The Diagnosis of Persistent Low Back & Referred Lower Limb Pain Programme | Compulsory Course Package

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.)

*Prerequisite - Principles of Clinical Diagnosis