicine, University of Ottawa, ON, 6CBI Health Group, Toronto, ON, 7Division of Neurosurgery, Toronto Western Hospital, Toronto, ON,

8Department of Surgery, University of Toronto, Toronto, ON.

Abstract

Obesity and low back pain are equally complex medical conditions with multi-factorial etiologies. Their clinical practice guidelines both include recommendations for screening and examination that can be easily implemented. There is sufficient information to compile a framework for the primary care provider, partnering with the patient and appropriate specialists, to manage obesity and low back pain in a structured fashion. Weight loss and exercise are paramount and should be recommended as the first options. Cognitive behavioural therapy, pharmacological treatment and bariatric surgery may then be implemented sequentially depending upon the effectiveness of the initial interventions.

Key Words: Obesity, low back pain, exercise, nutrition, cognitive behavioural therapy, bariatric surgery, weight loss, pharmacological, evidence-based guideline.

Untitled Document

1,2Darren M. Roffey PhD; 1Simon Dagenais DC, PhD, MSc; 3Ted Findlay DO, CCFP; 4,5Travis E. Marion MD, MSc; 6Greg McIntosh MSc; 7,8Mohammed F. Shamji MD, PhD, FRCSC; 1,2,4,5Eugene K. Wai MD, MSc, FRCSC

July 22, 2014

1,2Darren M. Roffey PhD; 1Simon Dagenais DC, PhD, MSc; 3Ted Findlay DO, CCFP; 4,5Travis E. Marion MD, MSc; 6Greg McIntosh MSc; 7,8Mohammed F. Shamji MD, PhD, FRCSC; 1,2,4,5Eugene K. Wai MD, MSc, FRCSC

1University of Ottawa Spine Program, The Ottawa Hospital, Ottawa, ON, 2Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON,

3
Department of Family Medicine, University of Calgary, Calgary, AB, 4Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, 5Department of Surgery, Faculty of Medicine, University of Ottawa, ON, 6CBI Health Group, Toronto, ON, 7Division of Neurosurgery, Toronto Western Hospital, Toronto, ON,

8Department of Surgery, University of Toronto, Toronto, ON.

Abstract

Recognizing that the increasing incidence of obesity coincides with the rising prevalence of LBP, there is growing interest in establishing the relationship between over-weight and back pain. It is likely that any association is multi-factorial and that the connection is not as mechanistically simple as previously believed. Systemic inflammation associated with obesity may be an important contributor. Proposed treatment options vary from cognitive behavioural therapy to bariatric surgery with none yet fully proven. Despite the ambiguity, it appears prudent for primary care providers treating obese patients with LBP to recommend weight loss and exercise.

Key Words: Obesity, low back pain, inflammation, intervertebral disc, multi-factorial, causality, association.

Untitled Document

1,2Darren M. Roffey PhD; 1Simon Dagenais DC, PhD, MSc; 3Ted Findlay DO, CCFP; 4,5Travis E. Marion MD, MSc; 6Greg McIntosh MSc; 7,8Mohammed F. Shamji MD, PhD, FRCSC; 1,2,4,5Eugene K. Wai MD, MSc, FRCSC

May 29, 2014

Dr. Ted Findlay, DO, CCFP, Clinical Assistant Professor, Department of Family Medicine, University of Calgary, Calgary, Alberta.

Mohammed F. Shamji, MD, PhD, FRCSC, Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Abstract
Low back pain is one of the most common conditions for which patients seek medical attention. It can be managed with lifestyle modification, or less commonly medical and surgical intervention. Appropriate selection among various pharmacological options mandates an understanding of the underlying symptomatology and the over-riding treatment plan and objectives. The range of potential medications is substantial: over-the-counter analgesics include acetaminophen and non-steroidal anti-inflammatory drugs, muscle relaxants, and weak opioid combinations including codeine or tramadol. More potent versions of many of the same components are available on prescription, commonly employing stronger opioids either singly or in a combination analgesic. When the pain involves either chronic or neuropathic features, other classes of medications, including anti-epileptic drugs and anti-depressants, may be appropriate.
Key Words: low back pain, acute, chronic, neuropathic pain, nociceptive pain, medications.

Untitled Document

Dr. Ted Findlay, DO, CCFP, Clinical Assistant Professor, Department of Family Medicine, University of Calgary, Calgary, Alberta.

April 1, 2014

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH, is a Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. In addition, she trained as a physiotherapist and maintained an active license for 30 years. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor.

