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An Approach to Foot Drop for Primary Care Physicians

What is foot drop?

Foot drop refers to weakness of the ankle dorsiflexors leading to an inability to lift the forefoot. This can lead to functional limitations with gait, mobility, and can be associated with chronic pain.

What are the causes of foot drop?

Most of the time, foot drop is the result of a neurological process, but a ruptured tendon involved in dorsiflexion can also be a cause. Neurological causes include the following:

  • Compression of the:
    • peroneal nerve near the fibular head (and less commonly in other locations)
    • L5 nerve root near the spine
  • Direct trauma of the peroneal nerve or its branches, especially those injuries that lead to fractures, dislocations, or deep lacerations.
  • Compartment syndrome in the leg leading to nerve ischemia
  • Neurological disorders such as Charcot-Marie-Tooth, amyotrophic lateral sclerosis, or multiple sclerosis
  • A systemic condition leading to nerve damage, such as diabetes or vasculitis

How do you evaluate a patient with foot drop?

History

  • The patient may complain of dragging their toes, problem walking or climbing stairs, or frequent tripping and falling.
  • There may be numbness in the anterolateral leg, dorsum of the foot, and/or first toe webspace.
  • Look for clues to the etiology:
    • Presence of trauma
    • Presence of back pain and/or sciatic symptoms
    • Factors that can lead peroneal nerve compression such as rapid weight loss, habitual leg crossing, and prolonged squatting.
    • Signs and symptoms of systemic conditions such as vasculitis or diabetes
    • Presence of other neurological symptoms not limited to the distribution of L5 or peroneal nerve

Physical exam

  • A thorough neurological exam of the lower extremity is required including an assessment of all dermatomes, myotomes, reflexes, and upper motor neuron signs.
  • Pay particular attention to peroneal nerve function:
    • Motor: assess for weakness in ankle dorsiflexion (deep branch), eversion, and plantarflexion (superficial branch)
    • Sensory: assess for decreased sensation of anterolateral leg, and dorsum of foot (superficial branch), as well as first webspace (deep branch)
  • The following chart of motor functions helps to differentiate between peroneal dysfunction and L5 radiculopathy:
WeakPeronealL5
Dorsiflexion (Deep peroneal)YesYes
Eversion (Superficial peroneal)YesYes
Inversion (Tibial)NoYes
Hip abduction (Gluteal)NoYes
Knee flexion (Sciatic)NoYes (medial hamstrings)

Investigations

  • Electromyography/Nerve Conduction Studies (EMG/NCS) should be ordered approximately three to four weeks after the onset of injury. If done too early, significant pathologies may be missed.
  • Imaging studies may be ordered to rule out a compressive lesion if:
    • an L5 lesion is suspected, a spine MRI should be ordered.
    • a peroneal lesion is suspected, an MRI of the leg (or an ultrasound if the suspected mass is superficial) should be obtained.
  • Serological lab tests should be ordered based on clinical suspicion of a systemic metabolic or autoimmune process.

How should you manage a patient with food drop?

  • Conservative therapy may be attempted in most patients as many cases will improve over time. These include:
    • Protect the peroneal nerve from further injury – padding around the fibular head, avoid leg crossing or prolonged squatting.
    • Physical therapy to maintain ankle and foot mobility and to prevent contractures
    • Electrostimulation of the affected muscles may help with recovery of function
    • Use of ankle foot orthosis to help with foot clearance during ambulation
  • Surgical referrals are indicated in the following situations:
    • If the foot drop developed acutely following a significant injury where a nerve transection is suspected, the patient should be referred urgently to a surgical center specializing in peripheral nerve injuries.
    • If there is evidence of severe nerve damage on EMG/NCS and/or lack of any functional recovery at three months, these patients should be referred to a surgical center specializing in peripheral nerve injuries within three to four months. They may be candidates for nerve transfer surgery if referred early.
    • If an obvious compressive mass is identified, it may be amenable to surgical excision
    • If patient continues to have functional deficits after conservative therapy, they may be referred for consideration of tendon transfer surgery (posterior tibial to lateral cuneiform or cuboid) to restore dorsiflexion

Summary: Foot drop refers to a weakness of the ankle dorsiflexors leading to an inability to lift the forefoot. The most common causes are injuries to the peroneal nerve or an L5 radiculopathy. The evaluation should focus on identifying which nerve structure is injured, the etiology of nerve injury, and to determine the extent of dysfunction. Most patients will improve with conservative therapy, but certain scenarios require timely surgical referral such as when a severe injury to the nerve is suspected.

