The Diagnosis of Persistent Low Back & Referred Lower Limb Pain Programme | All Courses

Program Objectives

  1. Provide a selective overview of the sources and causes of low back and referred lower extremity pain and discuss their relationship to classification systems and national guidelines.
  2. Provide a selective review of the evidence in support of the diagnostic accuracy of the clinical examination for causes of back and referred pain.
  3. Provide the framework for evidence based-clinical reasoning as it applies to diagnosis of low back disorders. This includes the basis for “diagnosis by subtraction”.
  4. Provide up-to-date, evidence-based diagnosis of discogenic, radicular, facetogenic, sacroiliac joint and other patho-anatomic pain syndromes.
  5. Provide a standardized patient history protocol that supports clinical reasoning to a diagnosis and to patient management.
  6. Provide simple methods of identifying important factors that confound both diagnosis and treatment, such as neuropathic pain, central sensitisation and illness behaviours.
  7. Practice performance of key examination tests for nerve root compression and sacroiliac joint pain.

Programme Structure

Introductory Lessons & Activities Course

The first course in this program of instruction eases you into the online learning environment with videos on  first activities that you need to complete: like downloading the course manual template, introducing yourself to the Course Forum, and downloading the PDFs of the first reading list.

There are three formal lessons that are essential in understanding the concept of diagnostic triage that is a central part of basic guideline management. The lessons are:

  • Pain drawings and their interpretation
  • Red Flag identification and what these mean
  • The basic neurologic screening examination that is a key part of the physical examination for all patients with back and referral of symptoms into the lower limb

There are two videos to watch. These are of a real patient with persistent low back pain. The first provides detail of the history taking process, and the second is the standard physical examination used throughout this program of instruction.

At the end there is a quiz to test your understanding of the material.

*Compulsory first course 

Study time: 6 hrs (approx.)

Principles of Clinical Diagnosis Course

The second course in this instructional program gets into the nitty-gritty of diagnostic methodology within the clinic on the real patients we see every day. The focus here is on clinical diagnosis. That is, the diagnosis one can achieve in the clinic using the history and physical examination, and highly selective use of technology.

There are three formal lessons to complete. The lessons are:

  • Sources and causes of Low Back and Referred Lower Limb pain. This is a basic overview of known painful patho-anatomical categories of conditions. Basic knowledge is assumed of course but the idea is to provide a summary of basic categories for context and content needed for the next two lessons
  • The second lesson is Part 1 of the lesson on Diagnosis by Subtraction. Diagnosis by subtraction draws on the concepts of specificity & sensitivity to rule in and rule out different diagnostic categories.
  • The third lesson is Part 2 of the lesson on Diagnosis by subtraction. In this lesson you will see how expert clinicians reduce the pool of possible diagnostic conclusions to one, or a small number of diagnostic possibilities, so that treatment can be initiated or further diagnostic investigation planned.

There is one case study video to watch. This shows the centralization of pain graphically which is important, since centralisers are the largest subgroup within the back pain population.

You will also download the case notes of the patient seen in the introductory course and be encouraged to self test your own clinical reasoning skills using the details of this case and the learning from the three lectures on the principles of clinical diagnosis.

There is only one paper to download and read, and that is the 2017 paper of Petersen, Laslett & Juhl on the systematic reviews we carried out on the latest evidence on diagnosis and classification. You will need to read this thoroughly, because the course quiz will focus on that strongly.

At the end there is a quiz to test your understanding of the material.

Also you will be able to download the PDF forms I have used for clinical records. This documentation may be of use, or may not, but does give you a good idea of the sort of questionnaires I have patients complete, and notes I keep for all cases presenting in the clinic.

*Prerequisite - First Activities and Introduction

Study time: 4 hrs (approx.)

Radicular Syndrome

The third course in this program looks at radicular syndrome, that is, pain arising from irritation and/or compression of nerve roots, the dorsal root ganglion and dura mater.

