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

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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.

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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.

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James W. Cooper, RPh, PhD, BCPS, CGP, FASCP, FASHP, Emeritus Professor and Consultant Pharmacist, College of Pharmacy, University of Georgia, Athens, and Assistant Clinical Professor of Family Medicine, Medical College of Georgia, Augusta, GA, USA.
Allison H. Burfield, RN, PhD, Assistant Professor, School of Nursing, College of Health and Human Services, University of North Carolina-Charlotte, Charlotte, NC, USA.

The high incidence of falls among older adults leads to increased health care costs and decrements in functional status. Psychoactive medications consumed by older adults are often implicated in falls. This article briefly reviews the associations between falls and psychoactive medications, with a focus on the long-term care setting, and offers an assessment method and strategies to reduce the risk of certain classes of medications known to contribute to fall risk.
Key words: falls, medications, psychoactive load, interventions, older adults.

Elliott M. Kanner, MD, PhD, Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA.
James C. Tsai, MD, Associate Professor and Director, Glaucoma Division, Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA.

Glaucoma is a sight-threatening, progressive optic neuropathy whose incidence increases with age. Currently, the only proven treatment for glaucoma is the reduction of intraocular pressure (IOP). As medical treatment has become safer and diagnostic modalities have become more sensitive, it has become possible to detect and treat glaucoma earlier. This means that with more aggressive screening and treatment, a common cause of irreversible blindness can be prevented. As more patients are treated earlier, it is important not only for ophthalmologists but also for primary care physicians to be aware of the barriers to adherence and possible interactions and side effects of glaucoma medications. Parallels between glaucoma and other neurodegenerative disease are stimulating new approaches to therapy beyond IOP control, targeted directly at the prevention of axonal loss.
Key words: glaucoma, intraocular pressure, medications, neuroprotection, retinal ganglion cell.

Lilia Malkin, BSc

Heart disease is a major cause of morbidity and mortality in the geriatric population. According to Health Canada, myocardial infarction (MI) and ischemic heart disease (IHD) accounted for over one-third of deaths in men and women aged 65 and older in 1995, once again firmly establishing coronary artery disease (CAD) as the leading cause of mortality in Canada. In Ontario, 23 percent of patients die within one year of experiencing MI and one-third of congestive heart failure (CHF) patients succumb within one year of being hospitalized for CHF. Importantly, as Dr. David Naylor, co-editor of the 1999 Institute for Clinical Evaluative Sciences (ICES) Cardiovascular Atlas points out, the Canadian demographic profile is shifting toward a larger geriatric population, potentially greatly increasing the number of Canadians vulnerable to heart disease. Therefore, it is imperative that both primary and secondary prevention methods be used as extensively as possible to reduce the morbidity and mortality due to CAD.