Yuhao Shi, MD
Sports and Exercise Medicine Fellow, University of Ottawa
Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

References:

  1. Elkwood, AI, Kaufman, MR, Abdollahi, H. Foot drop: Etiology, diagnosis, and treatment. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2021.
  2. Poage C, Roth C, Scott B. Peroneal Nerve Palsy. J Am Acad Orthop Surg. 2016 Jan 1;24(1):1–10.
  3. Nori SL, Stretanski MF. Foot Drop. StatPearls. StatPearls Publishing; 2020.

Shoulder Impingement Syndrome: Will Surgery Make a Difference?

Shoulder impingement syndrome (SIS) is one of the most common causes of chronic shoulder pain in adults, and one that is frequently seen in primary care. Typical symptoms include pain with overhead movements, and classic physical exam tests include Neer’s sign, Hawkins-Kennedy sign, and a painful arc.

Pain from shoulder impingement is thought to be secondary to impingement of the rotator cuff tendons due to decreased subacromial space. Subacromial space can be reduced due to multiple reasons:

  • Poor posture creating a protracted shoulder girdle with internally rotated glenohumeral joint, creating a functionally reduced subacromial space
  • Subacromial bursitis, either acute or chronic (although this can also be seen secondary to the former point)
  • Spurring of the inferior surface of the acromion

Treatment of shoulder impingement syndrome typically involves:

  • Physiotherapy to develop pain-free ROM, strengthening of the rotator cuff and periscapular muscles, improved posture, and improved scapular kinetics
  • Oral NSAIDs are commonly prescribed
  • Corticosteroid injection of the subacromial bursa can be considered if pain is severe or the patient has failed a trial of more conservative management

What about surgery?

  • Arthroscopic subacromial decompression is a commonly performed surgery
  • It typically involves shaving down the inferior aspect of the acromion, thereby creating a larger subacromial space
  • A Cochrane review concluded that evidence does not support subacromial decompression surgery as a treatment for shoulder impingement, as it does not provide clinically meaningful benefits in terms of pain relief1
  • The BMJ released a clinical practice guideline strongly recommending against subacromial decompression surgery for the treatment of shoulder pain2
  • More recently, an RCT published in the British Journal of Sports Medicine that involved 5 year follow-up failed to detect any difference in pain between patients who underwent subacromial decompression, patients who underwent diagnostic arthroscopy (placebo surgery), or patients who completed an exercise program3

Bottom line?

Evidence suggests that there is no benefit to subacromial decompression surgery for the treatment of shoulder impingement. Patients with this condition should be reassured that surgery is unlikely to help their symptoms, and that treatment should focus on conservative management.

Janet Barber MD, MSc, BSc

PGY3 Sport and Exercise Medicine, University of Ottawa

Advisor: Dr Taryn-Lise Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

References:

  1. Karjalainen, T. V., Jain, N. B., Page, C. M., Lähdeoja, T. A., Johnston, R. V., Salamh, P., … & Buchbinder, R. (2019). Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews, (1).
  2. Vandvik, P. O., Lähdeoja, T., Ardern, C., Buchbinder, R., Moro, J., Brox, J. I., … & Noorduyn, J. (2019). Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. Bmj364.
  3. Paavola, M., Kanto, K., Ranstam, J., Malmivaara, A., Inkinen, J., Kalske, J., … & Järvinen, T. L. (2020). Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial. British journal of sports medicine.

Take home message from “Arthroscopy Association of Canada: Position Statement on Intra-articular Injections for Knee Osteoarthritis”i

Arthroscopic surgery for knee OA is not recommended. The AAC recommends a 6- to 9-month trial of “appropriate and comprehensive nonoperative treatment” before considering surgical intervention such as arthroplasty. Alternative treatments including intra-articular injections will be discussed below. Although these guidelines discuss injections, it is important to remember that we also have other successful conservative tools to recommend:

  • Weight loss is the first and probably most efficient way to help patients with knee osteoarthritis (OA)
  • Modification of the patient’s activities to low impact such as switching from running to biking or swimming
  • Sleeve braces
  • Unloading braces
  • Strengthening programs for quadriceps, hamstrings, gluteus and abdominal muscles by a physiotherapist
  • Oral NSAIDs in acute flares
  • Topical NSAIDs

These treatments should be optimized, encouraged and followed up on to ensure the patient has attempted all other options before referring to surgery. An active treatment program designed by a physiotherapist with several sessions of exercises & teaching (not only passive therapies such as heat, ice, TENS for the whole session) with an assigned, progressive home exercise program that the patient is compliant to for many weeks.