This is the one condition that international guidelines agree may be diagnosed with some confidence using the history and physical examination. This perspective is a surgical one dating and unchanged from the 1980s. This is an outdated view in my opinion, and you will see as the program develops that we can do much better, given current evidence. However, for now, you must be thoroughly familiar with the standard orthopaedic perspective on radicular syndrome, the terms and concepts that are accepted internationally and the evidence supporting diagnosis, conservative care and surgical intervention.

There are four formal lessons to complete. The lessons are:

  • Introductory concepts of radicular syndrome. Here the distinctions between radicular syndrome, radicular pain and radiculopathy, are clarified using definitions and taxonomy from the international Association for the Study of Pain. The patho-anatomy and physiology of nerve root pain and impairment are covered also.
  • The second lesson looks specifically at disc herniation as the single biggest cause of radicular syndrome
  • The third lesson looks at discectomy, the indications for, and alternatives to discectomy. We look at complications following discectomy also.\
  • The fourth lesson looks at the adherent nerve root. This condition and its treatment was first described by Robin McKenzie. It is probably equivalent to the MRI finding of epidural scarring and occurs in adolescents who develop root compression from disc herniation, and following discectomy

There are three videos to watch. 

  • The first is rare footage from the estate of Dr Stephen Kuslich who reported on the many hundreds of cases he operated on under progressive local anaesthesia on conscious patients. Very important work and fascinating. 
  • The second video is a short video from Rob PT via Utube, on treatment options for adherent nerve root. 
  • The third video shows a rare case where a neurologic deficit is to seen come and go depending on load.

You will also download published guidelines which are an example of accepted international standards for diagnosis and treatment of radicular syndrome.

There is a significant reading list and a quiz to test your understanding.

This is the last of the compulsory courses and completes the realm of what is known as diagnostic triage. The next course you do is entirely up to you. However, regardless of your prior experience, I strongly recommend that the next course you do is the one on mechanical discogenic pain. This course covers the single largest subgroup of the back pain population. That is, those having rapidly reversible and repeatable pain patterns and behaviours. There are several case study videos of the management of cases with acute and persistent deformities.

*Prerequisite - Principles of Clinical Diagnosis.

Study time: 6 hrs (approx.)

Mechanical Discogenic Pain

This course looks at the largest patho-anatomical subgroup in the back pain spectrum. These are patients whose symptoms can be made to centralise, and/or display a repeatable and reversible directional preference when examined using a standardized repeated movement assessment.

The fact that mechanical loading in one direction decreases or centralizes pain, and the opposite direction has the opposite effect, and that this behaviour is both repeatable and rapidly reversible, is what gives rise to the labelling of this group of patients as having mechanical pain.

We know from our own diagnostic accuracy research that only patients with confirmed discogenic pain behave in this way. That is, almost all cases who are categorized as centralisers or show a directional preference will have positive provocation discography, which is the accepted reference standard for discogenic pain.

There are four formal lessons in this course:

  • Lesson one explores the biomechanics and patho-anatomy of the intervertebral disc as a baseline of understanding how it might be, that symptoms can be made to demonstrate this peculiar reversible and repeatable directional preference phenomenon.
  • Lesson 2 looks at the evidence and opinion regarding mechanical discogenic pain and how centralization has been observed and studied over the decades
  • Lesson 3 looks at case studies, mostly drawn from our own diagnostic accuracy research. Here we can see that not all discogenic pain cases centralize, and that discogenic pain is a broad category of painful patho-anatomy, with distinct subgroups of its own
  • Lesson 4 looks at the acquired deformities as distinct from the developmental ones like idiopathic scoliosis. Hypotheses and explanations for the lateral shift, acute lumbar kyphosis and acute fixed lordosis are discussed.
  • There is a 5th lecture which looks specifically at the diagnostic accuracy of directional preference, as distinct from centralization. This is not published in a journal, but was presented to a conference and revised to be put in the public domain.

There are several case study videos of management of the acute lateral shift, the acute kyphosis and acute fixed lumbar lordosis. There is one video of a fixed lumbar lordosis in a patient with more than 10 years of daily severe pain, that was rapidly reversible. He is being followed up still.

There is a quiz to complete so that you may test your understanding of this material.

