The most important stage in diagnosis is the first stage – screen for pathologies, and put safety first. The AXB chatbot does this by using the Red Flag questions referred to in the main course.
Red Flag questions are questions we ask clients in order to determine whether they need medical assessment or not.
Basically there are only 3 broad categories of lower back pain (LBP):
- Pathological – where there is an underlying disease process. These make up less than 1%. This is what the Red Flag questions are screening for.
- Disc/nerve related – most of which result in radiating pain into the leg (although non-disc/non-nerve problems can also cause leg pain). These make up around 10-15% (the pain may or may not be in the sciatic distribution)
- Non-specific LBP – these make up around 85-90%. As you will see in the next lesson, we further split this category by using a Functional Assessment.
More on the types of LBP in this episode of the AXB podcast:
Interestingly, the idea of further diagnosing non-specific lower back pain by using the “tissue causing symptoms” approach has little value.
What I mean by that, is that giving clients a tissue-based diagnosis like “You’ve strained a ligament / pulled a muscle / slipped a disc” is unhelpful at best, and damaging at worst.
The review by Eyal Lederman of the “Fall of The Postural Structural Biomechanical Model” is a good place to start if this is a surprise to you. (You can probably stop there too as it’s pretty comprehensive). If this is a huge surprise to you, and undermines your whole approach to manual therapy, DON’T WORRY. There is still plenty of evidence that manual therapy is helpful. But it just doesn’t work the way you thought it works. As an aside, I had a clinical tutor when I was an osteopathic student – Dr Peter Randall. He was an unusual combination of osteopath and clinical psychologist. He used to unsettle the students by constantly telling us “Remember, many of your patients will get better… Despite what you do to them.” Annoying but almost certainly true. I know you like to feel confident in what you do with clients. And this course will help you gain a lot of confidence in knowing that you are applying best-practice. It will uncover some deficiencies too, but that’s how we improve isn’t it? Finding out things that we didn’t know. There are almost certainly a huge number of things that the clinical community does now that will subsequently be proven to be unhelpful – we just don’t know which ones yet.
Coming back to providing a structural diagnosis, here are some of the disadvantages:
- MRI and XRay findings are very poorly correlated with symptoms
- There is very little agreement between clinicians in making diagnoses
- It disempowers the client and makes them dependent on the therapist to fix them
- All of this leads to greater anxiety, which is very bad for pain, and fear of movement
- Which is equally bad for recovery
Listen to the AXB podcast episode “Why does the bone-out theory refuse to go away?”
The Benefits of a Functional Assessment:
- Doesn’t create the same fear as a mechanical/structural diagnosis
- Empowers the client by indicating the movements they can and should do
- Informs which exercises are likely to relieve their pain
- Informs which daily habits and movements they need to work on adapting, stabilising, and then strengthening
Most importantly for you, it tells you – their clinician – which movements to avoid or adapt in the short-term and what needs to be worked on in the long-term. You’ll find more details on this in the main course.
How do you differentiate the types of lower back pain and sciatica based on function?
Use a Functional Assessment as referred to in Lesson 10 of the main course.
| Flexion Intolerant | Extension Intolerant |
| Worse when sitting | Worse when standing |
| Worse bending forwards | Worse bending backwards |
| Worse getting up from sitting |
In our clinic, which has seen thousands of lower back pain and sciatica sufferers, our audit revealed that of the last 1200 patients, 72% of them were flexion intolerant. 12% were extension intolerant, 10% were both and 6% were neither.
What does this mean? If you are flexion intolerant, your lower back doesn’t like bending forwards. How do we know this? Because you experience more pain when or after bending forwards, and/or sitting.
If you are extension intolerant, your back doesn’t like bending backwards, which often happens when you’ve been standing for a while.
Some people are flexion AND extension intolerant, and some people don ‘t seem to be affected by either of these movements. Someone may have flexion intolerant lower back pain (lumbago on the AXB naming system) AND extension intolerant sciatica. This is a tricky combination when it comes to rehabilitation – but one you’ll cope with just fine when you have all the knowledge and tools from the main course.
So the AXB free assessment determines which group the client is in. If you know your back is worse when you sit or try to get your socks on in the morning, then you’re flexion intolerant.
If your pain is worse when you stand for a while, or reach up to high shelves, then you’re extension intolerant.
You may be both, and you may be neither.
We include more than flexion/extension intolerance in our functional assessment, but this element is arguably the most important when informing the relief stage.