Corticosteroid injections:

While cortisone injections are commonly used in family medicine practice, there is still some conflicting evidence around its efficacy for pain and function due to small sample sizes and studies of poor methodological quality.

Highlights:

  • More efficient pain relief and function improvement when the OA is less severe (Kellgren-Lawrence grades 1-2).
  • On the other hand, patients with moderate to severe OA and obese patients tend to have limited improvement.
  • The effects of corticosteroids are of a limited duration and commonly last up to 3 months with no benefit over 6 months.

We should also counsel the patient on having a maximum of “3 injections per year”. The rationale behind this recommendation was demonstrated in a study published in the JAMA 2017ii that tried to demonstrate the effects of repeated cortisone injections. The results showed an increase in cartilage volume loss on MRI (but of only 0.11mm) after 2 years of intra-articular triamcinolone injections given every 3 months when compared to saline injections. The cartilage volume loss was of 0.11 mm which has to be taken into consideration in the decision making with the patient as it might be of limited concern in an older patient with severe osteoarthritis, especially with contraindications for arthroplasty.

Recommendation: In patients with mild OA, intra-articular corticosteroid injections provide moderate short-term pain relief and restoration of function, as well as offer a cost-effective treatment option.

Strength of recommendation: Good – A

Hyaluronic acid (HA):

Highlights:

  • HA increases viscosity of synovial fluid, compressive strength of articular cartilage and decreases inflammation
  • Low risk of adverse effects: infection and granulomatous inflammation in 4-13% of injections
  • High-molecular weight (HMW) (> 3000kDa) more efficient than low-molecular weight (LMW) or placebo iii, iv
  • Highly cross-linked more efficient
  • Effect lasting up to 26 weeks but up to a year in some patients
  • Improves pain, function & stiffness in mild to moderate OA

Recommendation:

In patients with mild to moderate knee OA, HMW HA intra-articular knee injection provides pain & function improvement.

Strength of recommendation: Good – A

Platelet-rich plasma (PRP):

Highlights:

  • Plasma with a minimum of 1 million platelets per millilitre
  • Pain & function improvement more significant than placebo (saline) at 6 & 12 months
  • Equal effect to HA at 6 months but superior to HA at 12 months
  • Safe, low risk adverse events (same as placebo)
  • Better efficacy in low grade OA (Kellgren- Lawrence grades 1-2) & younger patients
  • No evidence in severe OA

Recommendation: In mild to moderate knee OA, PRP injection potentially improves pain and functional outcomes up to 1 year after the injection.

PRP composition is affected by time of day & exercise, different PRP preparation systems, concentration of other constituents (WBC, growth factors, etc.). This makes preparations very heterogeneous and therefore harder to interpret, even in meta-analyses attempting to determine the optimal protocol and product. Further high-quality clinical studies are needed.

Strength of recommendation: Cf (f: for/in support of the intervention)

Stem cells:

Highlights:

  • Potential good benefit in lower grades of OA
  • Still very few studies with small sample sizes – more extensive research needed.

Recommendation:

MSC and BMAC injections limited to registered controlled trials only.

Strength of recommendation: Insufficient – I

In early stages of OA, sport medicine physicians prefer starting with weight loss, activity modification, bracing, strengthening exercises/physiotherapy, HA and PRP and then opting for cortisone injections because of the potential long-term effects of cortisone on articular cartilage. Of course, in all cases, treatment options should be personalized to the patient’s needs, severity of pain, functional impact, economic status and other individual variables. Referral to a sport medicine specialist should be considered if assistance is required to guide the patient through the spectrum of management options for knee OA.

Marie-Ève Roy, MD, CCFP
Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKin, MSC, MD, CCFP (SEM), Dip Sport Med


i McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA. 2017; 317(19):1967-1975.

ii Bhandari M, Bannuru RR, Babins EM, et al. Intra-articular hyaluronic acid in the treatment of knee osteoarthritis: a Canadian evidence based perspective. Ther Adv Musculoskelet Dis. 2017;9(9):231-246.

iii Vannabouathong C, Bhandari M, Bedi A, et al. Nonoperative treatments for knee osteoarthritis: an evaluation of treatment characteristics

and the intra-articular placebo effect. A systematic review. JBJS Rev. 2018;6(7).