Greg McIntosh, MSc, completed his Masters in Epidemiology from the University of Toronto’s Faculty of Medicine. He is currently the Director of Clinical Research for CBI Health Group and research consultant to the Canadian Spine Society.

Abstract
This article helps clinicians decide on appropriate referral to rehabilitation professionals while answering some of the common questions that clinicians are often asked by low back patients. The evidence for appropriate rehabilitation techniques will be interwoven into this article to promote a critical appraisal approach to evaluating rehabilitation outcomes. At the conclusion of this paper, clinicians should be able to identify best practices for rehabilitation referral.
Key Words: Low back pain, indications, rehabilitation, inter-professional referral.

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH, is a Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. In addition, she trained as a physiotherapist and maintained an active license for 30 years. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor.

February 3, 2014

Mohammed F. Shamji MD, PhD, FRCSC, Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Alina Shcharinsky RN (EC), MN, CNN(C), Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada.

Abstract
Chronic pain is a complex disease state associated with substantial individual disability and suffering alongside societal economic impact. The entity of neuropathic pain is a diagnosis of specific clinical characteristics and underlying pathophysiology. Failed back surgery syndrome represents persistent neuropathic leg pain following structurally corrective spinal surgery, often being refractory to escalated pharmacological management. In appropriately selected patients, spinal cord stimulation is a surgical technique that may offer reduced disability and pain, and improved economic outcomes for patients where medical management has been unsuccessful. Contemporary technological advances continue to improve this approach with greater success, lessened morbidity, and expanding indications.
Key Words: failed back surgery syndrome, neuropathic pain, spinal cord stimulation, neuromodulation.

Mohammed F. Shamji MD, PhD, FRCSC, Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Alina Shcharinsky RN (EC), MN, CNN(C), Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada.

November 14, 2013

When one thinks of music and movement, the natural association is dance. In all parts of the world and in all cultures, there is some musical expression through dance, ranging from what may appear to be relatively simple rhythmic movements to compelling drum beats to complex ballets with narratives and dozens if not more dancers doing intricate steps to full blown orchestras. Anyone that has raised children recalls how even very young children, will move and shake to rhythmic music and the massive industry in all western countries of dance lessons starting with child students attests to its natural attraction and ability to fulfill what appears to be an intrinsic human desire.

I recall as a child being taken to ballet, modern dance, musicals with dance and even the renowned Rockets at the Radio City Music Hall by my mother who herself had been a serious amateur dancer in her youth and then a lifelong ball-room and late-life folk dancer with her seniors' centre on West End Avenue in Brooklyn. There was even a period of my pre-teen years when my mother attempted to teach me ballet steps at home which very soon was transposed into my desire to learn to dance to Rock and Roll, using my sister four years my junior as my every accommodating dance partner. Even many years after, in our mature and pre-senior years, at family celebrations we often could still do a dance number to something of the order of Rock Around the Clock or the theme song for Saturday Night Fever. She has continued to engage with multi- cultural folk dancing whereas I have slowed down considerably in my abilities to participate although I enjoy watching others, dance especially my children and more recently my granddaughters.

The general assumption probably held by most individuals that with physical and especially neurological disability, the ability to engage or think about participating in dance would likely naturally diminish. For people living with conditions that impose physical challenges to free and fluid movements, the idea of dancing is more often a dream than a reality. It is likely that it would not even enter the consciousness of most people with neurological disorders, especially those like Parkinson's Disease might be able to participate in, respond to and benefit from music, especially when it is within a framework of dance.

With this in mind the recent article in October 25th issue of The Globe and Mail, by Gayle MacDonald, "Unlocking the secret of Dance" was exhilarating and inspiring. In a partnership with the world-renowned Canada's National Ballet School, with the collaboration and influence of some its most prominent members and in a cooperative effort with among others Toronto's York University and my own Baycrest Geriatric Health Care System, it is hoped that in addition to the great joy satisfaction that all the participants appear to be getting from the program, scientific research studies will demonstrate the mechanism of responsiveness and hopefully clinical improvement.

Dance appears to provide a number of benefits to those living with Parkinson's disease which affects seven million people world-wide including approximately 100,000 in Canada and a million people in the United States. It has been established that dance improves characteristics like balance, gait, posture and other physical measurements beyond the social joy and satisfaction from what is in essence a group and social undertaking. Studies are underway to try and determine what the dance does to the brain and the mechanisms by which improvements may occur and whether or not they are sustainable and may be an important adjunct to commonly used medication therapies that are not without their problems.

