In this episode I will be going over some common musculoskeletal lower back pain diagnoses.

If you have not listened to my episode on how I diagnose then please listen to it first before listening to this one. You can find it here.

By the end of this episode, you will learn about the 5 most common lower back pain complaints and some simple, quick and easy things to try to alleviate any discomfort (although this is not the main focus of this podcast).

Specifics on how to diagnose each one will feature in another episode. It is also important to note that there is not usually one single cause of back pain. I have laid out 5 separate diagnoses for the sake of simplicity, in reality, there are two or more of these at play with mechanical bak pain. Think of these as the main culprits in their presentations.

As always, the first step is to rule out any red flags. This process starts with the first contact you have with the patient (usually by phone when they book an appointment). For example, it typically takes less than 30 seconds to ask the basic cauda equine questions over the phone (not difficult!). Just for perspective, 99% of back pain will be musculoskeletal in origin with 1% being pathological. Don’t get caught out in that 1% bracket!

Lower back pain is a very common occurrence and can happen at any age. It tends to manifest in relation to one or more key factors:

• Birth defects - spina bifida, narrow spinal canal etc
• Injury - lifting with poor form, traffic accidents, falling over etc
• Psychosocial reasons - depression, stress, divorce etc
• Built up gradually over time (i.e. degenerative/wear and tear) - osteoarthritis, degenerative disk disease etc
• Recurrent cycles of lower back pain - poor conditioning/tone use of the body, poor physical health etc
• Systemic issues - aortic aneurism, kidney stones etc
• Disease process - autoimmune conditions such as AS, cancer, endometriosis, infection etc
• Environmental factors - pollution, humidity etc
• Lifestyle - diet, smoking, alcohol, IV drugs etc
• ‘Idiopathic’ (i.e. no known cause)
• Iatrogenic - due to medical error
• Referred pain from another structure

As a bonus point, see if you can spot the red flags in these categories (remember, we are talking in the context of mechanical lower back pain).

So, the 6 most common diagnoses for lower back pain are as follows:

• Disk herniation/discogenic pain - There are two common scenarios here. The first one is where the disk bulges to one side, pressing on nearby nerves and thereby provoking pain down the leg (in worst-case scenarios, you can have a central herniation whereby the disk can bulge toward your spinal column). The second is disk irritation without bulging, which would lead to back pain only if there is no substantial inflammation (some structures can refer pain to the buttock area). With this presentation, you would have morning stiffness/pain, find it difficult to put socks and shoes on, and find it hard to sit for prolonged periods of time. If you have irritated the nerves, you might also feel pins and needles, sharp shooting pains, numbness or a feeling that your leg might give way. The good news is that most disk-related issues heal on their own within 4-8 weeks depending on the severity, your metabolic and psychosocial health.

In the previous episode, I spoke about my framework for diagnosis and why it is so critically important to have this framework in place no matter what the presenting complaint is. I appreciate that this may have been too complex or difficult to digest from a patient's perspective, or maybe even not useful at all! Thus in this second episode, I want to create a helpful guide on what to expect and how to navigate the world of healthcare professionals from the patient’s perspective.

Maybe you have hurt your back and don’t know whether you should see an osteopath or chiropractor? Maybe you have already been in the healthcare system for years chasing scan after scan with no firm diagnosis or way forward? It is exactly these issues that I want to address and hopefully make your lives that little bit easier. A lot of these issues arise due to poor clinical practice can be offset if you know what to ask, say or expect.

The first (and arguably most important) phenomenon to understand is the landscape of allopathic medicine and what it is. What I mean by this, is that we need to understand what health issues we have in our modern society and if the system that exists can actually deal with these issues in the first place.

The short answer is that it, by definition, CANNOT.

We live in a pandemic of CHRONIC disease. The allopathic model (i.e. modern medicine as you know it) is good for dealing with ACUTE care issues, such as strokes, car accidents, fractures and so on. Not chronic issues such as the ones that currently plague the world.