*Prerequisite - First Activities and Introduction Course, Principles of Clinical Diagnosis Course and Radicular Syndrome Course.

Study time: 12 hrs (approx.)

Other Anterior column conditions

This course investigates the non-mechanical causes of pain arising from the anterior column. The anterior column refers to all structures anterior to the spinal canal, such as the intervertebral disc, the vertebral endplates and the vertebral body. Understanding these potential causes of pain and being able to identify them in the clinic, depends to a large extent on the material in the course on mechanical discogenic pain. Somewhere between 25 and 75% of anterior column pain cases will be classified as mechanical based on the repeated movement assessment, so it is important that you are familiar with that clinical procedure. Do that course first if you are not confident with the procedure of the repeated movement assessment and the interpretation of patient responses.

Prior to research published in the 2000s, most anterior column pain was referred to as simply internal disc disruption, to distinguish these cases from those with disc protrusions and herniations causing radicular syndrome. These were the cases that were positive to controlled provocation discography. And of course there are those cases with high tech imaging evidence of overt discitis, osteomyelitis, fracture or neoplastic disease affecting the vertebral body. This course addresses those cases that are non-centralisers and show no evidence of repeatable, and rapidly reversible directional preference.

There are two main lessons in this course that refer specifically to anterior column infection

  • The first lesson looks at overt and aggressive anterior column infections presenting as discitis or osteomyelitis. These are often identified by the presence of red flags, but not always. It is important to remain aware that serious medical conditions do slip through the red flag screen. The case studies are those that I have seen myself in recent years.
  • The second lesson looks at the MRI finding of endplate changes referred to as Modic changes. Modic changes may be caused by a low grade, low virulence infection as proposed by Hanne Albert and co-workers, or may be non-responsive to a long course of antibiotics, which means that we simply don’t know whether this is a resistant infection or whether the Modic changes have some other cause. Of course, it must be noted that not all cases with Modic changes are symptomatic.
  • There is a third lesson that has a quite different focus. This topic is dear to my heart and concerns the sudden onset severe low back pain case that presents to the Emergency Department. A significant proportion of these cases do not have acute disc prolapses, fractures or infections, but have acute anterior column disorders that present with sudden onset deformities or annular tears. Best management of these cases involves the material from the course on mechanical discogenic pain.\

There are three case study videos in this course. 

  • One presents with concerns about possible cauda equina symptoms. 
  • There is a case study of management of an acute lateral shift where various management techniques are used that were not seen in the case study seen is the mechanical discogenic pain course. 
  • There is another case study of anterior column pathology in a young man that is not reversible.
  • There is a video of my colleague Dr Charles Aprill discussing provocation discography and demonstrating the technique at three levels in the lumbar spine. 
  • There is a short video demonstrating the movement of disc material during flexion and extension over a variety of age groups using cadaver specimens.

There is a quiz to test your understanding of the material.

*Prerequisite - First Activities and Introduction Course, Principles of Clinical Diagnosis Course and Radicular Syndrome Course.

 Study time: 5 hrs (approx.)

Sacroiliac Joint and PGP Course

This course focuses on pain arising from the sacroiliac region rather than the lumbar spine. Another term in common usage is pelvic girdle pain or PGP. PGP refers to the symptoms, whereas sacroiliac joint pain refers to pain whose nociceptive source is the sacroiliac joint. The great majority of patients classified as PGP have a sacroiliac joint source of pain. Lumbosacral pain and sacroiliac joint pain are often similar in location and behave in ways that are very similar.

This course focuses on the diagnosis of intra-articular sacroiliac pain and makes a clear distinction between that, and the concept of sacroiliac joint dysfunction. The two terms should never be used interchangeably at all. Sacroiliac joint pain is a verifiable and testable phenomenon that patients report, whereas sacroiliac joint dysfunction is an hypothesis regarding altered or pathological function regarding movement or position. Sacroiliac joint dysfunction is an unreliable and outdated diagnosis that has no place in modern musculoskeletal medicine. Intra-articular sacroiliac joint pain is a real issue that can be diagnosed clinically, and using controlled anaesthetic blocks. Sacroiliac joint pain may affect people of all ages, but is most common among women during and after pregnancy, young males and females affected by spondyloarthropathy, and those people suffering significant pelvic trauma.