It has been well known for many years that those living with Parkinsonism can improve their gait by listening to rhythmic marching-type music and some have learned to use ear-phone-directed march music from iPods and other similar devices to provide the compelling rhythmic background to assist in their walking. (Neuroscience and Biobehavioral Reviews: Into the groove; Can rhythm influence Parkinson's disease? Cristina Nombela, Laura E. Hughes, Adrian M. Owen, Jessica A. Grahn, 2013. http://www.ncbi.nlm.nih.gov) In my own practice I have often taken my patients with such movement disorders and while walking with them up the corridor outside my office I hum loudly a well-known John Philip Sousa March, The Stars and Stripes Forever which most people recognize. Quite a lot of the patients and the family are amazed how all of a sudden the person who had been struggling with gait and speed would be walking alongside me to the loudly hummed musical refrain. If the result is good I instruct the person or family member to get some recordings of such marches or others if they are ones that resonate and put them on an iPod type device and place the march when the person wants to go for an enjoyable walk, for the purposes of actual exercise, or as one might in a garden or along a neighbourhood street.

If this Parkinson's ballet dance project proves successful it may result in a wide range of programs that bring dance and music to many individuals living with Parkinson's disease and provide a creative and satisfying and in many ways liberating enterprise for them.

When one thinks of music and movement, the natural association is dance. In all parts of the world and in all cultures, there is some musical expression through dance, ranging from what may appear to be relatively simple rhythmic movements to compelling drum beats to complex ballets with narratives and dozens if not more dancers doing intricate steps to full blown orchestras.

July 18, 2012

Abstract
From time-to-time we select a topic and present the information and facts in an exciting and visually informative format. Today our choice of condition to present as an infographic is Lumbar Spinal Stenosis, an important topic for which we are also developing a CME program that is scheduled for release later this year.
Keywords:  lumbar spinal stenosis, low back pain.

Abstract
From time-to-time we select a topic and present the information and facts in an exciting and visually informative format. Today our choice of condition to present as an infographic is Lumbar Spinal Stenosis, an important topic for which we are also developing a CME program that is scheduled for release later this year.
Keywords:  lumbar spinal stenosis, low back pain.

October 21, 2011

Kaitlyn Roland, MSc, Research Assistant, Interdisciplinary Graduate Studies, The University of British Columbia, Kelowna, BC.
Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Mary E. Jenkins, BSc(PT), BEd, MD, FRCPC, Associate Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.

Abstract
Burden is a psychological concept, a subjective interpretation by caregivers of the extent to which the caregiving experience impacts on one's health, social life, or financial status. In this article, we examine some of the predictors of caregiver burden, and look specifically at the burden experienced by caregivers of individuals with Parkinson's disease.
Keywords: Parkinson's disease, psychological health, physical health, caregiver burden

Kaitlyn Roland, MSc, Research Assistant, Interdisciplinary Graduate Studies, The University of British Columbia, Kelowna, BC.
Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Mary E. Jenkins, BSc(PT), BEd, MD, FRCPC, Associate Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.

July 18, 2011


Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario,
London, ON.
H. Christopher Hyson, MD, FRCPC, Assistant Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.
Kaitlyn P. Roland, MSc, Research Assistant, Interdisciplinary Graduate Studies, The University of British Columbia Okanagan, Kelowna, BC.

Abstract
Although Parkinson’s disease is primarily considered to be a motor disorder, it has inarguable effects on cognition and personality. The cluster of neuropsychiatric sequelae known as impulse-control disorders has been of particular interest in recent years, perhaps owing to the potentially disastrous effects that such behaviors can have on individuals and families. Research has suggested that impulse control disorders are significantly more prevalent among individuals with Parkinson’s disease, particularly with regards to pathological gambling and hypersexuality, and has further suggested that these disorders are significantly and substantively affected by the use of dopamine agonists. Treatment options for impulse control disorders tend to revolve around dopamine agonist dose reduction or cessation. The use of psychosocial strategies, or deep-brain stimulation of the subthalamic nucleus may also be considered in the management of patients with impulse control disorders.
Keywords: Impulse control disorders, Parkinson’s disease, dopamine agonists service use
.


Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario,
London, ON.
H. Christopher Hyson, MD, FRCPC, Assistant Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.
Kaitlyn P. Roland, MSc, Research Assistant, Interdisciplinary Graduate Studies, The University of British Columbia Okanagan, Kelowna, BC.

