Exploring physiotherapist’s ability to identify cauda equina syndrome early

Cauda Equina Syndrome (CES) is a rare and debilitating condition that commonly affects people with low back pain (LBP).¹ Cauda Equina Syndrome is a serious neurological disorder impacting the bundle of nerve roots of the distal end of the spinal cord, referred to as the cauda equina.² Moreover, CES requires urgent surgery to prevent potentially serious consequences, including bladder, bowel, and sexual dysfunctions; numbness; muscle weakness; and severe pain.^2,3 The CES can be caused by lumbar or sacral dysfunction owing to compression of the nerve roots or narrowing of the vertebral canals.⁴ Moreover, there are several other potential causes of CES, including discogenic injuries, tumors, infection, spondylolysis, spondylolisthesis.²

The CES can occur in individuals of all ages, but it is most commonly seen in adults between the ages of 30 and 60 years old.¹ Although CES is a very rare condition, primary care practitioners such as physiotherapists should consider it a possibility when examining and managing patients. Cauda Equina Syndrome is a critical condition that requires prompt identification and management to prevent long-term complications.⁵ When examining patients, it is important to remain vigilant regarding key symptoms such as bowel and bladder dysfunction, leg numbness, and weakness, as these could potentially indicate CES. However, diagnosing CES can be challenging owing to its rarity and symptom overlap with other conditions, such as other spinal pathologies, including lumbar disc herniation, spinal stenosis, or even infections. A previous meta-analysis found that timely surgery plays a critical role in achieving positive clinical outcomes for spine decompression procedures in patients with CES,⁶ highlighting the urgency of early identification and intervention in cases of suspected CES.

Physiotherapists may express uncertainty in identifying CES early, possibly due to a lack of advanced examination skills. As such, there is a need to enhance physiotherapists’ examination capabilities and ability to recognize CES at an early stage. One of the primary reasons contributing to delayed CES diagnosis is the absence of well-defined diagnostic criteria for primary care settings.⁷ However, useful facilitation safety assessment tools, such as toolkits and the cauda scale (TCS), are available to guide the management of patients with suspected CES.^8,9 For example, Greenhalgh et al⁸ developed a toolkit to facilitate the subjective examination of patients with LBP and decrease the risk of missed diagnosis. This toolkit can help healthcare professionals to identify the early warning signs and symptoms of CES, such as worsening LBP with or without progressive sensory-motor deficit in the lower limbs. This toolkit drew upon the lived experiences of individuals experiencing CES to inform on the content.⁸ According to Finucane et al,¹⁰ employing the toolkit for early identification of possible CES can help frontline practitioners to take timely clinical action.

In terms of early management of patients with suspected CES, positive signs and symptoms of CES based on clinical examination (for example, by a physiotherapist) should prompt an urgent referral for further investigations (for example, diagnostic imaging).¹¹ Further investigations could aid the clinical reasoning of the physiotherapist and prevent the consequences of CES if it is not picked up early enough.¹²

After searching the databases (Pubmed and Google Scholar) using a combination of keywords related to CES, early identification, and physiotherapy, we found only one research which was a qualitative study and aimed to investigate physiotherapists’ experiences for managing individuals with suspected CES.¹³ The study provides valuable insights into the challenges faced by physiotherapists in managing suspected cases of CES. However, the narrow focus on the experiences of a small sample of physiotherapists limits the ability to draw broader conclusions about the complex issues surrounding the diagnosis and treatment of this condition. The analysis lacks a critical examination of the study’s own methodological limitations and the need for further research to validate and expand upon the findings. A more comprehensive and balanced approach would strengthen the paper’s contribution to the field. Thus, the objectives of this study were twofold: (i) to explore the ability of physiotherapists to identify CES in a timely manner, and (ii) to identify the methods used by physiotherapists to manage patients with suspected CES.

Methods

Results

The total number of participants was 401 (mean age=29.51 (SD 5.54)). Among this cohort, 53.4% were female, 76.6% had a bachelor’s degree, and 42.2% had practiced for 1-5 years. The demographics of the study participants are shown in Table 1.