There are two lessons in the course. 

  • The first looks at the anatomy and biomechanics of the pelvis and sacroiliac joint to provide a solid understanding of movement, stability and the concepts of  form and force closure.
  • The second lesson looks specifically at sacroiliac joint pain, how the clinical assessment is used to make the diagnosis, and how that compares to the reference standard of guided single and controlled intra-articular blocks. The published evidence underpinning this assessment is covered in detail.

There are several case study videos

  • A full assessment of a young woman with spondyloarthropathy. 
  • The sacroiliac joint tests are described and shown in considerable detail so the variations in the direction and amount of pressure used is clear. 
  • There is a link to a public domain lecture on the SIJ that is worth watching as well.

There is a significant reading list and a quiz to test your understanding of the material.

*Prerequisites - First Activities and Introduction Course, Principles of Clinical Diagnosis Course and Radicular Syndrome Course.

Study time: 4hrs (approx.)

The Posterior Column Course

This course looks at those structures posterior to the vertebral body which includes the posterior column and spinal canal. I have included coverage of spinal stenosis in this course because patients with either symptomatic or asymptomatic spinal stenosis, often have symptomatic facet joint disorders concurrently. Separating these two issues requires some careful reasoning. The concepts of spinal stability and instability are included in this course too, because the facet joints and posterior column are key determinants in maintaining structural integrity and stability. The diagnoses of spondylolysis and spondylolisthesis are intertwined with discussion of the idea of spinal instability. Management strategies for these usually involve exercise therapies that, for better or worse, revolve around the notions or core strength and stability.

There are four formal lessons in this course.

  • The first covers the diagnosis of pain arising from the zygapophyseal, that is, the facet joint.
  • The second investigates spondylolysis and spondylolisthesis
  • The third reviews symptomatic and asymptomatic spinal stenosis
  • And the fourth looks at the notion of lumbar spinal instability

There are cases studies in the lessons and two full video case studies of patients with the clinical diagnosis of facet joint pain.

There is a significant reading list. You will be required to read fully, one of our own papers on the diagnostic accuracy of the clinical assessment in relation to diagnostic blocks of the facet joints. This is a complex paper that brings together many features of the different dimension of diagnostic accuracy research, compared to research into outcomes and therapeutic efficiency.

There are quizzes for each topic in this course to test your understanding of the material.

*Prerequisites - First Activities and Introduction Course, Principles of Clinical Diagnosis Course and Radicular Syndrome Course.

Study time: 4hrs (approx.)

Confounders & Masqueraders

This course looks at two aspects of the back pain complexity. The first consideration is simply that back pain, leg pain and pelvic girdle pain are symptoms, not diagnoses. At best, they are the categories of symptom location. Back and leg pain may not arise from the lumbar spine or pelvis at all, and may be caused by some other condition that just refers pain in ways that masquerade as pain arising from spinal structures. This course looks at some of these. In particular, there is peripheral vascular disease affecting the proximal vessels that can look a lot like spinal stenosis. This is usually easy enough to tease out, but that requires a particular assessment and reasoning process.

Then there are the conditions affecting the hip and deep structures of the buttock, like gluteal tendinopathy or bursitis. These may produce symptoms that look a lot like pain referred from the lumbar spine. They too can be teased out from spinal problems with reasonable ease.

The second aspect of this course looks at confounders, rather than masqueraders. By this I mean, those non-nociceptive neurogenic and central nervous system activities, that seem to lower the threshold of pain perception to the point where the clinical picture is confused by hypersensitivity. Pain intensity seems quite disproportionate to any nociception – that’s if nociception is even still present. In patients with persistent pain, sensitization and neuropathic pain are often all mixed up with psycho-emotional distress and nociception. These complex cases can be hard to sort out. Determining what is nociceptive, neurogenic, psycho-emotional distress or cognitive error, is not an exact science by any means, and this course does not present all the relevant dimensions of this issue. That is a course on its own and I am not the best person to teach that. However, we do acknowledge the problem and offer a simple overview to make it clear, that in patients with persistent pain, diagnosis and management must be considered a bio-psycho-social program.