August 1, 2009

Amitabh Gupta, MD, Clinical Fellow, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.
Susan Fox, MD, Assistant Professor, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.

Progressive supranuclear palsy (PSP) is a rare, fatal neurodegenerative disease with limited treatment options that is characterized by gait and postural instability and a classical vertical supranuclear gaze palsy. Initially often misdiagnosed as idiopathic Parkinson’s disease (IPD), proper patient care in PSP may be delayed until late into the disease course, after dopaminergic medication fails to improve symptoms. Here, we review the diagnostic criteria that help to separate PSP from IPD and rarer forms of parkinsonian diseases to help clinicians with earlier recognition. We discuss current treatment concepts as well as ongoing experimental approaches that are derived from an emerging pathological understanding.
Key words: progressive supranuclear palsy, clinical diagnosis, imaging, differential diagnosis, management.

Amitabh Gupta, MD, Clinical Fellow, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.
Susan Fox, MD, Assistant Professor, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.

May 1, 2008

Shen-Yang Lim, MBBS, FRACP, Movement Disorder Centre, University of Toronto, Toronto Western Hospital, Toronto, ON.
Susan H. Fox, MRCP (UK), PhD, Movement Disorder Centre, University of Toronto, Toronto Western Hospital, Toronto, ON.

Parkinson’s disease (PD) is characterized by the presence of bradykinesia, rigidity, and rest tremor. Nonmotor symptoms are also very common in PD and may result in significant disability. Many approaches are available to reduce symptoms. In this article we provide an update on the management of PD. We also discuss the limitations of current treatments.
Key words: Parkinson’s disease, treatment, motor response complications, nonmotor, nondopaminergic.

Shen-Yang Lim, MBBS, FRACP, Movement Disorder Centre, University of Toronto, Toronto Western Hospital, Toronto, ON.
Susan H. Fox, MRCP (UK), PhD, Movement Disorder Centre, University of Toronto, Toronto Western Hospital, Toronto, ON.

May 1, 2008

Joel S. Hurwitz, MB, FRCPC, FRCP (London), Associate Professor, Department of Medicine (Division of Geriatric Medicine), University of Western Ontario, London, ON.

This article will assist the clinician in defining and categorizing tremor, also suggesting key questions and physical examination techniques to facilitate a probable diagnosis in an older adult. The role of many drugs in the causation and exacerbation of tremor is discussed and the treatment of several specific tremor disorders is reviewed.
Key words: essential tremor, postural tremor, kinetic tremor, enhanced physiological tremor, parkinsonism.

Joel S. Hurwitz, MB, FRCPC, FRCP (London), Associate Professor, Department of Medicine (Division of Geriatric Medicine), University of Western Ontario, London, ON.

May 1, 2008

The neurological exam is arguably the highest yield examination in all of medicine. It certainly is the most elegant part of the physical examination, and watching an experienced neurologist perform an examination can be a thing of beauty. Despite this, my long experience as a teacher suggests that for internists and family physicians the neurological exam is the most feared and probably most poorly executed aspect of the physical examination. I think there are many reasons for this, including the fact that in training we spend less time learning about neurology than, for example, cardiology. As well, an informed neurological exam depends on having a reasonable knowledge of neuroanatomy. For many of us that knowledge seems to steadily erode over the years. In a generalist practice, we almost always examine the lungs and heart of sick patients, but not always the neurological system, so there is less practice. As well, older patients often have multiple neurological findings, and it is hard to separate the background conditions from the important findings.

This is my long-winded explanation of why periodic updates in neurology are of value for most practitioners, and we hope that you will find this primer on neurology helpful. When I mentioned that watching a neurological exam can be a thing of beauty, I was particularly thinking of the author of this month’s CME article, “The Role of the Neurologic Examination in the Diagnosis and Categorization of Dementia.” Dr. John Wherrett is one of Canada’s most accomplished neurologists, and has excelled at one point or another in every area of neurology. New information on the significance and prognosis of essential tremor has recently become available, so the article on “Approach to Tremor in Older Adults” by Dr. Joel Hurwitz is of particular importance. Parkinson’s disease is extremely common among older adults, making the article “An Update on the Management of Parkinson’s Disease” by Drs. Shen-Yang Lim and Susan Fox particularly helpful to those of us who care for older adults. Our Dementia column fits in well with our focus this month, namely “Mild Cognitive Impairment: What Is It and Where Does It Lead?” by Lesley J. Ritchie and Dr. Holly Tuokko.