A statistically significant difference was found in educational qualifications across CES management ability levels (p=0.006). In the “Proficient” group, the majority held a bachelor’s degree as their highest level of education (63.5%), followed by those with a master’s degree (30.8%). However, having a bachelor’s degree as the highest level of education was more common when considering those with only “Good” (75.9%) or “Fair” (79.6%) ability.

Of the 401 physiotherapists, 52 (13.0%) were classified as having proficient ability, 203 (50.6%) as good, 108 (26.9%) as fair, and 38 (9.5%) as poor in identifying and managing CES early (Table 1). This distribution indicates that while most participants (63.6%) had proficient-good ability, a substantial proportion (36.4%) were categorized as having fair-poor ability.

Most participants (63.6%) had a proficient–good ability to identify and manage CES early, among whom most were female (55.7%), had a bachelor’s degree (73.3%), and had practiced between 1-5 years (38.8%). Participant demographics categorized by ‘proficient ability’, ‘good ability’, ‘fair ability’ and ‘poor ability’ are shown in Table 1.

In general, consensus for the CES statements was achieved for 8 (>67%) statements [numbers 1, 2, 3, 4, 5, 8, 9, 12] out of 12. Among these statements that showed consensus among the participants, most agreed that a patient was suspected of having CES when they exhibited urinary difficulties of neurogenic origin (including loss of desire to void, poor stream, needing to strain to empty their bladder, and loss of urinary sensation) (88.3%), and/or when they described their pain as radicular pain on both sides (bilateral radiculopathy, 85.5%). Moreover, most participants agreed that an MRI should be performed with extreme urgency when managing a patient with suspected CES (88.0%).

Conversely, consensus was not achieved for 4 (33%) statements [numbers 6, 7, 10, 11]. These statements revolved around communication with patients with suspected CES, the instructions given to those patients, and the appropriate management provided for patients with CES.

Discussion

Delayed diagnosis of CES can lead to serious complications in patients with suspected CES. However, some physiotherapists may find diagnosing patients with suspected CES challenging.¹³ This quantitative study aimed to explore the ability of physiotherapists to identify patients with suspected cauda equina syndrome early, and to identify the methods used by physiotherapists in the management of CES.

The results showed that the majority of physiotherapists have a proficient–good ability to identify and manage CES early. This is a promising discovery, indicating that a considerable proportion of physiotherapists are equipped with the knowledge and abilities required to detect and treat CES early.¹⁶ This may be explained by their education, background, or continued career advancement. Another finding is that female made up a somewhat higher proportion of physiotherapists with a “good ability” (53.7%). This encourages conducting additional research into aspects connected to gender, as some research has indicated that gender may have an impact on patient interactions and communication patterns, which could be important for diagnosing and treating medical illnesses.¹⁷

In this study, the importance of formal education is revealed by the fact that most physiotherapists (63.5%) who were classified as having a “proficient ability” held a bachelor’s degree. A bachelor’s degree provides students with critical thinking skills, problem-solving ability, and good communication approaches, which are crucial in the modern complex and evolving healthcare industry. Moreover, this study found that most physiotherapists who have been practicing for 1 to 5 years had a “proficient ability” to identify or manage CES early. This may suggest that this experience is critical for mastering the diagnosis and treatment of disorders such as CES.

In terms of evaluating patients with suspected CES, most participants agreed that an MRI should be requested with extreme urgency when managing patients with suspected CES, as MRI has high validity in detecting CES in patients displaying indicative signs and symptoms.^18-20 Additionally, most participants agreed that patients should be suspected of having CES when they present with urinary difficulties of neurogenic origin. The urinary problems, such as abnormalities in bladder function, are frequently regarded as a “red flag” symptom.^20-22 Urinary issues are a significant red flag in cases of CES, where the cauda equina nerve roots are compressed. In addition, the clinical expertise of physiotherapists is a major factor in the identification of clinical patterns. They might have been more aware of the symptoms, such as trouble urinating, after seeing patients with CES or disorders comparable to it over time.²³

One of the primary findings of this study was the lack of consensus among physiotherapists on the crucial information to communicate to patients. Additionally, the study revealed that physiotherapists often provide inappropriate instructions to those with suspected CES. To ensure safe management, it is vital that patients understand what symptoms to monitor for potential worsening. Prior research has suggested that enhancing patient-centered communication, collaborative decision-making, and a robust therapeutic relationship can improve communication. However, physiotherapists’ self-perceived deficits in clinical expertise may hinder the adoption of these strategies. The safety netting strategy is recommended for managing ambiguity related to serious pathology and should be utilized and implemented when working with patients suspected of having CES.^7,24 Furthermore, a previous investigation found that physiotherapists endorsed the use of this strategy.¹³

The findings of this study could help to reduce the risk of serious and long-term complications by highlighting the specializations and regions in which physiotherapists thrive and may benefit from focused interventions or training. Our study further sheds light on potential areas for further training, or resources which could help physiotherapists to improve their ability to recognize and manage patients with suspected CES in a timely manner. These results could thus help to shape continuing education programs for professional development, guaranteeing that physiotherapists are prepared to manage patients with intricate neurological disorders.

Better communication between physiotherapists and other medical specialists, including neurologists, neurosurgeons and orthopedic surgeons, is crucial to ensure the effective management of patients with CES. Such communication promotes a team-based method of patient care, particularly when a multidisciplinary effort is necessary. Early identification of CES by physiotherapists can help to improve the effectiveness of the healthcare system as a whole. Simplified patient paths could reduce unnecessary waiting time for diagnosis and treatment, which could lessen the load on emergency services. Training regarding CES diagnosis and management could be organized and provided to enhance the understanding of CES, its accompanying symptoms, and its management, in addition to fostering better communication with patients and other medical professionals. The results of this study could contribute to the development of sensitive, evidence-based, and unambiguous guidelines for clinical questioning regarding symptoms that may seem humiliating but are clinically important.

The study’s results have important implications for the development and refinement of clinical standards and protocols related to the early identification and management of CES by physiotherapists, ultimately contributing to enhanced patient care in Saudi Arabia. The high proficiency levels reported among physiotherapists suggest that they are well-positioned to play a crucial role in the timely recognition and treatment of this serious condition. Nevertheless, the lack of consensus on certain aspects of CES management points to areas where further training and standardization of practices could be beneficial. Ongoing education and research can help address these gaps, ensuring physiotherapists are equipped with the knowledge and skills necessary to provide optimal care for patients at risk of CES.

The study’s findings emphasize the importance of empowering physiotherapists as key members of the healthcare team in the early identification and management of CES. By leveraging the expertise of these professionals, healthcare systems can enhance their ability to prevent permanent neurological deficits and improve patient outcomes. This study’s findings can aid in the creation or improvement of clinical standards and protocols pertaining to physiotherapists’ roles in the early detection of CES, which could enhance care uniformity and standardize procedures within the field. Future research should investigate the long-term impact of these clinical standards and protocols on patient outcomes, as well as explore the effectiveness of specific training and education programs for physiotherapists in the early detection and management of CES. Future research using this survey could benefit from further psychometric assessment to substantiate its validation and reliability in assessing CES competence among healthcare providers.

One limitation of this study is the use of convenience sampling to distribute surveys, which can ensure a cost-effective and timely gathering of data but may limit the generalizability of the findings. Future research could consider employing a more rigorous sampling method, such as random sampling, to increase the generalizability of the findings. Another limitation is relying on self-reported data, which can impact the accuracy of results due to potential bias or errors in participants’ responses. To address this limitation, using multiple methods of data collection could triangulate the findings and improve result validity; incorporating qualitative data alongside quantitative measures could provide a more comprehensive understanding of research topics. Finally, the cutoff scores utilized in this study to categorize participants’ competence levels were based on expert opinion rather than formal validation. While these cutoffs were informed by insights from experienced physiotherapists and physicians, further research is needed to empirically validate these thresholds to ensure they accurately reflect competence levels in CES identification and management.