Knowledge of autonomic dysreflexia among physical therapists

INTRODUCTION

A spinal cord injury (SCI) profoundly alters life, creating significant challenges for individuals and their families. Muscle paralysis below the injury level diminishes the ability to walk, perform daily tasks, and engage socially. In addition to motor deficits, SCI patients face serious health risks, including complications such as urinary tract infections, deep vein thrombosis, osteoporosis, respiratory infections, and pressure ulcers that hinder recovery and quality of life.^[1]

Individuals with higher-level SCIs, particularly those affecting the upper thoracic and cervical regions, are at a significant risk for experiencing a recurring condition known as autonomic dysreflexia (AD).^[2] AD is a medical emergency that affects between 48% and 90% of individuals with SCIs above the sixth thoracic vertebra. Its impact is particularly severe for those with traumatic or complete SCIs, posing a greater risk to their health and functional abilities.^[3]Although many cardiovascular conditions that emerge after SCI are linked to an increased risk of death, AD stands out as the only cardiovascular condition that can directly lead to death or cause irreversible damage if not promptly managed.^[4]

AD is marked by a sudden, dangerous increase in blood pressure (BP), typically 20–30 mmHg above the patient’s baseline systolic pressure, accompanied by symptoms such as blurred vision, severe headache, skin flushing (erythema), and profuse sweating above the injury level.^[5] The severity of symptoms depends on the level and completeness of the injury. Multiple triggers can precipitate AD episodes; bladder distention and irritation are the most common, accounting for about 80% of cases.^[6] Accordingly, many SCI patients regularly experience uncomfortable AD episodes throughout the day and night, most often due to a full bladder or constipation.^[7] Although AD is more common in the chronic phase after spinal shock, it can occur at any time post-injury.^[5] Non-traumatic SCIs, such as intramedullary astrocytoma and multiple sclerosis, can also cause AD, broadening its clinical significance.^[8,9]

Despite AD’s severity, physical therapists – key providers in SCI patient rehabilitation – often lack sufficient knowledge of this life-threatening condition. Misdiagnosis or poor management can result in devastating outcomes, including myocardial ischemia, stroke, seizures, and death.^[10] Physical therapists must be fully prepared to identify and manage AD episodes. To date, no study has evaluated physical therapists’ knowledge of AD in Saudi Arabia. The present study, therefore, aimed to measure their knowledge and assess its association with clinical practice characteristics.

MATERIALS AND METHODS

The data collection for this cross-sectional study was conducted among physical therapists in Saudi Arabia from June 2024 to December 2024. Majmaah University Research Ethics Committee granted ethical approval for this research (Ref no: MUREC-Apr.30/COM-2024/14-4).

A convenience sample of 184 physical therapists participated, each with a minimum of a Bachelor’s degree in Physical Therapy, at least 1 year of patient experience, and a valid license from the Saudi Commission for Health Specialties. No a priori sample size calculation was performed; recruitment continued until the pragmatic target was met. Data were collected using a custom questionnaire. The first section gathered sociodemographic and clinical practice details, including age, gender, education, workplace, years of experience, practice setting, and SCI patient load in the past month.

The second section consisted of items related to knowledge of AD, like definition, causes, signs and symptoms, complications, and treatment for individuals who experience episodes of AD. Few items have more than one correct response. One point was awarded for one correct response. The maximum number of points for this section is 23. The knowledge level of the respondents was categorized as good, fair, and poor based on their scores: 80% or above (19–23 points), 60–79% (14–18 points), and <60% (<14 points), respectively.^[11] The items regarding the knowledge component were drafted after reviewing similar studies conducted among emergency healthcare professionals, nursing, and physical therapy participants.^[5,12,13]

A group of six physical therapy experts assessed content validity by rating the items of the knowledge component. Each item was rated on a 4-point ordinal scale (i.e., 1 for not relevant, 2 for somewhat relevant, 3 for quite relevant, and 4 for highly relevant) by each of the six expert committee members to determine the item-level content validity (I-CVI). The I-CVI was calculated for each item by dividing the number of experts who gave a rating of three or four by the total number of experts. The scale CVI was determined by averaging the I-CVIs for every item on the scale. The CVIs for the items were >0.83, and the scale CVI was determined as 0.97, which was considered excellent.^[14,15]

The reliability of the knowledge component items has been assessed using test-retest reliability. The test-retest reliability was assessed among 20 participants with a 2-week interval between test administrations. The test-retest analysis was performed using Spearman’s rank correlation coefficient. The ‘r’ value for all the items was more than 0.81, and the p values were found to be significant (p < 0.05).^[14-16] The online informed consent was obtained from all the participants. The study questionnaire was administered online using Google Forms. Participation was voluntary, and responses were collected anonymously.

RESULTS

The study included 184 participants. Table 1 details their demographic and clinical characteristics. The average age was 27.6 ± 4.2 years. Gender distribution was almost equal (52.2% female and 47.8% male). Most (85.3%) held a Bachelor’s degree; others had a doctor of physical therapy (4.3%), Master’s (9.8%), or PhD (0.5%). The majority worked in private rehabilitation centers (59.8%), in outpatient settings (53.3%), and had 1–5 years’ experience (81%). In addition, 31.5% had treated 2–10 patients with SCIs in the previous month.

