Confounders & Masqueraders Course

Confounders & Masqueraders Course

This course looks at two aspects of the back pain complexity.

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



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.)

Duration: 30 days
Price: NZ$98.00