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Patients’ perceptions of repair, rehabilitation and recovery after major orthopaedic trauma: a qualitative study
Accepted Manuscript Title: Patients’ perceptions of repair, rehabilitation and recovery after major orthopaedic trauma: a qualitative study Author: J. Claydon L. Robinson S. Aldridge PII: DOI: Reference:
S0031-9406(15)03857-2 http://dx.doi.org/doi:10.1016/j.physio.2015.11.002 PHYST 878
To appear in:
Physiotherapy
Received date: Accepted date:
30-3-2015 2-11-2015
Please cite this article as: Claydon J, Robinson L, Aldridge S, Patients’ perceptions of repair, rehabilitation and recovery after major orthopaedic trauma: a qualitative study, Physiotherapy (2015), http://dx.doi.org/10.1016/j.physio.2015.11.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Patients’ perceptions of repair, rehabilitation and recovery after major orthopaedic trauma: a qualitative study
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J. Claydon*, L. Robinson, S. Aldridge
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Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle
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upon Tyne, UK
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Corresponding author. Address: Physiotherapy Department, Newcastle upon Tyne Hospitals NHS Foundation
Trust, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK. Tel.: +44 (0)191 2825484. E-mail address: [email protected] (J. Claydon).
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*Abstract
Abstract Background The most common major trauma injuries are multiple fractures. Orthopaedic trauma research has traditionally focused on surgical techniques, and the impact of this major life event on the patient is not well understood. This study explores how patients make sense
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of their rehabilitation and recovery following major orthopaedic trauma. Design Qualitative study using an Interpretative Phenomenological Analysis approach.
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Methods Semi-structured interviews of a purposive sample of 15 patients 3 to 6 months after
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sustaining major orthopaedic injuries, treated at a major trauma centre in England.
Findings Recovery after trauma was conceptualised as a journey through repair and
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rehabilitation to achieve recovery. These phases were represented by three superordinate themes: getting back on your feet, getting the right help to get there, and regaining a sense of
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normality. Participants considered orthopaedic consultants and physiotherapists to be the primary professionals to provide the tools to enable them to help themselves. Improving
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physical function helped to restore emotional well-being, with recovery only attained when participants had normalised a new sense of self, and regained confidence or enjoyment in
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their chosen activities.
Conclusion Rehabilitation is a complex process of coming to terms with physical and social limitations to normalise a new sense of self. Individuals considered rehabilitation to be their
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responsibility; however, they needed expert help to know what to do. Physiotherapists were key to getting people back on their feet, and by facilitating physical recovery, physiotherapists were able to have a positive impact on emotional well-being.
Keywords: Rehabilitation; Physiotherapy; Orthopaedics; Trauma; Fracture; Psychology
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Background An incident resulting in multiple or serious traumatic injuries is a major life event. Many people do not survive after this trauma, with 10,000 deaths after major injury in England and Wales every year [1], and many more disabilities requiring ongoing medical intervention and
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rehabilitation [2,3]. In the UK, major trauma is defined by the severity of injuries, using the Injury Severity Score (ISS) [4], rather than the mechanism of injury. The most common
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major trauma injuries are multiple fractures, accounting for 49% of admissions under the
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major trauma pathway [5]. This highlights the importance of understanding the impact of these complex orthopaedic injuries.
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In April 2012, acute National Health Services were restructured into major trauma networks; this has improved survival rates for patients experiencing the most severe injuries
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[6]. Attention is now focusing on developing major trauma rehabilitation networks. The lack of standardised outcome measures for trauma [7,8] and the nationally recognised paucity of
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data collected by allied health professionals [9] create difficulties for evaluating recovery outcomes [10]. A prospective study within major orthopaedic trauma highlighted the
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difficulties with access to and transition between rehabilitation services, particularly after discharge from hospital. Forty-eight percent (n=143) of patients failed to achieve their potential outcome up to 12 months after injury and were referred to physiotherapy (25%),
[5].
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health psychology (13%) or falls input (6%) to help address their unmet rehabilitation needs
Involving individuals who have experienced major orthopaedic trauma in developing
rehabilitation networks can create services that are effective and are the type of services that people want to use [11,12]. Traditionally, orthopaedic trauma research has focused on surgical techniques [13–15], but more recent qualitative studies have started to explore patients’ experiences [11,16,17]. Patients who had experienced major trauma reported that
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physiotherapy played a central role in rehabilitation [17], but how is any perceived benefit achieved? Physiotherapy has traditionally aligned its professional identify to a biomedical view of the physical body [18], and has focused on restoring function. As trauma is known to elicit an emotional response [19], additional knowledge may be gained considering a
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philosophical construct encompassing physical, social and self [18]. Common emotional responses to trauma include post-traumatic stress and post-
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traumatic growth (PTG). PTG is a rapidly growing field within positive psychology and
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describes attaining a higher level of psychological well-being after trauma [20]. PTG can include enhanced relationships, a change in view of self, acceptance of limitations, and a
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change in life philosophy [21]. Interpretative Phenomenological Analysis (IPA) is a qualitative approach used increasingly for health research [22]; this has evolved from
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psychology, and therefore this methodology derives greater understanding of the meanings that people attribute to physical, social and emotional perspectives during the recovery
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process. Improved awareness of more holistic needs may support delivery of more compassionate care. This study explored how patients make sense of their rehabilitation and
Methods
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recovery following major orthopaedic trauma, and how they manage these perceptions.
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Study design
An IPA approach was taken. This qualitative methodology has evolved from health psychology and examines how people make sense of major life experiences [23,24].
Sampling and recruitment A purposive sample of 15 patients who had experienced major orthopaedic trauma was included in this study. IPA promotes small sample sizes to obtain rich data and detailed
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interpretative analysis to adhere to its idiographic principles [24,25]. Individuals with significant and lasting head, spinal cord or peripheral nerve injury were excluded from this study. This permitted a fairly homogenous sample of patients treated at the same major trauma centre within a certain time window for whom the research question was meaningful
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[23]. Patients attending a trauma rehabilitation appointment were invited to take part by an orthopaedic consultant or trauma rehabilitation specialist physiotherapist, who was not
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involved in delivering routine physiotherapy. Consent was obtained in accordance with Good
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Clinical Practice for Research [26].