Our Cardiovascular Disease column this month by Dr. Christian Werner and Dr. Michael Böhm asks a very topical question: “Is Dual Blockade Most Effective for CHF? When to Use ARB and ACE Inhibitors Together”. Our Nutrition column will be of benefit for those who counsel both younger and older patients on diet. It is entitled “Nutritional Guidelines in Canada and the US: Differences between Younger and Older Adults” by Joan Pleuss. And this month’s Case Study is on the topic of “Dysphagia among Older Adults” by Dr. Amira Rana, Anselmo Mendez, and Dr. Shabbir Alibhai.

Enjoy this issue,
Barry Goldlist

May 1, 2008

John R. Wherrett, MD, FRCP(C), PhD, Professor Emeritus, Division of Neurology, University of Toronto; consultant in Neurology, Toronto Western Hospital and Toronto Rehabilitation Institute; member, Memory Clinic, Toronto Western Hospital, Toronto, ON.

Nonneurologist practitioners faced with the diagnosis of dementia cannot be expected to conduct the detailed assessments for which neurologists are trained. Nonetheless, they should be able to diagnose the most common forms of neurodegenerative dementia and identify individuals that require more detailed neurologic workup. A neurologic examination algorithm is described that allows the practitioner, in a stepwise and efficient manner, to elicit findings that distinguish the main categories of neurodegenerative and vascular dementia, namely, Alzheimer’s disease, dementia with Lewy bodies, vascular dementia, and frontotemporal lobar degenerations. Patients are assessed for gait, frontal signs, signs of parkinsonism, signs of focal or lateralized lesions, neuro-ophthalmologic signs, and signs characteristic of frontotemporal lobar degeneration.
Key words: neurologic, examination, neurodegenerative, dementia, diagnosis, gait, frontal dysfunction, cognitive impairment.

John R. Wherrett, MD, FRCP(C), PhD, Professor Emeritus, Division of Neurology, University of Toronto; consultant in Neurology, Toronto Western Hospital and Toronto Rehabilitation Institute; member, Memory Clinic, Toronto Western Hospital, Toronto, ON.

February 1, 2008

Bhaskar Ghosh, MD, DNB, DM, MNAMS, Movement Disorders Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.
Oksana Suchowersky, MD, FRCPC, FCCMG, Movement Disorders Program, Department of Clinical Neurosciences; Department of Medical Genetics, Faculty of Medicine, University of Calgary, Calgary, AB.

Chorea is a hyperkinetic movement disorder characterized by nonsustained, rapid, and random contractions that may affect all body parts. Chorea is hypothesized to be due to an imbalance between the direct and indirect pathways in the basal ganglia circuitry. Important causes of chorea among older adults include medications, stroke, and toxic-metabolic, infective, immune-mediated, and genetic causes. The history and clinical examination guide appropriate investigations and help determine an accurate diagnosis. In secondary causes, removal of the precipitating cause is the mainstay of treatment. If the chorea is persistent or progressive, drug therapy may be instituted. Genetic counselling is important in hereditary chorea.
Key words: movement disorders, chorea, older adults, diagnosis, treatment.

Bhaskar Ghosh, MD, DNB, DM, MNAMS, Movement Disorders Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.
Oksana Suchowersky, MD, FRCPC, FCCMG, Movement Disorders Program, Department of Clinical Neurosciences; Department of Medical Genetics, Faculty of Medicine, University of Calgary, Calgary, AB.

May 1, 2007

A.M. Johnson, PhD, Assistant Professor, Faculty of Health Sciences, University of Western Ontario, London, ON.
Q.J. Almeida, PhD, Director, Movement Disorders Research & Rehabilitation Centre, Wilfrid Laurier University, Waterloo, ON.

Although medication therapy is generally effective in the clinical management of Parkinson’s disease (PD), additional improvement of some gross motor symptoms may be achieved through the use of nonpharmacological treatments, such as physical therapy and exercise rehabilitation. Despite the fact that PD is a neurological disorder, successful rehabilitation has been demonstrated with treatments that combine cognitive and physical approaches. While the exact mechanism through which these therapies obtain successful outcomes is still largely unknown, it is worthwhile to explore these adjunctive approaches to treating the motor output symptoms of PD.
Key words: Parkinson’s disease, movement disorders, exercise rehabilitation, physical therapy, motor control.