Evaluating the Heart Wise Exercise program: a model for safe community exercise programming

Jennifer L. Reed, Jennifer M. Harris, Liz Midence, Elizabeth B. Yee, Sherry L. Grace.

BMC Public Health, Volume16, February 2016.

Promoting physical activity in the primary care setting remains a significant challenge. The Canadian Guidelines for Physical Activity recommend that adults should get at least 150 minutes of moderate to vigorous physical activity per week, in bouts of 10 minutes or more. Despite the overwhelming evidence that regular aerobic exercise is one of the most beneficial things one can do for their health, many barriers stand in the way for patients who may seek to make positive behavioural change.

Increasingly, our patients are living with many chronic diseases including heart disease, diabetes, and chronic obstructive pulmonary disease. Often times, patients with these ailments do not understand how physical activity can be a regular part of their lives, and will often cite their poor overall health as a reason not to be active.

The Heart Wise Exercise Program was started at the University of Ottawa Heart Institute as a way to combat this issue. The program seeks to work with community physical activity providers to designate facilities, programs, and classes where participants can exercise regularly to prevent or limit the negative effects of living with a chronic health condition. Heart Wise Exercise was launched in 2007 in partnership with several local organizations and support from the Ontario Ministry of Health Promotion.

A program or class that displays the Heart Wise Exercise logo satisfies 6 criteria. In 2015, Reed et al. utilized a piloted checklist and audited 45 Heart Wise Exercise programs for the 6 criteria, in addition to administering a survey to a convenience sample of 147 participants:

  • Encourages regular, daily aerobic exercise – 71% of exercise leaders encouraged daily aerobic exercise. Participants reported engaging in an average of 149 minutes of aerobic exercise per week.
  • Encourages and incorporates warm up, cool down, and self-monitoring with all exercise sections – 100% of programs incorporated a warm-up and cool down, and 84% encouraged self-monitoring in class.
  • Allows participants to exercise at a safe level and offers options to modify intensity – 98% of programs offered different options for participants exercise at appropriate intensity levels.
  • Includes participants with chronic health conditions – participants reported living with a variety of chronic health conditions including arthritis, osteoporosis, diabetes, heart disease, and chronic obstructive pulmonary disease.
  • Offers health screening for all participants – 93% of instructors offered health screening for patients.
  • Has a documented emergency plan that is known to all exercise leaders, including the requirement of current CPR certification, phone access to local paramedic services and presence of a defibrillator – 100% of the exercise sites had automated external defibrillators, and 90% of instructors were aware of the documented emergency plan.
  • Furthermore, participants reported being, on average, “somewhat happy” to “very happy” with their Heart Wise Exercise locations, program dates and times, leaders’ knowledge of disease and exercise, cost, and the social aspect of being part of a group.

In all, Heart Wise Exercise Programs are safe and appropriate for your patients with various chronic health conditions. Current participants are highly satisfied with their programs. For more information, please visit:

https://heartwise.ottawaheart.ca

 

Sean Mindra MD, CCFP

PGY3 – Sport and Exercise Medicine, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

The Noisy Knee

Song, S. J., Park, C. H., Liang, H., & Kim, S. J. (2018). Noise around the Knee. Clinics in orthopedic surgery, 10(1), 1-8.

A common MSK question patients ask is “is it normal that my knee makes this sound?” While this review focuses on the knee, the approach can be generalized to any shoulder. Noise in the knee is common, and often patients are worried the noise is pathological.

Noise around the knee can be separated into physiologic and pathologic causes. This is defined by whether the sound is associated with pain, swelling, and abnormal range of motion. There are also many different types of sounds which are more likely to describe one cause than another. Crepitus is a vague descriptor used to represent a sound during a joint’s range of movement. Popping is a sudden explosive and well perceived sound, usually associated with injury such as meniscal, cruciate, or collateral ligament tears. Clunking is a loud singular noise due to release against resistance, often suggestive of something that was subluxed and now relocated. Clicking is a tiny, singular noise that occurs during one cycle of knee extension and flexion, this can be associated with various causes. Grinding and grating are used to describe continuous scratching sounds and are more associated with degenerative OA and patellofemoral pain syndrome.

Physiologic Sounds:

Not associated with any history of trauma, swelling, or pain.