Aside from this, allopathic medicine focuses on treating symptoms. Not root causes. Fixing a symptom will NEVER fix a disease process or any other health related complaints. In order to heal and get better, one needs to address the underlying reasons for that symptom expression. Let me explain this further by giving a brief meta level overview on how our bodies breakdown when chronically stressed (by stress I am talking about total allostatic load on the body).

We have multiple systems in our bodies such as the cardiovascular, respiratory and gastroenterological systems just to name a few. When these systems become dysfunctional, disturbed or start to change in anyway, they will create signs or symptoms that we may or may not notice through changes in the physiology that underlies these systems (i.e chronically increased blood sugar damages nerves over time, damaged neves exhibit neurological symptoms such as numbness pins and needles, weakness and so on). The signs or symptoms we thus feel or see and go to the doctor with are the end expression of dysfunction in these systems that potentially started a long time ago. These are often not immediate, they often take a while to build up. Examples include the gradual increase in blood pressure due to smoking. Most of the time you do not know of feel when your blood pressure is high. Yet every second that it is too high, means increased pressure in our cardiovascular system that has the potential to predispose multiple conditions from strokes and heart attacks to - all without feeling a thing! If some of us do notice these subtle signs and symptoms, we often end up dismissing them due to getting older.

Lets start with the case history.

• Full case history - First job is to greet the patient, welcome them, explain the process and gain informed consent (this is a big topic that most therapists don’t understand in the slightest - I will do a separate video on this). Ask if they have any questions before starting (you can address nervousness, anger etc here before you start - very important) then start to rule out red flags and make sure your patient is appropriate for your scope of practice.

The first section in the case history is about their presenting complaint (i.e. what they came to see you for). There are many ways to do this section. You can ask a set number of questions that you should ask, or you can let the patient talk about what is wrong and you can note down the key parts of what they are saying. Both work, it just depends on your style and what type of patient you have in front of you (talkative, angry, sad etc). The questions you should ask relate to you trying to understand what is going on. These are:

1/ what, when and how did it happen

2/ how has it affected your day to day, is your function affected

3/ is it getting better or worse

4/ any neurological signs or symptoms

5/ any associated signs or symptoms

6/ quality and nature of the pain

7/ have you had this before

8/ better for, worse for factors

9/ Previous history of pain and interventions

10/ what are you expectations in coming to see us

11/ What are your concerns and beliefs about what has happened

12/ how bad is the pain on a 1-10 scale

13/ daily pattern

14/ occupation + hx

Next you have your medical health history. One needs to enquire about the following:

Smoking/drinking

Accidents

Illnesses

Surgeries

Investigations - BT CT MRI etc all of them

Medication

Family history

Nutrition/diet

Lifestyle

Exercise

Next is your systemic enquiry. These are specific questions related to various systems in the body (such as asking about dizziness and low blood pressure). General questions should be asked to all patients irrespective of their presenting complaint. More detailed and specific questions must be asked when you are clarifying the diagnosis or there are many things going on. For example, calf pain on walking up a hill can be a completely different diagnosis to calf pain when walking down a hill. You would use focused systemic questioning to figure out if there calf pain was vascular in nature or mechanical. Without looking for these risk factors, you cannot know which differential diagnosis to follow.

The categories are:

CVS

Resp

Endocrine

Gastro

Urogenital/gynae

Bowel/bladder

Psychosocial

Other that is relevant (headaches, constitutional symptoms, sleep, stress, vision, ears, energy, pregnancy/children, bruising, general well-being etc)

The last part (and one that is very important) is to ask the patient if they have any questions or anything else to say/add before moving on (you would be surprised as to how many times patients have said something very important at this stage that had the potential to change the entire course of action).

Next section is examination:

• Examination - first job is to explain what and why you are examining, the risks involved, alternatives available and subsequently gain informed consent. Your examination is used to confirm or reject your working diagnosis. This means that your testing has to be directly relevant to what you think may be going on with your patient. Not just testing random stuff. It is well known that if you have no idea wha