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Data collection
Data were collected from participants during one-to-one digital audio-recorded semi-
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structured interviews lasting approximately 1 hour. Interviews were conducted 3 to 6 months after injury by the lead author, an experienced orthopaedic trauma physiotherapist and
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research associate with IPA training and Masters level qualitative research skills. Participants were asked to describe the impact of their injury, rehabilitation and recovery on their
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everyday lives and expectations for the future. They were encouraged to talk about the topics that were important to them, even if they were not included in the interview guide (compiled using available literature, the researchers’ clinical experiences and consultation with peers). If
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any concerns were identified about a participant’s emotional well-being during the interview, a referral letter was sent to their general practritioner or appropriate psychology service with their consent.
Data analysis All interviews were transcribed verbatim. Any identifiable details were removed and participants were allocated a pseudonym to protect anonymity. Transcripts were analysed by
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the lead author using methods characteristic of the IPA approach, and interpretations were verified by the co-authors [23]. The first transcript was read multiple times and initial notes were taken of descriptive, linguistic and conceptual components within the data. Emergent themes were interpreted for the first participant and subsequently clustered into superordinate
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themes. This analytical process was completed for each transcript individually before
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comparing patterns across cases.
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Findings Participants
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The personal characteristics of the 15 participants are presented in Table 1. Two patients approached did not wish to participate in the study (one not interested in research; one unable
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to arrange convenient appointment time). Four interviews were conducted at the participant’s
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home, and the remaining 11 interviews were conducted in hospital outpatients.
Patients’ perceptions of rehabilitation and recovery Patients’ perceptions of major orthopaedic trauma were conceptualised as a journey through
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repair and rehabilitation to achieve recovery. These three phases were characterised by superordinate and subthemes derived through IPA analysis, represented by italics in this section. Key quotes supporting these themes are provided in Table 2.
Theme 1. Repair: getting back on your feet
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Repair described the period immediately after injury until participants had received the orthopaedic intervention necessary for their injury to be fixed, either through surgery or conservative management. Participants expressed a strong desire to return to functional independence and getting back on their feet, referring to both the literal meaning (return to
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walking for lower limb injuries) and the figurative meaning (return to usual activities) (Table 2).
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Many participants felt that they had to get on with it and deal with the consequences
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of their injuries to start their journey towards recovery. During this period of adjustment, most participants expressed anxieties associated with dealing with the uncertainties they
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faced, specifically whether their broken bones would heal, how long this would take, and when they could return to their usual activities. Feelings of frustration were expressed by
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most participants. Frustration was attributed to the physical restrictions caused by their injury, the lack of progress with everyday activities whilst waiting for the body to heal, loss of
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independence, and an overall sense of loss of control. Frustration was exacerbated when participants experienced set-backs, such as delayed fracture healing, failure of surgical
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implant or infection. One participant (Isla) was so concerned at the slow healing of her clavicular fracture that she developed a strong fear it would never heal and she would never regain an acceptable quality of life. Learning to control my frustration was important to help
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cope with the emotional stresses of trauma. Strategies employed to manage these feelings of frustration included looking to the future, setting goals and doing what they could to help themselves. One participant (Lewis) was not able to remain positive, experiencing flashbacks, depression, social withdrawal and anger as a consequence of his traumatic event. These symptoms intensified when he experienced multiple infections requiring unplanned surgery.
Theme 2. Rehabilitation: getting the right help to get there
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There was a transition from repair to rehabilitation as fracture healing progressed and participants restarted physical and functional activities. All participants considered rehabilitation to be up to me and the outcome achieved was directly dependent upon their own actions; however, they needed the right help to get there (Table 2). All participants were
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motivated to get better after their traumatic injuries and wanted to do the right thing. They trusted the experts and followed advice from healthcare professionals to optimise their
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recovery. Some participants received conflicting advice. One participant (Gary) described
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how conflicting advice regarding his weight-bearing status caused him confusion.
Participants described their expectations of healthcare professionals during
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rehabilitation. Several participants wanted access to professionals with specialist orthopaedic knowledge who could answer their questions, primarily orthopaedic consultants and
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physiotherapists. Participants looked to orthopaedic consultants to make decisions about injury management, progressing any orthopaedic rehabilitation restrictions and return to
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driving and/or work. After hospital discharge, physiotherapists were the primary source for advice regarding expectations of recovery and future, specialist exercises and restoring usual
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activities appropriate to the stage of fracture healing. Advice and reassurance from physiotherapists helped the participants come to terms with the impact of their injuries, and provided the tools necessary to help get themselves better. The participants that did not attend
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physiotherapy after hospital discharge or experienced a delay for an appointment said that they were uncertain about what they should be doing and were concerned they might cause themselves harm.
Theme 3. Recovery: regaining a sense of normality Participants expressed recovery as regaining a sense of normality (Table 2). Most participants sought reassurance by measuring progress, by comparing their ability over time
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or by assessment from healthcare professionals. Participants evaluated their progress using a range of parameters, including physiological (fractured healing), physical (range of movement, starting to weight bear), functional (return to work or usual activities) and emotional (confidence, enjoyment). In the early stages after trauma, participants compared
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themselves with their old, pre-injury status. During the rehabilitation phase, participants gradually stopped looking back and started to re-align their expectations and redefine me.
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One participant (Beth) described the benefits gained through not having to cycle to work;
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something she had enjoyed prior to her injury.
Restoring independence and returning to work or usual activities were important to
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most participants. Although being able to achieve and perform a task was important, they did not consider themselves to be fully recovered until they were able to do so with confidence
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and enjoyment. One participant (Alice) described feeling emotional when she was able to enjoy being in the countryside on her own, and she realised she was regaining a sense of
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Discussion
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normality.
Repair, rehabilitation, recovery
After major orthopaedic trauma, participants described a journey through repair and
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rehabilitation to recovery. The recovery process after orthopaedic trauma is not always clearly delineated [27]. When participants required multiple operations or if any complications arose, many described a sense of feeling ‘stuck’, cycling between repair and rehabilitation, which delayed them attaining recovery. In the early days after injury, repair of the physical body was a priority for individuals. This physical repair was considered to be the first stage in returning to their usual activities, and highlights the perceived social context of injury. As time progressed,
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individuals started to come to terms with changes in their physical body and associated changes in social participation to gradually redefine their sense of self. Participants considered rehabilitation to be their responsibility; however, they relied upon healthcare professionals, especially physiotherapists, to provide the tools to enable them to help
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themselves. Recovery was not just about achieving and performing an activity (physical, social), but being able to enjoy and complete the activity with confidence, having accepted a
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new sense of self (self).
Perceptions of physiotherapy
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These data support previous findings that physiotherapy is pivotal to rehabilitation after trauma [28]. Participants considered physiotherapy to be integral to getting started with
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rehabilitation, and associated commencing physiotherapy with hope for their future recovery. Hope can be a purposeful force for recovery [27]. Participants perceived physiotherapists to
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provide expert knowledge, advice and exercises to show them what to do, and to provide reassurance and encouragement to keep them going, even when rehabilitation was difficult or
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painful. Participants attributed physiotherapy to getting better with their physical abilities. The physical improvements enabled them to increase their functional activities and consequently helped them to restore confidence to feel better. The improved emotional state
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helped to motivate individuals to set new goals and make further progress. This rehabilitation cycle (Fig. 1) highlights how physiotherapy can influence social context and sense of self through improving the physical body. Further research exploring the therapeutic relationship considering a philosophical construct of the body may enhance understanding how physiotherapy facilitates recovery and improves quality of life after trauma [18].
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Coping The themes identified through this qualitative analysis provide valuable insight into the strategies that patients employ to cope after trauma. Coping strategies can broadly be
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classified as problem, appraisal or emotion focused [29]. Participants relied primarily upon problem-focused coping by attempting to take control of their new situation and seeking
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information to promote autonomy. A similar sense of individual responsibility for
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rehabilitation was evident amongst patients with whiplash disorder [15]. A practical approach to coping has been associated with PTG [30] and improved outcome for patients with spinal
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cord injury [31]. Most participants described a sense of optimism and motivation which supports the theory that people are intrinsically motivated after trauma to process new
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information positively to maximise psychological well-being [32]. Appraisal-focused techniques, such as altering goals and values, and emotion-focused responses became more
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prevalent when individuals were approaching recovery and were able to complete physical
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and functional tasks with confidence and enjoyment.
Redefining me
In the early stages of rehabilitation, participants focused on regaining their old self. They
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tended to look back and compare their current physical and emotional well-being with their previous, uninjured sense of self. These feelings of loss and grief are consistent with the concept that trauma is an assault on the self [33]. With time and progression towards recovery, participants underwent an adjustment process of coming to terms with any limitations and adjusting to their new post-trauma self; this demonstrates how normalising a new sense of self is part of the healing process after major orthopaedic trauma.
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Clinical implications Previous research has identified that patients value expert information, communication and support [11,17] to help them move forwards after trauma [27]. By communicating accurate information, healthcare professionals can promote effective problem-focused coping and thus
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reduce psychological stresses or even enhance PTG. This demonstrates one method whereby healthcare professionals can influence not only the physical body but also the self during
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rehabilitation.
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The valuable role of healthcare professionals in managing expectations and supporting development of goals during rehabilitation from trauma supports previous patient
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experience studies [16,17], and has been described as constructing realistic hope [27]. This study provides new insight into how these interventions may contribute positively to
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recovery, facilitating the adjustment process whilst individuals redefine their sense of self and promoting PTG. One study of road traffic accident survivors identified differences between
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perceived and actual PTG [34]. Consequently, healthcare professionals should be alert to a potential risk that patients may not achieve their full recovery after trauma if they normalise
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suboptimal performance. This could also have implications for the validity of patient-reported outcome measures that are increasingly relied upon to assess quality of healthcare services
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and research.
Quality assurances To promote high-quality research findings, this study was evaluated using an evaluative framework [35] of four key principles appropriate for IPA research [23,25].
Sensitivity to context
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IPA is an interpretative process and prone to prejudice. The researchers strived to maximise trustworthiness by recording thoughts, conceptions and professional predispositions during and after interview, and discussing interpretations with the author group to maximise sensitivity to context. Participants were aware of the interviewer’s clinical background prior
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to data collection, and were encouraged to speak freely when discussing physiotherapy-
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related matters.
Feedback
from
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experienced
qualitative
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Commitment and rigour researcher
for
interview
techniques,
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appropriateness of data, and depth of analysis was obtained to optimise commitment and
Coherence and transparency
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rigour.
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Transparency and coherence of data collection and analysis were confirmed through an
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auditable record of all stages of the research process.
Impact and importance
This qualitative study provides a foundation for patient-centred evidence from which to build
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major trauma services and future research. The research has produced new knowledge of patients’ perspectives of factors influencing rehabilitation following major orthopaedic trauma. To date, very few studies have explored the role of physiotherapy considering the body as a philosophical construct [18]. Understanding the theoretical underpinnings of this construct through further research may help the profession to understand its effectiveness, and use this knowledge to improve rehabilitation for patients following major orthopaedic trauma.
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Limitations This qualitative research involved a small homogenous sample of patients from a single major trauma centre in the North of England. Participants had experienced a mixed
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combination of injuries, interventions and orthopaedic restrictions. Although highly context specific, this exploratory qualitative study reflects the complex reality of undertaking
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research in a trauma population. Interviews were completed between 3 and 6 months after
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injury, with some participants believing that they had not yet achieved full recovery. Data were collected during one interview. A longitudinal study may provide additional details of
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coping and adjustment over time.
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Conclusion
From this study, recovery after orthopaedic major trauma can be viewed as a journey through
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repair and rehabilitation to regain a sense of normality. Rehabilitation was a complex process of coming to terms with any physical and social limitations to redefine the self.
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Rehabilitation was described as ‘getting the right help to get back on your feet’. Patients who had experienced major orthopaedic trauma perceived physiotherapy to provide the necessary tools to enable them to take responsibility for their own rehabilitation. Exercises, information
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and support from physiotherapists improve physical ability whilst promoting coping strategies. These coping strategies included changing views of self, accepting limitations and re-evaluating life philosophies; typical components of PTG. PTG has been associated with a better outcome after trauma, suggesting that physiotherapy contributes to positive psychology. These findings encourage physiotherapy to explore its professional identity with respect to the body as a wider philosophical construct beyond the biomedical model [18].
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Ethical approval: Oxford C Research Ethics Committee (13/SC/0417).
Funding: Clinical research associate secondment from CLRN.
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Conflict of interest: None declared.
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Table 1
Sex
Mechanism
ISS
Fractures
Alice Beth Chris
55 49 38
Female Female Male
Horse riding Bicycle Motorbike
9 9 16
Dave Ewan
53 39
Male Male
Fall from height Bicycle vs car
5 33
Frank Gary
81 46
Male Male
Motorbike Horse riding
9 22
Harry
63
Male
Fall from height
13
Isla
63
Female
Road traffic accident
24
John Kevin
78 76
Male Male
Slip Pedestrian vs car
9 29
Lewis Michael
21 50
Male Male
Motorbike Road traffic accident
10 16
Neil
51
Male
Fall height
20
Owen
50
Male
Bicycle vs car
14
Pelvis Open elbow Clavicle Femur Bilateral calcaneus Wrist Ribs Pelvis Open ankle Femoral shaft Multiple ribs Pilon ankle Thoracic vertebral wedge Clavicle Multiple ribs Open ankle Tibia Elbow Clavicle Skull (hairline) Open tibia/fibula Pelvis Sacrum Lumbar spine Elbow Proximal femur Clavicle Scapula Multiple ribs
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Age
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Participant demographics
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ISS, Injurity Severity Score.
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Showing me what to do
Getting better
Keeping me going
Getting me started
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Fig. 1. Patients’ perceptions of rehabilitation.
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Feeling better
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Table 2 Patients’ perceptions of repair, rehabilitation and recovery
– –
the
ep te
d
–
Helping myself Dealing with practicalities Coming to terms
Quotes Participant Well, I guess I’ve just got on with it really … I feel very, Beth you know, accepting of what’s happened and just got to get on with it really
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Subtheme Getting on with it
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Superordinate theme 1. Getting back on your feet
Dealing with uncertainty Healing Outcome Future
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– – –
Control my frustration – – – –
Distraction Doing what I can Looking to the future, goals Staying positive
And when sat back and thought about it, I went, yeah, yeah, Harry I’ve been through a trauma. Cos you think, well you don’t realise what it is, but you think there’s nothing wrong with you, but there is I didn’t feel as though it was … healing correctly and I, it, it Chris still feels in exactly the same as it did when I did it It often doesn’t heal very well and it sounds you know, awful. …. When I felt me collarbones the other day and I felt Isla this one which was normal. And I felt that one and it just stops. It sort of, it just, there’s a big bone and then it just stops. It’s … frights you a bit that it’s like that Couldn’t quite do it yet. Yeah, it was more of the, the Michael frustration than anything. Like I say, it’s, that’s, I think it’s the brain that makes the body get better. It’s got to be because, keeping focused and having that goal Over the past 8, 6 to 8 weeks, um, it [flashbacks] started to happen more and more often, and then it started to interrupt Lewis 19 Page 21 of 24
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Taking advice Trusting the experts
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Doing the right thing
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2. Getting the right help to get there
sleep and stuff like that. And I started to take out general anger with my friends and my girlfriend and people like that I take notice of everything they say. I like to, I just want to Neil get better, that’s me main aim to get better …. Well I, just do things what they say
ep te
It’s up to me
d
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I do the exercises to strengthen the muscles. But et, that the Kevin rehab team gave me. I do those three times a day.
My responsibility
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–
Being a burden on others
The physio was saying it was toe touch, whereas what the surgeon had said was non-load bearing at all on the left, so Gary there was a bit of conflict going on there, a bit of confusion
Basically at the end of the day, it’s up to me I think. Whether Beth I, I mean obviously the operations and things weren’t up to me, but I feel the physio, it, it’s you can get the best advice, but unless you take it and get on with it you may not get the best result Rehabilitation, getting back on your feet and getting help to Chris get there And I must have waited I don’t know how long, ages. Four weeks, I can’t remember. I don’t know how long it was. Anyway nobody came in touch with us. So I ended up phoning …. And I was just, was just in a bit of limbo, and Owen that’s probably when you do your own thing So I’m happy to admit that I’ve been emotional but I Alice
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Impact on others Changing relationships Using limited NHS I think Kath’s done very well really. I mean she had a lot to John resources cope with
a
sense
of Measuring progress
It had a detrimental effect on how often my children. Um Chris because obviously I couldn’t do the football run and the dancing run and things, things that normally, normally that I would do and that would be, you know, my few hours with the, the kids and stuff and so … that side of it, it kind a … gets you quite low I’ve tried not to give the NHS any more work than they’ve had to have Frank If you can set goals, it’s a good idea, yeah. [Why?]. Well, Owen because if gives you something to aim for doesn’t it?
– –
Managing expectations Achievable milestones, If there’s a clear quantified level, then you know where you setting new ones are and it’s measurable ….. you always want to beat your last Ewan score don’t you? Regaining old me If I could get on my feet and walk. If I can walk, I’ll be happy. Even if I’ve got to walk with a stick, as long as I can, Dave like, can get out and go to the shops Regaining independence But it was being able to sit on a rock and look at a stream Alice [tearful] and that actually, and that is a funny thing to get – Achieving and doing emotional about, that is the thing. Just being outside, under
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3. Regaining normality
ep te
d
M
an
– – –
certainly don’t, didn’t want to burden other people with my crap, you know
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Feeling: pleasure
confidence, my own steam on my own is fantastic. That was the bit, getting my, my core pleasure back, was being outside on my own
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–
Redefining me
d
I used to cycle to work every day, and um, I’m quite Beth enjoying not cycling so I don’t have to get changed when I get into work and I don’t have helmet hair I kind of think it’s made us stronger. I know more, I was determined and had stamina before and I think I’ve got even Michael more than I had then
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NHS, National Health Service.
Accepting limitations Normalising new me
ep te
– –
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an
I started to feel better towards the end of my time off; I did Ewan actually start to enjoy my time off. You know I could actually start going out and doing things when I physically and emotionally felt a bit better
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S0031-9406(15)03857-2 http://dx.doi.org/doi:10.1016/j.physio.2015.11.002 PHYST 878
To appear in:
Physiotherapy
Received date: Accepted date:
30-3-2015 2-11-2015
Please cite this article as: Claydon J, Robinson L, Aldridge S, Patients’ perceptions of repair, rehabilitation and recovery after major orthopaedic trauma: a qualitative study, Physiotherapy (2015), http://dx.doi.org/10.1016/j.physio.2015.11.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Patients’ perceptions of repair, rehabilitation and recovery after major orthopaedic trauma: a qualitative study
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J. Claydon*, L. Robinson, S. Aldridge
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Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle
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upon Tyne, UK
*
Corresponding author. Address: Physiotherapy Department, Newcastle upon Tyne Hospitals NHS Foundation
Trust, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK. Tel.: +44 (0)191 2825484. E-mail address: [email protected] (J. Claydon).
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*Abstract
Abstract Background The most common major trauma injuries are multiple fractures. Orthopaedic trauma research has traditionally focused on surgical techniques, and the impact of this major life event on the patient is not well understood. This study explores how patients make sense
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of their rehabilitation and recovery following major orthopaedic trauma. Design Qualitative study using an Interpretative Phenomenological Analysis approach.
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Methods Semi-structured interviews of a purposive sample of 15 patients 3 to 6 months after
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sustaining major orthopaedic injuries, treated at a major trauma centre in England.
Findings Recovery after trauma was conceptualised as a journey through repair and
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rehabilitation to achieve recovery. These phases were represented by three superordinate themes: getting back on your feet, getting the right help to get there, and regaining a sense of
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normality. Participants considered orthopaedic consultants and physiotherapists to be the primary professionals to provide the tools to enable them to help themselves. Improving
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physical function helped to restore emotional well-being, with recovery only attained when participants had normalised a new sense of self, and regained confidence or enjoyment in
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their chosen activities.
Conclusion Rehabilitation is a complex process of coming to terms with physical and social limitations to normalise a new sense of self. Individuals considered rehabilitation to be their
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responsibility; however, they needed expert help to know what to do. Physiotherapists were key to getting people back on their feet, and by facilitating physical recovery, physiotherapists were able to have a positive impact on emotional well-being.
Keywords: Rehabilitation; Physiotherapy; Orthopaedics; Trauma; Fracture; Psychology
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Background An incident resulting in multiple or serious traumatic injuries is a major life event. Many people do not survive after this trauma, with 10,000 deaths after major injury in England and Wales every year [1], and many more disabilities requiring ongoing medical intervention and
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rehabilitation [2,3]. In the UK, major trauma is defined by the severity of injuries, using the Injury Severity Score (ISS) [4], rather than the mechanism of injury. The most common
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major trauma injuries are multiple fractures, accounting for 49% of admissions under the
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major trauma pathway [5]. This highlights the importance of understanding the impact of these complex orthopaedic injuries.
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In April 2012, acute National Health Services were restructured into major trauma networks; this has improved survival rates for patients experiencing the most severe injuries
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[6]. Attention is now focusing on developing major trauma rehabilitation networks. The lack of standardised outcome measures for trauma [7,8] and the nationally recognised paucity of
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data collected by allied health professionals [9] create difficulties for evaluating recovery outcomes [10]. A prospective study within major orthopaedic trauma highlighted the
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difficulties with access to and transition between rehabilitation services, particularly after discharge from hospital. Forty-eight percent (n=143) of patients failed to achieve their potential outcome up to 12 months after injury and were referred to physiotherapy (25%),
[5].
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health psychology (13%) or falls input (6%) to help address their unmet rehabilitation needs
Involving individuals who have experienced major orthopaedic trauma in developing
rehabilitation networks can create services that are effective and are the type of services that people want to use [11,12]. Traditionally, orthopaedic trauma research has focused on surgical techniques [13–15], but more recent qualitative studies have started to explore patients’ experiences [11,16,17]. Patients who had experienced major trauma reported that
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physiotherapy played a central role in rehabilitation [17], but how is any perceived benefit achieved? Physiotherapy has traditionally aligned its professional identify to a biomedical view of the physical body [18], and has focused on restoring function. As trauma is known to elicit an emotional response [19], additional knowledge may be gained considering a
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philosophical construct encompassing physical, social and self [18]. Common emotional responses to trauma include post-traumatic stress and post-
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traumatic growth (PTG). PTG is a rapidly growing field within positive psychology and
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describes attaining a higher level of psychological well-being after trauma [20]. PTG can include enhanced relationships, a change in view of self, acceptance of limitations, and a
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change in life philosophy [21]. Interpretative Phenomenological Analysis (IPA) is a qualitative approach used increasingly for health research [22]; this has evolved from
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psychology, and therefore this methodology derives greater understanding of the meanings that people attribute to physical, social and emotional perspectives during the recovery
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process. Improved awareness of more holistic needs may support delivery of more compassionate care. This study explored how patients make sense of their rehabilitation and
Methods
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recovery following major orthopaedic trauma, and how they manage these perceptions.
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Study design
An IPA approach was taken. This qualitative methodology has evolved from health psychology and examines how people make sense of major life experiences [23,24].
Sampling and recruitment A purposive sample of 15 patients who had experienced major orthopaedic trauma was included in this study. IPA promotes small sample sizes to obtain rich data and detailed
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interpretative analysis to adhere to its idiographic principles [24,25]. Individuals with significant and lasting head, spinal cord or peripheral nerve injury were excluded from this study. This permitted a fairly homogenous sample of patients treated at the same major trauma centre within a certain time window for whom the research question was meaningful
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[23]. Patients attending a trauma rehabilitation appointment were invited to take part by an orthopaedic consultant or trauma rehabilitation specialist physiotherapist, who was not
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involved in delivering routine physiotherapy. Consent was obtained in accordance with Good
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Clinical Practice for Research [26].
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Data collection
Data were collected from participants during one-to-one digital audio-recorded semi-
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structured interviews lasting approximately 1 hour. Interviews were conducted 3 to 6 months after injury by the lead author, an experienced orthopaedic trauma physiotherapist and
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research associate with IPA training and Masters level qualitative research skills. Participants were asked to describe the impact of their injury, rehabilitation and recovery on their
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everyday lives and expectations for the future. They were encouraged to talk about the topics that were important to them, even if they were not included in the interview guide (compiled using available literature, the researchers’ clinical experiences and consultation with peers). If
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any concerns were identified about a participant’s emotional well-being during the interview, a referral letter was sent to their general practritioner or appropriate psychology service with their consent.
Data analysis All interviews were transcribed verbatim. Any identifiable details were removed and participants were allocated a pseudonym to protect anonymity. Transcripts were analysed by
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the lead author using methods characteristic of the IPA approach, and interpretations were verified by the co-authors [23]. The first transcript was read multiple times and initial notes were taken of descriptive, linguistic and conceptual components within the data. Emergent themes were interpreted for the first participant and subsequently clustered into superordinate
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themes. This analytical process was completed for each transcript individually before
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comparing patterns across cases.
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Findings Participants
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The personal characteristics of the 15 participants are presented in Table 1. Two patients approached did not wish to participate in the study (one not interested in research; one unable
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to arrange convenient appointment time). Four interviews were conducted at the participant’s
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home, and the remaining 11 interviews were conducted in hospital outpatients.
Patients’ perceptions of rehabilitation and recovery Patients’ perceptions of major orthopaedic trauma were conceptualised as a journey through
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repair and rehabilitation to achieve recovery. These three phases were characterised by superordinate and subthemes derived through IPA analysis, represented by italics in this section. Key quotes supporting these themes are provided in Table 2.
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Repair described the period immediately after injury until participants had received the orthopaedic intervention necessary for their injury to be fixed, either through surgery or conservative management. Participants expressed a strong desire to return to functional independence and getting back on their feet, referring to both the literal meaning (return to
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walking for lower limb injuries) and the figurative meaning (return to usual activities) (Table 2).
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Many participants felt that they had to get on with it and deal with the consequences
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of their injuries to start their journey towards recovery. During this period of adjustment, most participants expressed anxieties associated with dealing with the uncertainties they
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faced, specifically whether their broken bones would heal, how long this would take, and when they could return to their usual activities. Feelings of frustration were expressed by
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most participants. Frustration was attributed to the physical restrictions caused by their injury, the lack of progress with everyday activities whilst waiting for the body to heal, loss of
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independence, and an overall sense of loss of control. Frustration was exacerbated when participants experienced set-backs, such as delayed fracture healing, failure of surgical
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implant or infection. One participant (Isla) was so concerned at the slow healing of her clavicular fracture that she developed a strong fear it would never heal and she would never regain an acceptable quality of life. Learning to control my frustration was important to help
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cope with the emotional stresses of trauma. Strategies employed to manage these feelings of frustration included looking to the future, setting goals and doing what they could to help themselves. One participant (Lewis) was not able to remain positive, experiencing flashbacks, depression, social withdrawal and anger as a consequence of his traumatic event. These symptoms intensified when he experienced multiple infections requiring unplanned surgery.
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There was a transition from repair to rehabilitation as fracture healing progressed and participants restarted physical and functional activities. All participants considered rehabilitation to be up to me and the outcome achieved was directly dependent upon their own actions; however, they needed the right help to get there (Table 2). All participants were
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motivated to get better after their traumatic injuries and wanted to do the right thing. They trusted the experts and followed advice from healthcare professionals to optimise their
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recovery. Some participants received conflicting advice. One participant (Gary) described
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how conflicting advice regarding his weight-bearing status caused him confusion.
Participants described their expectations of healthcare professionals during
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rehabilitation. Several participants wanted access to professionals with specialist orthopaedic knowledge who could answer their questions, primarily orthopaedic consultants and
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physiotherapists. Participants looked to orthopaedic consultants to make decisions about injury management, progressing any orthopaedic rehabilitation restrictions and return to
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driving and/or work. After hospital discharge, physiotherapists were the primary source for advice regarding expectations of recovery and future, specialist exercises and restoring usual
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activities appropriate to the stage of fracture healing. Advice and reassurance from physiotherapists helped the participants come to terms with the impact of their injuries, and provided the tools necessary to help get themselves better. The participants that did not attend
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physiotherapy after hospital discharge or experienced a delay for an appointment said that they were uncertain about what they should be doing and were concerned they might cause themselves harm.
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or by assessment from healthcare professionals. Participants evaluated their progress using a range of parameters, including physiological (fractured healing), physical (range of movement, starting to weight bear), functional (return to work or usual activities) and emotional (confidence, enjoyment). In the early stages after trauma, participants compared
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themselves with their old, pre-injury status. During the rehabilitation phase, participants gradually stopped looking back and started to re-align their expectations and redefine me.
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One participant (Beth) described the benefits gained through not having to cycle to work;
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something she had enjoyed prior to her injury.
Restoring independence and returning to work or usual activities were important to
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most participants. Although being able to achieve and perform a task was important, they did not consider themselves to be fully recovered until they were able to do so with confidence
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and enjoyment. One participant (Alice) described feeling emotional when she was able to enjoy being in the countryside on her own, and she realised she was regaining a sense of
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Discussion
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normality.
Repair, rehabilitation, recovery
After major orthopaedic trauma, participants described a journey through repair and
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rehabilitation to recovery. The recovery process after orthopaedic trauma is not always clearly delineated [27]. When participants required multiple operations or if any complications arose, many described a sense of feeling ‘stuck’, cycling between repair and rehabilitation, which delayed them attaining recovery. In the early days after injury, repair of the physical body was a priority for individuals. This physical repair was considered to be the first stage in returning to their usual activities, and highlights the perceived social context of injury. As time progressed,
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individuals started to come to terms with changes in their physical body and associated changes in social participation to gradually redefine their sense of self. Participants considered rehabilitation to be their responsibility; however, they relied upon healthcare professionals, especially physiotherapists, to provide the tools to enable them to help
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themselves. Recovery was not just about achieving and performing an activity (physical, social), but being able to enjoy and complete the activity with confidence, having accepted a
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new sense of self (self).
Perceptions of physiotherapy
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These data support previous findings that physiotherapy is pivotal to rehabilitation after trauma [28]. Participants considered physiotherapy to be integral to getting started with
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rehabilitation, and associated commencing physiotherapy with hope for their future recovery. Hope can be a purposeful force for recovery [27]. Participants perceived physiotherapists to
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provide expert knowledge, advice and exercises to show them what to do, and to provide reassurance and encouragement to keep them going, even when rehabilitation was difficult or
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painful. Participants attributed physiotherapy to getting better with their physical abilities. The physical improvements enabled them to increase their functional activities and consequently helped them to restore confidence to feel better. The improved emotional state
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helped to motivate individuals to set new goals and make further progress. This rehabilitation cycle (Fig. 1) highlights how physiotherapy can influence social context and sense of self through improving the physical body. Further research exploring the therapeutic relationship considering a philosophical construct of the body may enhance understanding how physiotherapy facilitates recovery and improves quality of life after trauma [18].
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Coping The themes identified through this qualitative analysis provide valuable insight into the strategies that patients employ to cope after trauma. Coping strategies can broadly be
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classified as problem, appraisal or emotion focused [29]. Participants relied primarily upon problem-focused coping by attempting to take control of their new situation and seeking
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information to promote autonomy. A similar sense of individual responsibility for
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rehabilitation was evident amongst patients with whiplash disorder [15]. A practical approach to coping has been associated with PTG [30] and improved outcome for patients with spinal
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cord injury [31]. Most participants described a sense of optimism and motivation which supports the theory that people are intrinsically motivated after trauma to process new
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information positively to maximise psychological well-being [32]. Appraisal-focused techniques, such as altering goals and values, and emotion-focused responses became more
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prevalent when individuals were approaching recovery and were able to complete physical
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and functional tasks with confidence and enjoyment.
Redefining me
In the early stages of rehabilitation, participants focused on regaining their old self. They
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tended to look back and compare their current physical and emotional well-being with their previous, uninjured sense of self. These feelings of loss and grief are consistent with the concept that trauma is an assault on the self [33]. With time and progression towards recovery, participants underwent an adjustment process of coming to terms with any limitations and adjusting to their new post-trauma self; this demonstrates how normalising a new sense of self is part of the healing process after major orthopaedic trauma.
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Clinical implications Previous research has identified that patients value expert information, communication and support [11,17] to help them move forwards after trauma [27]. By communicating accurate information, healthcare professionals can promote effective problem-focused coping and thus
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reduce psychological stresses or even enhance PTG. This demonstrates one method whereby healthcare professionals can influence not only the physical body but also the self during
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rehabilitation.
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The valuable role of healthcare professionals in managing expectations and supporting development of goals during rehabilitation from trauma supports previous patient
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experience studies [16,17], and has been described as constructing realistic hope [27]. This study provides new insight into how these interventions may contribute positively to
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recovery, facilitating the adjustment process whilst individuals redefine their sense of self and promoting PTG. One study of road traffic accident survivors identified differences between
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perceived and actual PTG [34]. Consequently, healthcare professionals should be alert to a potential risk that patients may not achieve their full recovery after trauma if they normalise
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suboptimal performance. This could also have implications for the validity of patient-reported outcome measures that are increasingly relied upon to assess quality of healthcare services
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and research.
Quality assurances To promote high-quality research findings, this study was evaluated using an evaluative framework [35] of four key principles appropriate for IPA research [23,25].
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IPA is an interpretative process and prone to prejudice. The researchers strived to maximise trustworthiness by recording thoughts, conceptions and professional predispositions during and after interview, and discussing interpretations with the author group to maximise sensitivity to context. Participants were aware of the interviewer’s clinical background prior
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to data collection, and were encouraged to speak freely when discussing physiotherapy-
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related matters.
Feedback
from
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experienced
qualitative
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for
interview
techniques,
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appropriateness of data, and depth of analysis was obtained to optimise commitment and
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rigour.
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Transparency and coherence of data collection and analysis were confirmed through an
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auditable record of all stages of the research process.
This qualitative study provides a foundation for patient-centred evidence from which to build
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major trauma services and future research. The research has produced new knowledge of patients’ perspectives of factors influencing rehabilitation following major orthopaedic trauma. To date, very few studies have explored the role of physiotherapy considering the body as a philosophical construct [18]. Understanding the theoretical underpinnings of this construct through further research may help the profession to understand its effectiveness, and use this knowledge to improve rehabilitation for patients following major orthopaedic trauma.
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Limitations This qualitative research involved a small homogenous sample of patients from a single major trauma centre in the North of England. Participants had experienced a mixed
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combination of injuries, interventions and orthopaedic restrictions. Although highly context specific, this exploratory qualitative study reflects the complex reality of undertaking
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research in a trauma population. Interviews were completed between 3 and 6 months after
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injury, with some participants believing that they had not yet achieved full recovery. Data were collected during one interview. A longitudinal study may provide additional details of
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coping and adjustment over time.
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Conclusion
From this study, recovery after orthopaedic major trauma can be viewed as a journey through
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repair and rehabilitation to regain a sense of normality. Rehabilitation was a complex process of coming to terms with any physical and social limitations to redefine the self.
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Rehabilitation was described as ‘getting the right help to get back on your feet’. Patients who had experienced major orthopaedic trauma perceived physiotherapy to provide the necessary tools to enable them to take responsibility for their own rehabilitation. Exercises, information
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and support from physiotherapists improve physical ability whilst promoting coping strategies. These coping strategies included changing views of self, accepting limitations and re-evaluating life philosophies; typical components of PTG. PTG has been associated with a better outcome after trauma, suggesting that physiotherapy contributes to positive psychology. These findings encourage physiotherapy to explore its professional identity with respect to the body as a wider philosophical construct beyond the biomedical model [18].
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Ethical approval: Oxford C Research Ethics Committee (13/SC/0417).
Funding: Clinical research associate secondment from CLRN.
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Conflict of interest: None declared.
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Table 1
Sex
Mechanism
ISS
Fractures
Alice Beth Chris
55 49 38
Female Female Male
Horse riding Bicycle Motorbike
9 9 16
Dave Ewan
53 39
Male Male
Fall from height Bicycle vs car
5 33
Frank Gary
81 46
Male Male
Motorbike Horse riding
9 22
Harry
63
Male
Fall from height
13
Isla
63
Female
Road traffic accident
24
John Kevin
78 76
Male Male
Slip Pedestrian vs car
9 29
Lewis Michael
21 50
Male Male
Motorbike Road traffic accident
10 16
Neil
51
Male
Fall height
20
Owen
50
Male
Bicycle vs car
14
Pelvis Open elbow Clavicle Femur Bilateral calcaneus Wrist Ribs Pelvis Open ankle Femoral shaft Multiple ribs Pilon ankle Thoracic vertebral wedge Clavicle Multiple ribs Open ankle Tibia Elbow Clavicle Skull (hairline) Open tibia/fibula Pelvis Sacrum Lumbar spine Elbow Proximal femur Clavicle Scapula Multiple ribs
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Age
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Participant demographics
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ISS, Injurity Severity Score.
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Showing me what to do
Getting better
Keeping me going
Getting me started
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Fig. 1. Patients’ perceptions of rehabilitation.
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Feeling better
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Table 2 Patients’ perceptions of repair, rehabilitation and recovery
– –
the
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Helping myself Dealing with practicalities Coming to terms
Quotes Participant Well, I guess I’ve just got on with it really … I feel very, Beth you know, accepting of what’s happened and just got to get on with it really
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Subtheme Getting on with it
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Superordinate theme 1. Getting back on your feet
Dealing with uncertainty Healing Outcome Future
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Control my frustration – – – –
Distraction Doing what I can Looking to the future, goals Staying positive
And when sat back and thought about it, I went, yeah, yeah, Harry I’ve been through a trauma. Cos you think, well you don’t realise what it is, but you think there’s nothing wrong with you, but there is I didn’t feel as though it was … healing correctly and I, it, it Chris still feels in exactly the same as it did when I did it It often doesn’t heal very well and it sounds you know, awful. …. When I felt me collarbones the other day and I felt Isla this one which was normal. And I felt that one and it just stops. It sort of, it just, there’s a big bone and then it just stops. It’s … frights you a bit that it’s like that Couldn’t quite do it yet. Yeah, it was more of the, the Michael frustration than anything. Like I say, it’s, that’s, I think it’s the brain that makes the body get better. It’s got to be because, keeping focused and having that goal Over the past 8, 6 to 8 weeks, um, it [flashbacks] started to happen more and more often, and then it started to interrupt Lewis 19 Page 21 of 24
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Taking advice Trusting the experts
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Doing the right thing
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2. Getting the right help to get there
sleep and stuff like that. And I started to take out general anger with my friends and my girlfriend and people like that I take notice of everything they say. I like to, I just want to Neil get better, that’s me main aim to get better …. Well I, just do things what they say
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It’s up to me
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I do the exercises to strengthen the muscles. But et, that the Kevin rehab team gave me. I do those three times a day.
My responsibility
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Being a burden on others
The physio was saying it was toe touch, whereas what the surgeon had said was non-load bearing at all on the left, so Gary there was a bit of conflict going on there, a bit of confusion
Basically at the end of the day, it’s up to me I think. Whether Beth I, I mean obviously the operations and things weren’t up to me, but I feel the physio, it, it’s you can get the best advice, but unless you take it and get on with it you may not get the best result Rehabilitation, getting back on your feet and getting help to Chris get there And I must have waited I don’t know how long, ages. Four weeks, I can’t remember. I don’t know how long it was. Anyway nobody came in touch with us. So I ended up phoning …. And I was just, was just in a bit of limbo, and Owen that’s probably when you do your own thing So I’m happy to admit that I’ve been emotional but I Alice
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Impact on others Changing relationships Using limited NHS I think Kath’s done very well really. I mean she had a lot to John resources cope with
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of Measuring progress
It had a detrimental effect on how often my children. Um Chris because obviously I couldn’t do the football run and the dancing run and things, things that normally, normally that I would do and that would be, you know, my few hours with the, the kids and stuff and so … that side of it, it kind a … gets you quite low I’ve tried not to give the NHS any more work than they’ve had to have Frank If you can set goals, it’s a good idea, yeah. [Why?]. Well, Owen because if gives you something to aim for doesn’t it?
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Managing expectations Achievable milestones, If there’s a clear quantified level, then you know where you setting new ones are and it’s measurable ….. you always want to beat your last Ewan score don’t you? Regaining old me If I could get on my feet and walk. If I can walk, I’ll be happy. Even if I’ve got to walk with a stick, as long as I can, Dave like, can get out and go to the shops Regaining independence But it was being able to sit on a rock and look at a stream Alice [tearful] and that actually, and that is a funny thing to get – Achieving and doing emotional about, that is the thing. Just being outside, under
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3. Regaining normality
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certainly don’t, didn’t want to burden other people with my crap, you know
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Feeling: pleasure
confidence, my own steam on my own is fantastic. That was the bit, getting my, my core pleasure back, was being outside on my own
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Redefining me
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I used to cycle to work every day, and um, I’m quite Beth enjoying not cycling so I don’t have to get changed when I get into work and I don’t have helmet hair I kind of think it’s made us stronger. I know more, I was determined and had stamina before and I think I’ve got even Michael more than I had then
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NHS, National Health Service.
Accepting limitations Normalising new me
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I started to feel better towards the end of my time off; I did Ewan actually start to enjoy my time off. You know I could actually start going out and doing things when I physically and emotionally felt a bit better
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