A.M. Johnson, PhD, Assistant Professor, Faculty of Health Sciences, University of Western Ontario, London, ON.
Q.J. Almeida, PhD, Director, Movement Disorders Research & Rehabilitation Centre, Wilfrid Laurier University, Waterloo, ON.

April 1, 2007

Pooja Viswanathan, BMath, MSc Candidate, Department of Computer Science, University of British Columbia, Vancouver, BC.
Jennifer Boger, MASc, Research Manager, Intelligent Assistive Technology and Systems Lab, Department of Occupational Science and Occupational Therapy, University of Toronto; Toronto Rehabilitation Institute, Toronto, ON.
Jesse Hoey, PhD, Lecturer, School of Computing, University of Dundee, Dundee, Scotland; Toronto Rehabilitation Institute, Toronto, ON.
Pantelis Elinas, MSc, PhD Candidate, Department of Computer Science, University of British Columbia, Vancouver, BC.
Alex Mihailidis, PhD, PEng, Assistant Professor and Head of Intelligent Assistive Technology and Systems Lab, Department of Occupational Science and Occupational Therapy, University of Toronto; Toronto Rehabilitation Institute, Toronto, ON.

Mobility and independence are essential components of a high quality of life. Although they lack the strength to operate manual wheelchairs, most physically disabled older adults with cognitive impairment are also not permitted to use powered wheelchairs due to concerns about their safety. The resulting restriction of mobility often leads to frustration and depression. To address this need, the authors are developing an intelligent powered wheelchair to enable safe navigation and encourage interaction between the driver and his/her environment. The assistive technology described in this article is intended to increase independent mobility, thereby improving the quality of life of older adults with cognitive impairments.
Key words: mobility, artificial intelligence, assistive technology, wheelchairs, cognitive impairment.

Pooja Viswanathan, BMath, MSc Candidate, Department of Computer Science, University of British Columbia, Vancouver, BC.
Jennifer Boger, MASc, Research Manager, Intelligent Assistive Technology and Systems Lab, Department of Occupational Science and Occupational Therapy, University of Toronto; Toronto Rehabilitation Institute, Toronto, ON.
Jesse Hoey, PhD, Lecturer, School of Computing, University of Dundee, Dundee, Scotland; Toronto Rehabilitation Institute, Toronto, ON.

April 1, 2006

Felix Geser, MD, PhD, Clinical Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.
Gregor K. Wenning, MD, PhD, Clinical Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.

Multiple system atrophy (MSA) is a sporadic neurodegenerative disorder characterized clinically by various combinations of parkinsonian, autonomic, cerebellar, or pyramidal signs and pathologically by cell loss, gliosis, and a-synuclein-positive glial cytoplasmic inclusions in several brain and spinal cord structures. The clinical recognition of MSA has improved, and the recent consensus diagnostic criteria have been widely established in the research community as well as in movement disorders clinics. Although the diagnosis of this condition is largely based on clinical expertise, several investigations have been proposed in the last decade to assist in early differential diagnosis. Symptomatic therapeutic strategies are still limited.
Key words: multiple system atrophy, clinical presentation, diagnosis, treatment.

Felix Geser, MD, PhD, Clinical Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.
Gregor K. Wenning, MD, PhD, Clinical Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.

January 1, 2006

AM Johnson, PhD, Assistant Professor, School of Communication Sciences and Disorders, the University of Western Ontario, London, ON.
SG Adams, PhD, Associate Professor, School of Communication Sciences and Disorders, the University of Western Ontario, London, ON.

In addition to its widely recognized effects on gait, posture, balance, and upper limb coordination, Parkinson’s disease (PD) can have a profound effect on speech and voice, within a cluster of speech characteristics termed hypokinetic dysarthria. Although dopaminergic therapy produces significant benefits in the early stages of PD, speech symptoms may show selective resistance to pharmaceutical therapy in patients with a disease history of more than 10 years. This article discusses the pathophysiology of PD as it relates to speech disorders and considers nonpharmaceutical therapeutic options for hypokinetic dysarthria.
Key words: Parkinson’s disease, speech pathology, dysarthria, treatment.

AM Johnson, PhD, Assistant Professor, School of Communication Sciences and Disorders, the University of Western Ontario, London, ON.
SG Adams, PhD, Associate Professor, School of Communication Sciences and Disorders, the University of Western Ontario, London, ON.

