The prevalence of serious pathology in musculoskeletal physiotherapy patients - a nationwide register-based cohort study

Association between chiropractic spinal manipulation and cauda equina syndrome in adults with low back pain: Retrospective cohort study of US academic health centers

BACKGROUND

Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period.

METHODS

A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES.

RESULTS

67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up.

CONCLUSIONS

These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.

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.

The Ability of Austrian Qualified Physiotherapists to Make Accurate Keep-Refer Decisions and to Detect Serious Pathologies Based on Clinical Vignettes: Protocol for a Cross-sectional Web-Based Survey

BACKGROUND

The recognition of serious pathologies affecting the musculoskeletal (MSK) system, especially in the early stage of a disease, is an important but challenging task. The prevalence of such serious pathologies is currently low. However, in our progressing aging population, it is anticipated that serious pathologies affecting the MSK system will be on the rise. Physiotherapists, as part of a wider health care team, can play a valuable role in the recognition of serious pathologies. It is at present unknown how accurately Austrian qualified physiotherapists can detect the presence of serious pathologies affecting the MSK system and therefore determine whether physiotherapy management is indicated (keep patients) or not (refer patients to a medical doctor).

OBJECTIVE

We will explore the current ability of Austrian qualified physiotherapists to recognize serious pathologies by using validated clinical vignettes.

METHODS

As part of an electronic web-based survey, these vignettes will be distributed among a convenience sample of qualified Austrian physiotherapists working in a hospital or private setting. The survey will consist of four sections: (1) demographics and general information, (2) the clinical vignettes, (3) questions concerning the clinical vignettes, and (4) self-perceived knowledge gaps and learning preferences from the perspective of study participants. Results will further be used for (1) international comparison with similar studies from the existing literature and (2) gaining insight into the participants' self-perceived knowledge gaps and learning preferences for increasing their knowledge level about keep-refer decision-making and detecting serious pathologies.

RESULTS

Data collection took place between May 2022 and June 2022. As of June 2022, a total of 479 Austrian physiotherapists completed the survey. Data analysis has started, and we aim to publish the results in 2023.

CONCLUSIONS

The results of this survey will provide insights into the ability of Austrian physiotherapists to make accurate keep-refer decisions and to recognize the presence of serious pathologies using clinical vignettes. The results of this survey are expected to serve as a basis for future training in this area.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43028.

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.

Aggressive Vertebral Hemangioma and Spinal Cord Compression: A Particular Direct Access Case of Low Back Pain to Be Managed-A Case Report

Hemangiomas are the most common benign tumours affecting the spine, with an incidence of 10-12% of the general population. Although most hemangiomas are asymptomatic, there are aggressive forms which can develop symptoms, leading patients to show signs of disability. This case report aims to highlight the importance of red flags screening, and to report the physiotherapist's clinical reasoning that led him to refer his patient to other healthcare professionals. This case also illustrated the pre- and post-surgical treatment of a specific low back pain case in a patient affected by aggressive vertebral hemangioma and spinal cord compression. The patient is a 52-year-old man, who reported intense pain in his sacral region about three months prior, which worsened while in sitting position. The physiotherapist proceeded with a complete medical history investigation and clinical examination. After an impaired neurological examination, the patient was referred to another health professional, who diagnosed multiple vertebral hemangiomas in the patient's lumbosacral tract. The therapeutic intervention included the patient's post-surgical rehabilitation following a vascular embolization. This case report shows the importance of proper patient screening. Indeed, during patients' assessment, it is paramount to recognize red flags and to investigate them appropriately. An early referral of patients with conditions that require the support and expertise of other professionals can lead to a timely diagnosis and avoid costly and unnecessary rehabilitation procedures. In this case, the interdisciplinary collaboration between physiotherapist and neurosurgeon was crucial in guiding the patient towards recovery.

Defensive medicine: A symptom of uncertainty?

Defensive medicine is a well-documented phenomenon and refers to the practice of over-cautious management of patients, leading to excessive clinical activity such as over-investigation, unnecessary appointments and additional interventions. Adopting this approach is not in the best interest of patients and can lead to clinical reasoning being replaced by lists, guidelines and algorithms which do not consider the complexity of a patients presentation or the reasoning inherent in good clinical judgement. The drivers of defensive medicine are varied and include a high level of uncertainty alongside other factors including clinical experience with past cases, system pressures and patient expectations. This paper explores these drivers and considers strategies on how best to avoid a defensive medicine approach. It reinforces the need to adopt a patient centred focus and use sound clinical reasoning to support the management of patients.

Red flags for spinal pain in patients diagnosed with spinal infection in Nigeria: A 10-year medical records review

BACKGROUND

Spinal infection is a diagnostic challenge, the personal and economic consequences of misdiagnosis can be significant resulting in paralysis and instability of the spine and can ultimately be fatal. To aid identification of those at risk of spinal infection, a better understanding of the red flags for spinal infection is needed.

OBJECTIVE

To better understand which red flags may help to identify spinal infection.

DESIGN

and Methods: A 10-year medical records review of red flags for spinal infection in Nigeria, using a bespoke data extraction tool. Univariable and multivariable logistic regression was used to identify the main independent predictors of spinal pain.

RESULTS

124,913 records were reviewed, 1,645 patients were diagnosed with spinal infection. 79% of patients presented with spinal pain Univariable analysis revealed nine factors (some centres, all age groups above 16 years, co-morbidities, environmental factors, history of TB, radicular pain, pins and needles, numbness and spine tenderness.) were associated with greater odds (OR = 1.77-21.7, p < 0.001), whilst four (some centres, fatigue, fever and myotomal weakness) were associated with lower odds (OR = 0.51-0.59) of spine pain. Six factors were included in the final multivariable model associated with higher odds of spine pain: age groups above 16 years (OR 2.57 to 5.33, p < 0.05), co-morbidity (OR = 1.68, p < 0.05), history of TB (OR = 3.02, p < 0.05), weight loss (OR = 1.75, p < 0.01), radicular pain (OR = 19.88, p < 0.001); spine tenderness (OR = 6.54, p < 0.001). Myotomal weakness (OR = 0.66, p < 0.05) and fatigue (OR = 0.50, p < 0.01) were associated with lower odds of spinal pain in the final model.

CONCLUSION

Using data from ten hospitals in Nigeria within a ten-year period, we have produced a shortlist of red flags that can inform clinical decision making about potential spinal infection.

Medico-legal litigation of UK physiotherapists in relation to cauda equina syndrome: a multimethods study

OBJECTIVE

The aim was to investigate the extent of cauda equina syndrome (CES) litigation and explore the process of medico-legal litigation in relation to physiotherapy in the UK.

DESIGN

A multimethods inquiry that followed on from a previously conducted scoping literature review was undertaken to address the aim. This included freedom of information requests and direct communication with relevant stakeholders and organisations.

RESULTS

A total of 2496 CES claims were found in the UK between 2012 and 2020. 51 of these were attributed to physiotherapists. There was little information available to physiotherapists regarding the legal process of litigation and much of this information was not from a physiotherapist's perspective.

CONCLUSION

This is the first study that has investigated the extent and process of CES litigation in physiotherapy in the UK. The extent of CES litigation appears to be high considering CES is a rare spinal condition. Furthermore, the extent of CES litigation is suspected to be considerably higher than the data reported in this study due to the issues identified in how CES claims are recorded. Finally, there is no clearly articulated, easily accessible information describing the process and support available for physiotherapists in receipt of a legal claim.