Nonpharmacological Methods for Reducing Falls Risk Among Individuals Living with Progressive Supranuclear Palsy

Tichenoff, A.^1,2 Holmes, J.D.^1,3 Klapak, H.² Lemmon, J.² Picanco, M.² Torrieri, A.² and Johnson, A.M.^1,2
1Health and Rehabilitation Sciences, The University of Western Ontario, London, ON, Canada. ²School of Health Studies, The University of Western Ontario, London, ON, Canada. ³School of Occupational Therapy, The University of Western Ontario, London, ON, Canada.

Abstract
Progressive Supranuclear Palsy (PSP) is a fatal neurodegenerative disorder that is characterized by gaze palsy, bradykinesia, postural instability, and mild dementia. PSP is one of the most common parkinsonian disorders, second only to Parkinson's disease. Of primary concern to individuals with PSP are issues related to reduced mobility, particularly with regards to their increased frequency of falling backwards. Although medical treatment (predominantly pharmaceutical) has been found to be effective for improving some symptoms including slowness and rigidity, most of these interventions are only partially effective in maintaining and improving balance and gait. Mobility issues in PSP are, therefore, addressed primarily through fall prevention programs delivered by physical and occupational therapists. In this review article, we will provide an overview of the current literature that explores nonpharmacological methods for reducing fall risk among individuals living with PSP.
Key words: progressive supranuclear palsy, falls prevention, gait, balance, gait training, balance training, adaptive equipment.

Low Back Pain: It's Time for a Different Approach

Making Sense of Low Back Pain

Hamilton Hall, MD, FRCSC,¹ Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,² Yoga Raja Rampersaud, MD, FRCSC,³

CLINICAL TOOLS

• Abstract
• CME
• Visual Aids
• Key Points
• Clinical Pearls
• Premium Content

Abstract: In 1987, the Quebec Taskforce noted, "Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment." Identifying these patterns begins with the patient's history: "Where is your pain the worst?" "Is your pain constant or intermittent?" "Has there been any change in your bowel or bladder function?" This questioning establishes the mechanical nature of the pain, and a physical examination verifies or refutes the pattern established in the history. The examination involves two essential tests to detect upper motor and low sacral root involvement. A failure of the results to fit into one of four syndromes—two back dominant and two leg dominant—suggests a non-mechanical or more complex problem.

Key Words:patterns of back pain, pain location, pain characteristics, history, physical examination.

HealthPlexus is offering an eCME in support of the Back Pain Management Resource

eCME: The Latest in Back Pain Management

This CME activity offers interactive Videos, Animations, Pre- and Post-test Quizzes and you will be able to download a Certificate of Participation upon completion.

Proceed to the CME

• 
• 
• 
• 
• 
• 

90% of Low Back Pain is not related to serious pathology and does not require surgical intervention.

Mechanical Low Back Pain can be categorized to patterns that are identified in history and confirmed in the physical examination.

Findings on radiological imaging including x-ray, CT scan and MRI have not been found to correlate to pain-generating pathology, can increase patient anxiety and detract from successful recovery.

A concise history starts with two questions: "Where is your pain the worst?" and "Is your pain constant or intermittent?"

The goal of physical examination is to verify or refute the diagnostic assumptions made on the basis of the history.

Managing low back pain is not a one-time event. Low back pain is a chronic condition that demands ongoing care and follow-up.

To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.

Managing Back Dominant Pain

Hamilton Hall, MD, FRCSC,¹ Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,² Yoga Raja Rampersaud, MD, FRCSC,³

CLINICAL TOOLS

• Abstract
• CME
• Visual Aids
• Key Points
• Clinical Pearls
• Premium Content

Abstract: Back dominant pain is either intensified by flexion or is not aggravated by bending forward. The most common pattern, probably discogenic, subdivides into two groups: one with pain on flexion but relief on extension, the other with pain in both directions. The second pattern has symptoms with extension only. Treatment begins with education about the true benign nature of the problem. Mechanical pain responds to posture adjustment and pattern-specific movement. Medication has a secondary role. Imaging is not required for the responding patient. The inability to detect a pattern or a lack of anticipated response combined with non-mechanical findings indicates the need for appropriate referral.

Key Words:back dominant pain, education, medication, imaging, specialist referral.

HealthPlexus is offering an eCME in support of the Back Pain Management Resource

eCME: The Latest in Back Pain Management

This CME activity offers interactive Videos, Animations, Pre- and Post-test Quizzes and you will be able to download a Certificate of Participation upon completion.

Proceed to the CME

• 
• 

Back Dominant pain can be divided into two presentations: pain that is predominantly reproduced with flexion or pain that is reduced or unaffected by flexion.

The recognition of mechanical low back pain is based on a precise history, a validating physical examination and a positive treatment result.

Referred pain to the leg may occur with back dominant pain but, unlike radicular pain, the neurological examination will be normal.

Facilitating the patient to engage in activity that does not aggravate pain is the key to pain management and recovery.

The goal is control, not cure. Anything that relieves the pain and helps to restore mobility is valuable.

Medication has a limited and secondary role. There is no place for the routine use of narcotics or psychotropic drugs.

To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.