This course has 3 formal lessons:

  • Peripheral Vascular disease and Leriche Syndrome masquerading as spinal stenosis
  • Hip and buttock conditions that mimic pain referral from the spine
  • Central sensitization, neuropathic pain, the psychosocial dimension and Yellow Flags

Professor Tamar Pincus has an excellent series of short videos on the psychology of pain that are in the public domain. This is an outstanding resource and this course offers a link to one of these that I consider to be superb.

As this course is concerned with complex cases, there are several videoed case studies of patients I have seen in recent years. 

  • There is one case of Leriche syndrome that was one of the clearest instances of peripheral vascular disease being managed unsuccessfully as a musculoskeletal problem. The disabling pain was rapidly and completely resolved with angioplasty once the correct diagnosis was made.
  • There is a case where I could not decide whether the patient had spinal stenosis or peripheral vascular disease. In fact that patient had something else entirely, and I missed the diagnosis. 
  • There is another complex case where I still don’t know whether the patient has spinal stenosis or peripheral vascular disease.

*Prerequisites - First Activities and Introduction Course, Principles of Clinical Diagnosis Course and Radicular Syndrome Course.

 Study time: 4hrs (approx.)

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Dr Mark Laslett

After graduation as a physiotherapist in 1971, Mark owned and operated his own private practices in Auckland from 1972-2001, including a specialist Spine Care Clinic (1991-1997). He completed the Diploma in Manipulative Therapy in 1976 and the Diploma in Mechanical Diagnosis and Therapy in 1991. Mark moved to Christchurch in 2005 and has practiced as an independent musculoskeletal consultant for PhysioSouth Ltd since then. Mark was a manipulative therapy instructor for the spine and upper and lower extremities for the NZ Manipulative Therapists Association 1980-1988 and was president 1988-89. He commenced teaching mobilization and manipulation workshops for the McKenzie Institute International as an international instructor in 1985 and added his own courses on the upper and lower extremities in 1990. Mark ceased active involvement in the McKenzie Institute in 1997. He has presented about 250 short courses in Scandinavia, Europe, North America and Australasia, and has presented at many international conferences with free papers and as keynote presenter. Most recently in 2013 he has completed a teaching tour of courses and conferences that included presentations in Finland, Germany, The Netherlands, Denmark, France and the USA. His academic and research interest is in the theory and practice of diagnostics as distinct from therapeutics. He has over 40 publications, contributed chapters to two multi-author books and published his own text Mechanical Diagnosis and Therapy: The Upper Limb in 1996. See Reference List at end of this brief biography. Mark commenced doctoral studies at the University of Linköping, Sweden in 2001, successfully defending his thesis “Diagnostic accuracy of the clinical examination compared to available reference standards in chronic low back pain patients” in 2005. He became a Fellow of the New Zealand College of Physiotherapy in 2007 and served as a member of its Academic Board 2008-2014. He was a senior Research Fellow for AUT University from 2008-2012 supervising doctoral and Master’s research projects. He became the first physiotherapist to be registered as a clinical specialist in February 2014. Mark was made an honorary Life Member of Physiotherapy New Zealand in September 2014, and of the New Zealand Manipulative Physiotherapists Association in 2015. He continues to practice as a consultant clinician and remains active in clinical research. Main areas of Interest Painful musculoskeletal disorders of the spine and extremities with special emphasis on persistent low back, neck and shoulder pain. Musculoskeletal diagnostics (as distinct from therapeutics) remains an ongoing research interest. He is currently working with Dr Tom Petersen of Copenhagen on updating their lumbar spine classification system (2003) and with Dr Arianne Verhagen of Erasmus University in updating the systematic review of tests for lumbar radiculopathy. He is currently adjunct research fellow at AUT University on the basis of supervising a doctoral candidate whose research is based on the diagnostic accuracy of the clinical examination of the hip.