Physiotherapists' experiences of managing persons with suspected cauda equina syndrome: Overcoming the challenges

The experiences of uncertainty amongst musculoskeletal physiotherapists in first contact practitioner roles within primary care

AIM

The aim of this research was to explore the experiences of uncertainty amongst Musculoskeletal First Contact Practitioners working in primary care.

BACKGROUND

The Musculoskeletal First Contact Practitioner role involves advanced physiotherapists providing an alternative to the GP by acting as first point of contact for people presenting to primary care with musculoskeletal conditions. Limited research into the role exists but the first-contact aspect, clinical complexity and time pressures are deemed to contribute to uncertainty within the role.

METHOD

A qualitative research design was undertaken using a hermeneutic interpretative phenomenological approach. Data was collected using semi-structured interviews with subsequent thematic analysis of the data.

FINDINGS

Eight participants working as Musculoskeletal First Contact Practitioners across England were recruited using purposive sampling. Five themes were identified: (1) Role clarity within primary care, (2) Burden of responsibility, (3) Preparedness for the primary care environment, (4) 'I'm not really sure how long I am going to stay in this role', (5) Mitigating uncertainty.

CONCLUSION

This study demonstrates the multifaceted phenomenon of uncertainty amongst Musculoskeletal First Contact Practitioners. Uncertainty appeared to be influenced by the primary care environment, preparedness for the role and perceived burden of responsibility. Diagnostic uncertainty was prevalent with concerns of missing serious pathology evident. The impact of uncertainty on wellbeing was linked to possible burnout and retention issues. Consultation approaches, access to support networks and a cultural shift in tolerating uncertainty were reported to mitigate uncertainty. Further research into possible differences in experiences related to employment models appears warranted.

Cauda equina screening in Physiotherapy: A qualitative study of physiotherapists in a community musculoskeletal service: Are we asking the right questions and are we asking the questions right?

Cauda Equina Syndrome (CES) is a surgical emergency. With Physiotherapists increasingly taking on first-contact and spinal triage roles, screening for CES must be as thorough and effective as possible. This study explores whether Physiotherapists are asking the correct questions, in the correct way and investigates their experiences when screening for this serious condition. Thirty physiotherapists working in a community musculoskeletal service were purposively sampled and participated in semi-structured interviews. Data was transcribed and thematically analysed. All participants routinely asked bladder, bowel function and saddle anaesthesia screening questions although only 9 routinely asked about sexual function. Whether questions are asked in the correct way has never been studied. Sufficient depth of questioning, using lay terminology and explicit language was achieved by two-thirds of participants. Less than half of the participants framed the questions before asking them and only 5 participants combined all four dimensions. Whilst most clinicians felt comfortable asking general CES questions, half reported feeling uncomfortable when asking about sexual function. Issues around; gender, culture and language were also highlighted. Four main themes emerged from this study; i) Physiotherapists ask the right questions but frequently omit sexual function questions, ii) mostly, Physiotherapists ask CES questions in a way that patients understand however, there needs to be improvement in framing the context of the questions, iii) Physiotherapists generally feel comfortable with CES screening but there is some awkwardness surrounding discussion of sexual function and iv) Physiotherapists perceive there to be barriers to effective CES screening caused by culture and language.

A service evaluation of the management of patients with suspected cauda equina syndrome from an outpatient physiotherapy service in the United Kingdom

BACKGROUND

The expanding scope of physiotherapists worldwide has come with an increased responsibility to identify serious pathologies such as fracture, infection, tumour and cauda equina syndrome (CES). Guidelines recommend a low threshold for emergency MRI to avoid the potentially devastating consequences of CES, but a balanced approach is required to prevent excessive strain on emergency resources.

AIM

To evaluate the management of patients presenting to an outpatient physiotherapy service with suspected cauda equina syndrome.

DESIGN

Service evaluation with an embedded case series of patients with radiological CES.

METHOD

The records of patients who were identified by their outpatient physiotherapists as having suspected CES (n-231) over a 27-month period were included. Data was extracted from patients' medical records by a team of Advanced Clinical Practitioners (ACPs). The lead author further analysed the records of patients with clinical and radiological CES, in order to present the embedded case series.

RESULTS

In 79% of cases, it was decided that emergency referral was not required. The remaining 21% of patients were referred to the emergency department and 49% of these had an emergency MRI. In the case series of seven patients with cauda equina compression on MRI, four patients had a disc bulge and underwent emergency surgery. One patient had non-emergency surgery for a disc bulge combined with anterolisthesis and scoliosis. Two patients had stenosis and decided against surgical intervention.

CONCLUSIONS

Findings from this service evaluation suggest support for the use of safety netting and an effective communication chain to facilitate effective management of patients with suspected CES.