Managing Leg Dominant Pain

Yoga Raja Rampersaud, MD, FRCSC,¹ Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,² Hamilton Hall, MD, FRCSC,³

CLINICAL TOOLS

• Abstract
• CME
• Visual Aids
• Key Points
• Clinical Pearls
• Premium Content

Abstract: Leg dominant pain suggests direct nerve root involvement: radicular, not referred symptoms. Constant pain associated with positive neurological findings usually results from an acute disc herniation. Symptoms are the result of mechanical compression but principally reflect an inflammatory response, properly designated sciatica. Intermittent leg dominant pain triggered by activity in extension and relieved by rest in flexion probably represents neurogenic claudication: nerve root ischemia secondary to spinal stenosis. Except for acute cauda equina syndrome, acute sciatica is initially managed with scheduled rest, adequate medication, and time. Non-responsive cases may require surgery. Surgery also shows superior outcomes for disabling neurogenic claudication.

Key Words:leg dominant pain, sciatica, neurogenic claudication, cauda equina syndrome, surgery.

HealthPlexus is offering an eCME in support of the Back Pain Management Resource

eCME: The Latest in Back Pain Management

This CME activity offers interactive Videos, Animations, Pre- and Post-test Quizzes and you will be able to download a Certificate of Participation upon completion.

Proceed to the CME

• 
• 

True spine-generated, leg dominant pain is consistently reproduced by particular spinal movements or positions.

No imaging investigation is required for a patient presenting an unequivocal clinical picture and exhibiting steady predictable improvement.

Of the four back pain syndromes, only neurogenic claudication is consistently best treated by surgery.

In contrast to the back dominant cases, in sciatica there is a definite role for short-acting narcotics or psychotropic drugs for uncontrolled pain.

Criteria for Surgical Referral

Emergency Referral The symptoms of Cauda Equina Syndrome are: - Urinary retention followed by insensible urinary overflow. - Unrecognized fecal incontinence. - Loss or decrease in saddle/perineal sensation. Acute Cauda Equina Syndrome is a surgical emergency.

Consider Elective Referral Failure to respond to a trial of conservative care: - Unbearable constant leg dominant pain. - Worsening nerve irritation tests (SLR or femoral nerve stretch). - Expanding motor, sensory or reflex deficits. - Recurrent disabling sciatica. - Disabling neurogenic claudication.

To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.

Back Pain: Patient Education

Diagnosis and Management Approaches to Lumbar Spinal Stenosis

John D. Markman, M.D., Director, Translational Pain Research, Department of Neurosurgery, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA.
Maria E. Frazer, B.S., Health Project Coordinator, Translational Pain Research, Department of Neurosurgery, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA.
Pierre S. Girgis, M.D., Assistant Professor, Department of Neurosurgery, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA.
Kevin R. McCormick, M.D., Ph.D, Associate Professor, Department of Medicine, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA.

Lumbar spinal stenosis (LSS) is the leading cause of spinal surgery among older Americans, yet more than one-third do not gain significant relief from surgical treatment. The distinct pattern of lower back and leg pain induced by standing and walking associated with LSS is known as neurogenic intermittent claudication (NIC). Various treatment options for NIC include surgical interventions as well as pharmacological, biomechanical and conservative therapy (i.e., physical therapy). No specific treatment is associated with guaranteed outcome, which underscores the need to further evaluate the diagnosis and symptoms associated with LSS.
Key words: lumbar spinal stenosis, neuropathic pain, treatment, treadmill testing, epidural steroid injection.

Mobility and Quality of Life

Summer is almost here as I write this editorial. After a long winter in Canada, one of the real pleasures of spring and summer is getting out of the house and walking. It is a wonderful time to see neighbours again and to see the gardens blooming. However, these simple pleasures of life are difficult to enjoy if one’s mobility is limited and, unfortunately, this is often the case as we age. Arthritis is the number one condition impairing the quality of life of community-dwelling older people, but we physicians often do not take it seriously enough. That is why Geriatrics & Aging regularly has theme issues on musculoskeletal problems: we try to remind clinicians of the importance of mobility in maintaining quality of life.

We have all had muscle cramps at one time or another, but are the cramps older adults get different? It will be easy to find out, just read the article “Muscle Cramps in Older Adults” by Dr. David Guay. Modern imaging has made the diagnosis of spinal stenosis much easier to ascertain but has raised many questions about proper management. The article “Management of Spinal Stenosis” by Drs. Maria Frazer and John Markman is an attempt to answer some of these difficult questions. The article “Intra-articular Corticosteroids in Osteoarthritis” by Dr. Sunita Paudyal and Dr. Stephen Campbell will help the primary care physician utilize this treatment modality in a rational manner.

We also have our usual potpourri of articles on various topics. Our cardiovascular column “Orthostatic Hypotension Screening in Older Adults Taking Antihypertensive Agents” is by Dr. Kenneth Madden, who is also the new associate editor of the Canadian Journal of Geriatrics. Our dementia column addresses a difficult and eternal issue in geriatric medicine, “Adherence to Medication in Patients with Dementia: Problems and Solutions,” and is written by Dr. Dan Brauner. Our caregiving column addresses the topic of “Caregiver Stress: The Physician’s Role” and is by Dr. Abisola Famakinwa. Our technology in medicine column this month is relatively low tech but very important to older adults, namely “Canes & Walkers: A Practical Guide to Prescribing” by Dr. Robert Lam and Alison Wong.

Enjoy this month’s issue,
Barry Goldlist