Table 2 presents the participants’ responses to the questionnaire items that assess their knowledge of AD. Item 1: Only 45.1% of the participants were able to correctly answer “A sudden rise in BP and associated symptoms from noxious or non-noxious stimuli that trigger sympathetic hyperactivity of the spinal cord” as a definition for AD. Item 2: Among the study participants, only 18.5% were able to recognize that the typical resting systolic BP for a person with chronic tetraplegia will be “90–110 mmHg.” Item 3: Regarding the lowest spinal cord segment associated with AD, (44%) correctly identified T6, while others chose C6 (27.2%), T12 (19%), or T1 (9.8%). Item 4: When asked about the initial steps to manage a patient with signs of AD, 35.9% of participants correctly answered that the initial steps should “sit him up in bed, loosen any tight clothing or restrictive equipment, and empty his bladder.” Item 5: In response to the question about the signs and symptoms of AD (where participants could select more than one option), the correct responses included sudden increases in BP (65.8%), headache (63%), sudden low heart rate (31%), and flushed skin above the lesion (25.5%). In contrast, incorrect responses included sudden decreases in BP (22.3%) and flushed skin below the lesion (25.5%).

Item 6: Participants identified several typical causes of AD, including wrong positioning (54.9%), urinary bladder distension (46.7%), groin compression from tight trousers (41%), excessive exercise (41.8%), fecal congestion (27.2%), femoral fracture (25.5%), and ingrowing toenails (15.2%). Item 7: For the most frequent cause of AD, only 20.7% of participants correctly identified urinary bladder distension. Item 8: In response to whether medication is indicated to lower BP as part of managing AD, 81% of participants correctly answered “Yes,” while 19% answered “No.” Item 9: Regarding complications from severe, untreated episodes of AD, most participants frequently identified correct complications such as seizures (54.9%), intracranial hemorrhage (41.8%), myocardial infarction (40.8%), angina (29.3%), and death (31.5%). Item 10: Finally, in response to the question about the expected outcomes after removing the trigger for AD, 58.2% of participants correctly selected “all of the above.”

Table 3 shows that most participants (91.3%) exhibited poor knowledge of AD, with only 1.6% demonstrating good knowledge and 7.1% fair knowledge. This indicates a widespread lack of adequate knowledge among physical therapists regarding AD. Table 4 shows that none of the participant characteristics – including gender, workplace, years of experience, practice setting, or the number of patients with SCIs treated – were significantly associated with knowledge scores. This clearly demonstrates that knowledge gaps are present regardless of these factors.

DISCUSSION

The primary goal of this study was to assess the knowledge of AD among physical therapists in Saudi Arabia. Given the life-threatening nature of AD and its frequent occurrence in individuals with SCI, it is essential that healthcare professionals, including physical therapists, possess adequate knowledge to recognize and manage this condition effectively.^[17] Despite its potential life-threatening consequences, studies have consistently demonstrated gaps in knowledge about AD among physical therapists who play a crucial role in the rehabilitation and long-term care of SCI patients.^[3,6]

The study revealed significant knowledge gaps among physical therapists in Saudi Arabia regarding AD. Only 1.6% had good knowledge, 7.1% had fair knowledge, and 91.3% had poor knowledge, indicating an urgent need for targeted education and training. These findings are consistent with prior studies in Poland, which found similar shortcomings.^[3] Notably, just 35.9% correctly identified initial AD management, and 21.2% proposed inappropriate interventions. Such misunderstandings jeopardize patient safety, underscoring the need for standardized training.

A particularly alarming finding relates to item 2, which assessed participants’ knowledge of the typical resting systolic BP for individuals with chronic tetraplegia. Only 18.5% of participants correctly identified the BP range as 90–110 mmHg, while a significant proportion incorrectly selected higher ranges, such as 130–150 mmHg (31%) or 150 mmHg and above (29.9%). This deficit in understanding of baseline BP values undermines their ability to recognize abnormal increases in BP – a major symptom of AD. Misidentifying normal BP ranges unquestionably delays recognition of AD episodes and results in severe complications such as stroke, seizures, or death.^[18]

No participant characteristic – including gender, workplace, experience, setting, region, or SCI patient volume – was associated with knowledge scores. Tederko et al. found better scores among therapists with higher education and experience, while those treating fewer SCI patients or working in outpatient settings showed insufficient knowledge.^[3] Targeted educational interventions, such as Krassioukov et al.’s “ABCs of AD” seminar and Tomasone et al.’s online modules, may help improve knowledge.^[12,19]Combining traditional and digital strategies might be most effective.

Historically, individuals with SCIs experienced significantly decreased life expectancy due to limited access to specialized treatment and rehabilitation. Advances in healthcare have improved survival rates for this population. There is a clear and immediate need to improve the knowledge and skills of healthcare professionals, especially physical therapists, in managing AD. Academic institutions and healthcare organizations must prioritize and enforce focused measures to address this need. This study is the first in Saudi Arabia and the Gulf region to assess physical therapists’ knowledge of AD. The limitations include the use of convenience sampling and the inherent self-report bias of knowledge questionnaires, both of which may limit the representativeness of the findings and potentially affect their generalizability to the broader physical therapy community.

CONCLUSION

This study clearly demonstrated that physical therapists in Saudi Arabia have significant deficiencies in their knowledge of AD: 91.3% had poor knowledge, 7.1% fair, and only 1.6% good knowledge. Furthermore, factors such as gender, workplace, experience, setting, and number of SCI patients treated showed no significant relationship with knowledge scores. These results highlight an urgent need for improved education and training, with a focus on the prompt identification and management of AD within physical therapists’ professional roles.