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
  • 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.

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.

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.

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.

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.

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.