December 1, 2005


Roger Y. Wong, MD, FACP, FRCPC, Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC.

Mobility impairment is a common cause of disability in older persons. The etiology is often multiple, with medical illnesses that affect the musculoskeletal, neurologic, cardiac, and/or respiratory systems superimposed on aging-related changes in gait and balance. A detailed history on the onset, duration, nature, and course of the mobility impairment is helpful. Physical examination should focus on direct observation of gait and balance, while performance- based tests can quantify the abnormalities. Simple tests for assessing walking speed, endurance, and balance are available for both outpatient and inpatient settings. The management of mobility impairment requires a multifaceted interdisciplinary approach.
Key words: mobility, gait and balance, impairment, assessment, walk tests.


Roger Y. Wong, MD, FACP, FRCPC, Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC.

December 1, 2005


Steven E. Lo, MD, The Neurological Institute, Columbia University Medical Center, New York, NY, USA.
Steven J. Frucht, MD, The Neurological Institute, Columbia University Medical Center, New York, NY, USA.

Parkinson’s disease (PD) is a neurodegenerative disorder that can significantly impact older patients’ quality of life. Although there are many pharmacologic options to treat PD, the clinician needs to know the indications and potential adverse effects of new medications in the older patient population. Carbidopa/levodopa remains the gold standard for treatment, and new formulations and levodopa-extenders fill specific niches. This article reviews the pros and cons of these medications in older PD patients, and demonstrates therapeutic strategies through case presentations.
Key words: Parkinson’s disease, treatment, levodopa, COMT inhibitor, aging.


Steven E. Lo, MD, The Neurological Institute, Columbia University Medical Center, New York, NY, USA.
Steven J. Frucht, MD, The Neurological Institute, Columbia University Medical Center, New York, NY, USA.

September 1, 2005

Nages Nagaratnam, MD, FRCP, FRACP, FRCPA, FACC, Consultant Physician, Geriatric Medicine, formerly Blacktown-Mount Druitt Health, Blacktown, New South Wales, Australia.
Gowrie Pavan, MBBS, FRAGP, General Practitioner, The Surgery, Plympton Road, Beecroft, New South Wales, Australia.

Mutism in older adults is not uncommon. It is often confused with severe depression, locked-in syndrome, and persistent vegetative state, but it is important to distinguish among them as the management and prognosis are different. The family physician is the most consulted professional and so is the most helpful in making this distinction. Mutism is a neuropsychological disorder with marked heterogeneity among patients, raising the possibility of conditions such as advanced Alzheimer’s disease, Jacob-Creutzfeldt disease, frontotemporal dementias, and certain psychiatric and psychological conditions. It is both a symptom and a syndrome, and is often associated with akinesia when the term akinetic mutism is used. Akinetic mutism has a number of causes with varied pathology and is characterized by a marked reduction in motor function, including facial expression, gestures, and speech output, with awareness being preserved. All of the disease manifestations can be explained by damage to the frontal lobe or interruption of the complex frontal subcortical circuits and the frontal diencephalic brain stem system by focal lesions or diffuse brain damage.
Key words: mutism, akinetic mutism, frontal-subcortical circuitry, locked-in-syndrome, persistent vegetative state.


Nages Nagaratnam, MD, FRCP, FRACP, FRCPA, FACC, Consultant Physician, Geriatric Medicine, formerly Blacktown-Mount Druitt Health, Blacktown, New South Wales, Australia.
Gowrie Pavan, MBBS, FRAGP, General Practitioner, The Surgery, Plympton Road, Beecroft, New South Wales, Australia.

August 1, 2004

Barbara-Ann Millar MB ChB, FRCR, Clinical Fellow, Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON.

Normand Laperriere MD, FRCPC, Associate Professor, Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON

Radiation therapy is commonly used in the management of intracranial malignancies. Although the effects on the developing brain have been extensively documented, the impact of this treatment modality on the older brain requires further investigation. The effect of radiation treatment, the intracranial lesion, and associated comorbidities and medications all influence the individual’s overall outcome. This review looks at the pathophysiology of radiation injury within the brain and its impact on cerebral irradiation in older patients.

Key words: radiotherapy, older brain, tumour, neurocognitive effects.

Barbara-Ann Millar MB ChB, FRCR, Clinical Fellow, Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON.

Normand Laperriere MD, FRCPC, Associate Professor, Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON