Promoting early detection of spinal infection within physiotherapy. Multi-methods qualitative study.

Summary

Spinal infections are rare but serious conditions that can cause long‑term disability or even death if they are not identified early. The first symptom is often back pain, which is extremely common and usually caused by simple musculoskeletal problems. Because of this, early signs of spinal infection can be missed by both patients and healthcare professionals. Delayed diagnosis can lead to prolonged illness, avoidable harm, and distress for patients and families.

Physiotherapists are often the first professionals that people with back pain see, especially in community and primary care settings. However, there are currently no national safety‑netting tools or physiotherapy‑specific resources to help identify when back pain may be caused by a spinal infection. People at higher risk, including those affected by health inequalities, may also face additional barriers to seeking help early.

This study aims to improve the early detection of spinal infection by developing practical safety‑netting tools and a clinical education package for physiotherapists. The research will be carried out across three linked workstreams.

First, we will explore the experiences of healthcare professionals and adults who have been diagnosed with spinal infection, to understand barriers to early recognition. Second, we will work with patients, clinicians, and key stakeholders in a series of co‑design workshops to create safety‑netting tools that are acceptable, accessible, and grounded in lived experience. Finally, we will develop and refine an education package for physiotherapists, informed by the findings from the earlier stages.

Adults with lived experience of spinal infection and patient representatives will be involved throughout the project to ensure the tools and resources are relevant and meaningful. The overall aim is to support earlier health‑seeking behaviour, improve clinical suspicion of spinal infection, and ultimately reduce delays in diagnosis and treatment.

Overview of Study Design

This is a multi-method qualitative study designed to develop a variety of safety-netting tools and strategies for spinal infection, informed by the lived experiences of individuals with spinal infection, including those affected by health inequalities. Complemented by a clinical education package, these will encourage early health-seeking behaviour and inform clinical suspicion of spinal infection, ensuring timely diagnosis and management. The study consists of three interlinked workstreams.

Research Aim

To develop a range of safety netting tools and strategies for spinal infection, informed by the lived experiences of individuals with spinal infection, including those affected by health inequalities. Complemented by a clinical education package, these outputs aim to encourage early health-seeking behaviour and support clinical suspicion of spinal infection, thereby enabling timely diagnosis and management.

Objectives

To explore the experiences of healthcare professionals, including physiotherapists, involved in the care of patients with spinal infection, to identify diagnostic barriers to early detection.

Workstream 1

1. To explore the experiences of patients diagnosed with spinal infection, including those affected by health inequalities, focusing on symptom development, symptom interpretation, and missed diagnostic opportunities.
2. To investigate factors influencing health-seeking behaviour among patients with spinal infection, including the timing and frequency of healthcare contacts and the types of healthcare settings accessed.
3. To explore patient experiences and perceptions of unconscious bias within physiotherapy and wider healthcare encounters, and its perceived impact on the timeliness of diagnosis.
4. To explore participants’ understanding of their risk of spinal infection and to identify the types, formats, and communication channels of safety netting tools or strategies that may have empowered earlier healthcare engagement.

Workstream 2

1. To co-design a range of safety netting tools and strategies for spinal infection aimed at promoting early diagnosis and timely access to healthcare.

Workstream 3

1. To develop a clinical education package and associated online resources for healthcare professionals to enhance awareness, early recognition, and healthcare access for spinal infection among at-risk populations.
2. To promote the free dissemination and adoption of the co-designed safety netting tools, strategies, and clinical education package to encourage uptake at scale.

Outcomes

Measurable Outcomes Within the Project Period
(These are deliverables or changes that can be evidenced, observed, or produced during the 25 month study.)

• Increased awareness among healthcare professionals — Evidence generated through qualitative data (focus groups, interviews) demonstrating improved understanding of spinal infection as a potential cause of presenting symptoms among physiotherapists, other healthcare professionals, and community stakeholders.
• Co-designed safety netting tools — Development of safety netting tools and strategies created collaboratively with patients, clinicians, and stakeholders.
• Clinical education package — Production of a clinical education package, including freely accessible online safety netting tools and strategies.
• Enhanced patient-facing resources — Creation of patient-informed materials that support recognition of symptoms and appropriate health-seeking behaviour.
• Stakeholder engagement and consensus — Evidence of agreement on key safety netting messages and implementation strategies across professional and patient groups.

Long Term Anticipated Benefits (Not Measured Within This Project)
(These are expected downstream impacts but fall outside the scope of measurement for this study.)

• Improved patient awareness in at-risk patients that back pain and related symptoms may be due to spinal infection, leading to earlier and more appropriate health-seeking behaviour.
• Timelier detection and referral for spinal infection across primary care pathways and the Emergency Department (ED).
• Earlier initiation of treatment reduces the risk of long term complications, disability, or mortality.
• Reduced burden on the NHS by minimising delayed diagnoses, enabling more patients to be treated effectively with simple antibiotic regimens, reducing the need for hospital admission or shortening hospital stays, and decreasing complications associated with delayed or missed diagnosis, thereby improving overall patient pathways.
• Lower medico-legal risk associated with missed or delayed diagnosis of spinal infection.
• Improved long term patient outcomes through earlier recognition, timely intervention, and better-informed clinical decision making.

Ethics Approval

HRA and HCRW RED ID: 26/NW/0193