Tend to be sporadic in nature

No aggravation of sounds and combined symptoms

Causes include:

  • build up or bursting of tiny bubbles in the synovial fluid
  • snapping of ligaments
  • catching of the synovium or physiological plica
  • hypermobile or discoid meniscus.

One way to distinguish between these causes is whether the joint sound occurs repeated during range of motion. If it happens repeatedly, it is usually due to anatomic structures rubbing against each other, such as ligaments/tendons or plica over a bony prominence. One common is the bicep femoris tendon at the lateral aspect of the knee. If the crack has a refractory period, it is likely due to air build up in the joint, and subsequent changes in joint pressure during range of motion cause cavity formation which creates a popping sound.

Management of physiologic noise involves reassurance and stretching and strengthening of affected musculotendinous structures.

Pathologic Sounds:

Can have history of trauma or injury

Tend to be higher pitch/frequency

observed consistently, has gradual aggravation

Causes:

  • Degenerative changes
    • Structural cause such as bony spurs and cysts, meniscal tears…etc
  • Pathologic plica
    • If a plica gets irritated, it can cause synovitis and pain
  • Patellofemoral instability
    • Due to hypermobility of patella or subluxation of patella
  • Post-surgical
  • Pathologic snapping knee syndrome
    • Any extra or intra-articular structure that causes painful sounds, which can include ganglion cysts, lipoma, synovial nodules, fabella, osteochondromas, osteophytes

Management of these pathologic noises depends on the underlying cause.

Overall, noise around the knee is a common phenomenon, with one study suggesting 38.1% of women and 17.1% of men over 40. With this approach, careful evaluation of the noise can help prevent unnecessary diagnostic interventions and provide appropriate guidance for healthy patients experiencing physiologic noise.

 

Jim Niu MD, CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

Chronic Exertional Compartment Syndrome – An Introduction

We have all heard of compartment syndrome. This is a medical emergency where increased pressures within a compartment can lead to rapid ischemia, muscle damage, and even potential amputation after a trauma or injury.

How many of us have heard of chronic exertional compartment syndrome (CECS)?

CECS is a cause of chronic exertional leg pain. Most often seen in young runners and elite athletes, it is a relatively unknown and underdiagnosed condition. Its incidence and pathophysiology are not well understood. One theory suggests a noncompliant fascia that cannot accommodate the expansion of muscle volume during exercise, causing increased intracompartmental pressures.

Suspect CECS with athletes who present with chronic anterior/lateral leg pain that worsens with prolonged use and resolves shortly upon cessation of activity. Most cases will occur in the anterior or lateral compartments. Classically, these athletes will be able to tell you that a specific time, distance, or intensity will bring on the symptoms, characterized as burning, aching, cramping, or pressure. It usually resolves fairly shortly if they stop the activity unless they continue to push through the symptoms for longer durations. It is fairly common to be bilateral. They may have some numbness/tingling in the dermatomal distribution of the nerve that runs through the compartment and weakness of those muscle groups.

Physical exam is often normal at rest. Some people will have visible painless fascial herniations. On physical exam immediately after exercise, there may be pain on palpation of the muscles involved, pain with passive stretching of the muscles, and the compartments may be quite firm. No imaging is necessary but will commonly be done to rule out other diagnoses such as a stress fracture. The diagnosis of CECS can be made clinically but given its non-specific nature, it can be confirmed using immediate post-exercise intracompartmental pressure testing. If confirmed, a surgeon may be consulted for an ELECTIVE fasciotomy.

The differential diagnosis includes medial tibial stress syndrome (shin splints), stress fractures, fascial defects, nerve entrapment syndromes, popliteal artery entrapment syndrome, and vascular or neurogenic claudication.

It is important to note that shin splints present with pain on the medial border of the tibia. Shin splints are NEVER lateral! A high level of suspicion is required for the diagnosis of ant/lat CECS as all imaging will be reported as normal.

While uncomfortable, there is no evidence to suggest that the pain from CECS indicates any muscle damage or has long-lasting implications. Modified activity is a reasonable treatment option. People may choose to avoid continuous running and opt to bike, swim, skate or play shorter shifts. Hopefully, this brief introduction sheds some light on the subject.

Jim Niu MD, CCFP

Sport and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

HPV Related Diseases and HPV Vaccination

Author: Michael Fung-Kee-Fung, Gynecologist Oncologist, Chief Strategy Officer, The Society of Gynecology Oncology of Canada

A new edition of the reference guide on prevention of HPV and the care of patients with HPV has just been published online by the Society of Gynecologic Oncology of Canada (GOC).

Take a look to find answers to more than 50 questions.

Who should be vaccinated against HPV? Are 2 doses of HPV vaccine adequate? How do we treat persistent HPV disease? What is HPVthe best test for cure of cervical dysplasia.

Learn the answers and more at   https://g-o-c.org/publications/contemporary-clinical-questions-in-hpv-related-diseases-and-vaccination/

Nominate a Caregiver for a Heroes in the Home Award

Heroes in the Home logoAs a primary care practitioner, you may come across some truly exceptional caregivers in your community — family members, friends, and volunteers whose kindness and commitment allow loved ones to live better lives despite the limitations of age, illness or disability.

The Champlain Community Care Access Centre (CCAC) is currently accepting nominations for the 2015 Heroes in the Home Caregiver Recognition Awards.

How to nominate a caregiver

Recognize a caregiver you know by nominating them for a Heroes in the Home award – it’s easy and makes a difference! The deadline for nominations is February 27th, 2015.

  1. Submit your nomination online or
  2. Print the form and send it back to Champlain CCAC by e-mail, fax or mail

About Heroes in the Home

Watch a video of Dr. Steve Radke, Chief of Staff at Renfrew Victoria Hospital, as he speaks about the impact that caregivers make for their families, physicians and the community.

The Heroes in the Home Caregiver Recognition Awards are a small gesture to celebrate people who might otherwise go unnoticed. All nominees will be honoured at a series of award ceremonies in May 2015.

Learn more and see photos from last year’s ceremony at champlainccac.ca.

Register now: AMO 8th Annual Clinical Day is February 20th

The Academy of Medicine Ottawa’s 8th Annual Clinical Day will take place on Friday, February 20th, 2015 at the Ottawa Conference & Event Centre (200 Coventry Rd, Ottawa). Register now and save! Early bird registration is available until November 30th.

To support your clinical practice and promote better health for your patients

The AMO Clinical Day is designed for physicians, nurses and allied health professionals, to support clinical best practice and promote health for patients. We offer the highest quality accredited continuing medical education with an interdisciplinary program, to build awareness of options, strategies and resources.

Topics and speakers

  1. Slaying the zombies of smoking cessation – Andrew Pipe, CM, MD, LLD(Hon), DSc(Hon)
  2. Autism spectrum disorder – Susan Farrell, PhD
  3. Mindfulness starts here – Lynette Monteiro, PhD
  4. Helping our patients keep their marbles – Tony Hakim, OC, MD, PhD, FRCPC
  5. Choosing Wisely: prevention of unnecessary tests, treatments and procedures – Chris Simpson, MD, FRCPC, FACC, FHRS
  6. Sport concussion – Taryn Taylor, BKIN, MSc, MD, CCFP, DipSportMed
  7. Suicide prevention – Simon Hatcher, MD, MRCPsych, FRANZCP, FRCPC
  8. Lyme disease, MERS-CoV and other scarey bugs – Carolyn Pim, MD, FRCPC

CME credits

This program has been accredited by the College of Family Physicians of Canada and the Ontario Chapter for up to 6 Mainpro-M1 credits. This event is an accredited group learning activity (section 1) as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada, approved by the Canadian Psychiatric Association (CPA). The specific opinions and content of this event are not necessarily those of the CPA, and are the responsibility of the organizer(s) alone.

Register now and save!

Early bird registration until November 30. Registration includes continental breakfast, nutritional morning snack and lunch. Parking is free.

ABI System Navigator Recognized for Work Excellence

Suzanne McKenna poses after receiving an awardLast June the Champlain region’s Acquired Brain Injury (ABI) System Navigator was recognized for her work by the Ontario Association of Community Care Access Centres. In her role, Suzanne McKenna guides ABI survivors and caregivers who are unsure about where to start looking for care during this difficult time in their lives.

Since McKenna began her work in October of 2011, she has helped to connect more than 120 individuals in need of specialized services and supports.

“A brain injury doesn’t just change the life of the individual; it changes the lives of everyone around them. Creating a better life for those who suffer a brain injury, along with their families and caregivers, is my ultimate goal,” says McKenna.

ABI Resources for Primary Care

An ABI Primary Health Care Resource Guide is available to be used as a quick reference tool for ABI support services available in the Champlain region (e.g. day programs, transportation, continuing education, support groups, recreational opportunities).

Visit the Ontario Neurotrauma Foundation’s website to read the latest: