Experiences, views and perceptions of recovery following musculoskeletal trauma of patients and physiotherapists: a qualitative study

Abstract

The aim of this qualitative phenomenology study using two methods (semi-structured interviews, focus groups), was to explore patients’ and physiotherapists’ views and perceptions of recovery, and what constitutes successful recovery following musculoskeletal trauma within the early stages of recovery. Participants were recruited from one major trauma centre in the United Kingdom and data collected via Microsoft Teams, or via a telephone call. Inclusion criteria for patient interviews: purposive sample of adults (≥18 years) who sustained a traumatic musculoskeletal injury, admitted as an inpatient within 4 weeks of injury, mental capacity, and able to communicate in English. Purposive sampling included age, gender, and injury characteristics. Focus group inclusion criteria: physiotherapists with experience managing patients with musculoskeletal trauma. Interviews and focus groups were informed by an evidenced based topic guide, audio recorded and transcribed verbatim. Trustworthiness of the data was strengthened using multiple strategies, e.g., member checking. Interpretative Phenomenological Analysis was used for the patient interviews and the Kreuger Framework for the focus groups. Participants included 17 patient interviews and 10 physiotherapists in two focus groups. Three themes emerged from patient interviews: understanding and impact of the accident and injuries, the early stages of recovery and physiotherapy, and healthcare and setting influences. Eight themes emerged from the focus groups: process of recovery, what is being fully recovered, it’s more than just communicating with the patient, psychological impact of trauma affecting recovery, system influences/resources for recovery, influencers to recovery, barriers to using patient reported outcome measures to evaluate recovery, and what actually is useful to measure in trauma? Recovery following musculoskeletal trauma is complex, individual and focused on returning to ‘normal’. Similarities across patient and physiotherapist views of recovery exist. Differences between participant groups were evident, centred on communication and what is important to the patient in their recovery.

Introduction

Injuries following a traumatic event such as a fall or road traffic accident are common globally [1]. Annually, it is estimated up to 500,000 people are involved in a traumatic accident in the UK [2–4], and with advances in healthcare more people are now surviving complex injuries [5]. Patients often require complex rehabilitation beyond 12 months, with 30–40% of survivors not returning to their pre-injury level of work and daily activities within 12–24 months following injury [6–8]. High pain intensity at injury, psychological factors such as post-traumatic stress disorder (PTSD), reduced self-efficacy, and education levels have been suggested as prognostic factors associated with recovery [6,9–12]. Most of these studies [6,9–12] use pain as a measure of recovery, with ‘successful recovery’ not well defined within the literature. Various other outcome measures have also been used to define and measure recovery, including generic health related questionnaires such as SF-36, EuroQol, the Chronic Pain Grade Scale, return to work status and injury severity.

Current National Institute for Clinical Excellence (NICE) guidelines recommend a person-centred, individualised and holistic approach to optimise rehabilitation and recovery [4]. Physiotherapists are integral to rehabilitation aiming to reduce pain and restore function, and are key in signposting to other services and professionals where required [4].

Little is known about the patient perspective on recovery, what is important during their recovery, and what successful recovery means to them. This raises the question of whether we are using the most appropriate outcome measures to monitor recovery progress and highlights the need to explore the patients’ views on recovery. A recent qualitative systematic review aimed to synthesise current studies on patient perspectives of recovery [13]. This review included studies ranging from an early recovery to long-term recovery of up to 17 years. However, the studies which focused on early recovery (defined as less than 6 months) varied in methodological quality or were focused on very specific populations, e.g., tibial fractures or hand injuries. Furthermore, only one explored recovery within 35 days of injury, and this included just participants with lower limb fractures [14]. Systematic review findings highlighted the complexity of recovery with different themes emerging such as adapting and learning to manage their injuries [13]. However, no study explores the patient views and experiences at the very early stages following injury for all musculoskeletal trauma warranting further investigation. Evidence suggests that whilst distress following injury is a normal and expected response [15], prolonged distress in the weeks following the injury such as anxiety, catastrophic thinking, can predict poorer outcome [6,16–18]. It is vital to capture patient views and lived experiences at the early stage of recovery to understand how healthcare can support patients during this crucial time following injury when interactions with healthcare are at their highest. With a better understanding of the early recovery following the injury, there is potential to target interactions and rehabilitation interventions that are more patient centered, and shape recovery at an early stage, enabling a better return to function/return to work long term.

Physiotherapists are integral to rehabilitation following injury. However previous research focused on shoulder problems has found that physiotherapist views on recovery may not fully align with patient views [19]. To the authors knowledge no study has explored the views of physiotherapists on recovery and successful recovery in musculoskeletal trauma. It is imperative to not only gain the views of patients around recovery but to understand the views of physiotherapists on recovery, how they measure recovery, and whether this aligns with patient views.

Aim

To explore patients’ and physiotherapists’ views and perceptions of recovery, and what constitutes successful recovery in the early stages following musculoskeletal trauma.

Objectives

1. To understand and explore the initial stages of the patient journey following musculoskeletal trauma

2. To explore patients’ views and perceptions on the definition of successful recovery

3. To explore the physiotherapists’ views and perceptions of what they define as a successful patient recovery.

4. To explore views and perceptions of physiotherapists regarding outcome measures that are useful to assess recovery.

Methods

Design

A qualitative study was designed and undertaken using two complimentary methodologies according to a pre-defined and published protocol [20]. Both methodologies were situated within the same world view; Interpretative Phenomenological Analysis (IPA) with semi-structured interviews, [21], and the Krueger framework using interpretive hermeneutic phenomenology for the focus groups [22,23]. The reasons for and differences in these approaches can be seen in previous worked examples [24]. A critical reason for using different approaches was due to the inability to achieve specific outcomes of IPA from the focus group data, e.g., double hermeneutic. A world view of minimal hermeneutic realism was assumed. This view identifies that an external reality exists but the exact meaning is provided or constructed by an individual, in other words it is the encountering of facts which provides meaning to them [25]. This approach was taken and deemed important to undertake focus groups rather than individual interviews for the physiotherapists to gather multiple perspectives, generate discussion and monitor interactions rather than gaining individual perspectives in an interview [26]. Focus groups allow discussion and participants to share experiences and understanding which adds further meaning to the topic than semi-structured interviews alone, and has been used previously with IPA [27]. This study is reported according to Consolidated Criteria for Reporting Qualitative Studies (COREQ) and Standards for Reporting Qualitative Research [28,29].

Setting

Patients and physiotherapists were recruited from one Major Trauma NHS Trust Site within the United Kingdom. The Major Trauma Centre is the centre for Central England Trauma Network and serves a population of more than 1.9 million which has a mixture of both urban and rural areas. The area has a combination of some of the most affluent areas within the United Kingdom but also areas of deprivation with a broad range of ethnicities. Patients are accepted by road and helicopter and have access to therapies including physiotherapy, occupational therapy, speech and language and psychology assistants. Upon discharge they have access to the Major Trauma Signposting Network and can be referred to their local hospital, community teams or outpatient physiotherapy. This service provision will vary depending on the area and resources within the local teams.

Due to restrictions imposed by COVID-19, the patient interviews were conducted online via Microsoft Teams or a telephone call. The physiotherapist focus groups were conducted online via Microsoft Teams.

Ethical approval

This study was reviewed by London - Fulham Research Ethics Committee within the UK Health Departments’ Ethics Service and has gained approval from the Health Research Authority (HRA) (IRAS 287781/REC 20/PR/0712). The Research and Development team at the site approved and supported the study throughout. A participant information sheet was provided and written informed consent was obtained for all participants. Recruitment took place from Monday 6^th September 2021 to Friday 16^th December 2022.

Participants

Patient interviews.

Small sample sizes are traditionally used with IPA to achieve a rich detailed interpretive accounts with a homogenous population [30]. Past studies have however successfully employed IPA with up to 48 participants [31]. Acknowledging that the musculoskeletal trauma population can be heterogenous in terms of injury type, severity and location of injury etc, a higher sample size of 20 was sought to account for heterogeneity and ensure the breadth of the population was well represented in the study. A purposive sample was used to ensure a range of patient characteristics including age, gender, and injury characteristics including injury location, multiple versus single injuries and fractures versus soft tissue injuries were included.

Potential participants were identified through admissions lists of the major trauma and orthopaedic wards by a team of research nurses supported by the principal investigator (LS) using the pre-defined eligibility criteria. Participants were given a Participant Information Sheet (PIS) and the research nurse team returned within 24 hours and gained informed written consent for those willing to participate in the study. Participant contact details were then passed to lead researcher (NM) to organise the first interview. Recruitment continued until the Study Management Team (AR, AS, DF NH, NM) agreed that rich insight had been reached, and further recruitment would not add to understanding.

Physiotherapist focus groups.

A purposive sample of physiotherapists was recruited to capture both inpatient and outpatient physiotherapists with a range of clinical experience. This allows naturalisation and generalisation to the wider physiotherapy population [32]. A target of 10–12 physiotherapists was sought with the aim of completing 2 focus groups. Potential participants were identified by team leads and invited to participate in the focus groups. If interested, they were given the PIS and were asked to contact the lead researcher (NM). Written informed consent was obtained for all participants.

Eligibility criteria

Patient interviews.

Inclusion Criteria: Adults (≥18 years) who sustained a musculoskeletal injury from a traumatic event and were admitted to the major trauma/orthopaedic ward within 4 weeks of injury, mental capacity in order to give consent (score of more than 6 on the Abbreviated Mental Test) [33], and able to communicate in English.

Exclusion Criteria: Injury from a non-traumatic event or where the primary injury was a traumatic brain injury, spinal cord injury or neurological injury due to the different clinical pathway and recovery trajectory in which these conditions have.

Physiotherapist focus groups.

Inclusion Criteria: Any Health and Care Professional Council (HCPC) registered physiotherapist who was involved in the management of musculoskeletal trauma patients within the recruiting Major Trauma Centre.

Exclusion Criteria: No exclusion criteria

Data collection methods

Patient interviews.

Data was collected using in-depth semi structured interviews within 4 weeks of injury. The interviews were based on a topic guide developed by the research team and patient co-investigator using knowledge from a previous study [6] and informed by the International Classification of Function, Disability and Health (ICF) domains [34]. The majority of interviews (n = 10) were completed by the lead researcher (NM) with MM completing a small proportion (n = 7) whilst the lead researcher was on maternity leave. NM sought training in IPA approach from experienced researchers (AS, AR) and completed pilot interviews with the study patient co-investigator and two further cognitive interviews with patients who had experienced musculoskeletal trauma (members of the Centre of Precision Rehabilitation for Spinal Pain (CPR Spine) register/PPI group) prior to data collection. MM was experienced in conducting semi-structured interviews. All interviews were audio recorded and transcribed verbatim. Field notes and a reflexive diary was utilised to enhance trustworthiness of the data. The process of member checking was employed which allowed all participants the opportunity to review the transcript and add any additional comments and further insight [35].

Physiotherapist focus groups.

Data was collected using focus groups and led by the lead researcher (NM) and supported by a moderator (NH) who is experienced in conducting focus groups. Prior to the focus groups, NM sought training from experienced researchers (NH/AS/AR). The focus groups were based on a topic guide developed by the research team which aligned to the semi-structured interview topic guide to ensure similar topics were covered. NH was present for the focus groups and took field notes and monitored progress. All focus groups were audio recorded and transcribed verbatim. All participants were invited to review the transcript following the focus group and to add any additional comments/further insights.

Data analysis

Patient interviews.

Analysis consisted of four stages using IPA [36]

1. First read of transcripts by NM and MM independently.

2. Preliminary themes identified by NM and MM independently and coded in accordance with IPA. Discussion of preliminary themes with AS who acted as a critical friend during initial coding and presented to co-investigators

3. NM grouped emerging themes and presented these in a summary table with verbatim extracts. Themes were critically discussed with co-investigators (AR, AS DF, NH).

4. The summary table was subsequently presented to the Study Steering Group.

The injury severity score was used to categorise the injury severity. The Injury Severity scale is a retrospective tool used in a clinical setting where injury severity is rated using a numerical scale. The score ranges from 0–75 with a higher ISS score correlated with a greater risk of mortality. 0–8 is characterised as mild injury severity, 9–15 moderate and 10–24 major severity. A score over 25 indicates a profound injury. [37,38].

Physiotherapist focus groups.

Analysis consisted of four stages following guidance of the Kreuger Framework: [22,39]

1. NM read the transcripts several times

2. NM constructed a preliminary framework of themes and subthemes supported by supporting verbatim extracts and discussed with focus group moderator (NH)

3. Once the framework was developed, data was indexed and charted using a process of sorting and arranging quotations.

4. The framework was then presented to study management team (AS, AR, DF, NH) and Study Steering Group where the concept was defined, and findings explored for explanations and associations.

Transparency and trustworthiness of findings

To ensure trustworthiness multiple strategies were employed. Blind reviewing of the data in stage 1 and 2 (NM, MM) was completed. Presentation of the themes both at an early stage and later stage of analysis to the Study Management Group and to the Study Steering Group (NM, PPI co-investigator, LS, AS and independent chair) allowed peer and patient critique and collaborative approach. Additionally, acknowledging lead researchers potential preconceptions and beliefs and encouraging reflexivity enabled transparency [35].

Patient and public involvement

Patient and public involvement (PPI) has been integral to this project from inception. The study idea was presented to PPI groups at an early stage and has informed the development of the study including giving feedback on the initial idea, time points used and recruitment strategy. Our PPI co-investigator has been part of the study from inception and has provided feedback at the time of protocol and topic guide development and continued participation in the Study Steering Group Committee which included interpretation of the findings. Further detail on the role of PPI and Study Steering Group can be found in the published protocol [20]

Results

Participants

Patient interviews.

Twenty-five participants were recruited and consented to participate in the study. Of the 25, 8 participants did not complete the interview: 4 participants did not respond to emails/phone calls to arrange the interview, 2 requested to withdraw due to feeling they would not be able to discuss the accident and feeling overwhelmed following discharge, 1 died in the period from recruitment to organising the interview, and 1 experienced a change in mental capacity from recruitment to interview. Therefore, 17 participants were interviewed with their characteristics summarised in Table 1. The average time from injury to completing the interview was 23 days (range 5–44 days). Whilst the majority (n = 12) of the interviews were completed within the 4 weeks of injury. It was not possible due to other medical commitments, e.g., surgery and rehabilitation and being medically unwell to capture all participants within that time period. It was deemed valuable to include the data within the study and this highlights the challenges in capturing experiences at this crucial timepoint. The interviews lasted between 40–60 minutes. The majority of interviews were conducted after the patient had been discharged (n = 13) with n = 4 completed whilst the participant was an inpatient.

[Figure omitted. See PDF.]

Physiotherapist focus groups.

Ten physiotherapists (5 per focus group) were recruited and consented (female n = 8, male n = 2). Years qualified ranged from 14 months to 16 years including a range of junior staff to clinical specialist/team leader included. At the time of recruitment, the aim was to recruit both inpatient and outpatient physiotherapists for the focus groups. However, due to staffing and hospital pressures at the time of recruitment, all the participants were currently working within an inpatient setting and no current outpatient physiotherapists were included in the focus groups. This was discussed within the SSG and SMG with the pragmatic decision to stop recruiting for the focus groups. Both focus groups were 60 minutes in duration.

Findings - emerging themes

Patient perspectives.

Three main themes emerged: Understanding and impact of the accident and injuries, the early stages of recovery and physiotherapy, healthcare and setting influences. All participants embarked on a journey of recovery following their injuries and their progression through different stages of this recovery journey was individual regardless of severity of injury, mechanism of injury, age or gender. Some subthemes across the main themes are identified are the ‘process’ in which the participants go through as part of their journey, whereas some subthemes could potentially either negatively or positively impact on their journey and experience of recovery. All themes and subthemes are presented in Fig 1 and Tables 2–4-4.

[Figure omitted. See PDF.]

Those in blue represent the process of recovery with the red and green highlighting factors which are the researcher’s interpretation of what could negatively or positively impact on the recovery journey.

Understanding and impact of the accident and injuries.

Participants discussed the accident and injuries in detail during the interviews and it was clear that processing what happened to them required a significant amount of mental energy. This then linked to theme 2 (the early stages of the recovery journey) where they were starting to process their recovery. The consequences of the injuries affected all aspects of life which linked to the feeling of burden and guilt to which it has impacted on family and others. The loss of independence was evident, but this was not just described as the physical aspects such as walking and activities of daily living, but social aspects being important to them as well. Multiple emotions were highlighted including anger, frustration, and fear. There were however some positive changes to attitude and lifestyle, e.g., quitting smoking and feeling grateful towards healthcare professionals despite their experiences not always being positive (theme 3). Further detail on subthemes can be found in Table 2.

[Figure omitted. See PDF.]

The early stages of the recovery journey.

All participants embarked on a journey following injury but the speed at which they progressed through recovery was individual and appeared not to be related to injury severity, physical injury healing times, or time elapsed since injury. For example, a participant may have a more established understanding of what their recovery journey and successful recovery may look like. Other participants may be unsure what their recovery may look like and are looking for more guidance from healthcare professionals to help understand this journey and therefore have less focus on what successful recovery may look like. There were multiple reasons why some participants had a better understanding of their recovery journey, and this was individual to them. All subthemes in the early stages of the recovery journey give context for their current definition of successful recovery with successful recovery defined by all patients as ‘returning to normal’. This definition of normal was individual to them. Further detail on subthemes can be found in Table 3.

[Figure omitted. See PDF.]

Physiotherapy, healthcare and system influences to recovery.

There was a clear focus on the management of injuries rather than the individual with patient centred care often being overlooked. Discharge was often seen as being rushed, disjointed, and criteria based rather than patient led. For those who had been discharged at the time of interview, there was a feeling of a loss of a safety net upon discharge which created anxiety and worry amongst some participants and a heavy reliance on their support network (theme 1). There was a feeling of mixed messages with lack of consistency in what patients were told during their inpatient stay which impacted on their understanding of their recovery journey. Further detail on subthemes can be found in Table 4.

[Figure omitted. See PDF.]

Physiotherapist perspectives.

Eight overarching themes were identified: Process of recovery; What is being fully recovered?; It’s more than just communicating with the patient; Psychological impact of trauma affecting recovery; System influences/resources for recovery; Influencers to recovery; Barriers to using patient reported outcome measures (PROMs) to evaluate recovery; What actually is useful to measure in trauma? All themes and subthemes are summarised in Fig 2 and Table 5

[Figure omitted. See PDF.]

[Figure omitted. See PDF.]

Process of recovery.

There was agreement that there is a process and stages of recovery that all patients experience, and that recovery is individual to the patient. It was highlighted that how patients understand and process the injuries sustained is part of recovery and education throughout was an important aspect of recovery. Further detail on subthemes can be found in Table 5.

What is being fully recovered?.

There were multiple definitions of being fully recovered but importance was given to the idea that being fully recovered is individual to the patient. Recovery was defined as the patient’s pre-injury status but also defined as when the patient is happy with their level of function. However, in theme 6 (influencers to recovery), it was acknowledged that reaching pre-injury status/level of function wasn’t always possible for patients and this was related to injury severity highlighting the difficulty in one clear definition for being fully recovered. Further detail on subthemes can be found in Table 5.

It’s more than just communicating with the patient.

Communication was discussed throughout the focus groups as being of high importance. In particular, communication between multidisciplinary team (MDT) members to inform practice and ensure consistent messaging as well as good communication with the patient was emphasised. It was also acknowledged that it’s not just about communicating to the patient but that actively listening to patients is also important in recovery. There was no discussion around active listening to MDT members. Further detail on subthemes can be found in Table 5.

Psychological impact of trauma affecting recovery.

Psychological impact was discussed as affecting all who sustained a traumatic injury, but it was acknowledged that this didn’t mean a ‘formal diagnosis’ of a mental health disorder such as PTSD. Loss of independence and identity, fear of not returning to normal, acceptance, and a period of adjustment were all acknowledged as psychological factors observed which can affect the recovery journey. Further detail on subthemes can be found in Table 5.

System influences/resources for recovery.

Hospital pressures were discussed at length and how this affected the patient journey and recovery as well as lack of provisions for musculoskeletal trauma participants such as long-term rehabilitation and psychological support. It was highlighted that there was change within the local service to address some of these provisions particularly around psychological intervention and support, and this impacted positively on the recovery journey. Further detail on subthemes can be found in Table 5.

Influencers to recovery.

A number of factors physiotherapists have observed which could influence patients’ recovery were discussed, which included financial and occupational pressures, psychological wellbeing, medical management, and severity of injury. Further detail on subthemes can be found in Table 5.

Barriers to using patient reported outcome measures.

Multiple barriers were voiced when discussing PROMs including the practicality of using them in an inpatient setting (e.g., too long to complete), lack of specificity in capturing change and progress, and routine clinical practice does not use PROMs. Further detail on subthemes can be found in Table 5.

What actually is useful to measure in trauma?.

There was discussion around what would be useful to measure following musculoskeletal trauma and whether PROMs or physical measures would be useful and whether function would be more appropriate to monitor. There was also discussion around whether there is a full understanding of what needs to be measured is currently unknown and that the heterogeneity in the musculoskeletal trauma population makes this challenging. Further detail on subthemes can be found in Table 5.

Coherence and differences between patient and physiotherapist perspectives.

Coherence between themes of patients and physiotherapists were identified across all themes. These included that recovery is a journey and this needing to be individual and meaningful to the patient. Both patients and physiotherapists talked about the psychological impact on recovery including fear, adjustment and acceptance following the accident and accepting the injury were important and can affect recovery. It was recognised that patients wanted to focus on positive aspects of recovery and positivity and wellbeing was important for successful recovery. Both patients and physiotherapists discussed a shortfall in care with patients describing their care as being criteria led and discharge being quick and not well supported. Physiotherapists echoed this describing that the hospital system and pressures in the hospital impacts their ability to engage fully with the rehabilitation needs of the patient.

There was, however, differences observed between patient and physiotherapist views. The physiotherapists highlighted that communication, active listening and education was integral to the recovery journey and successful recovery and this was part of routine practice, yet patient views and experiences reported mixed messages and confusion. The definition of recovery also differed with the patients reporting this as normal and as they were before with the physiotherapist’s definition centered around a medical model framework which included to the severity of injury and medical management of the injuries. Finally, the patients discussed in detail trying to make sense of the accident and injuries and the impacts this may have on them, but this was not discussed or highlighted within the physiotherapist focus groups. Fig 3 illustrates the common themes which are similar/different between patients and physiotherapists

[Figure omitted. See PDF.]

Discussion

This study aimed to explore the patient and physiotherapists views and perceptions of recovery and what constitutes recovery in the early stages of recovery following musculoskeletal trauma. The findings highlight the complexity of recovery in this population.

Key findings from patient interviews indicate that understanding and processing the accident and injuries are significant in the early stages of recovery. The early stages of recovery was similar irrespective of injury severity, age or gender, and did not appear to follow standard soft tissue healing trajectories. Successful recovery was consistently defined as returning to ‘normal’. Multiple influences can positively or negatively affect the early stages of recovery.

Key findings from the physiotherapist focus groups showed similarities to patient interviews where system influences and influencers to recovery were discussed. However, differences in views on communication and definitions of successful recovery were noted. Barriers to using PROMS and what is useful to measure in trauma rehabilitation demonstrated the complexity in this population. Physiotherapists highlighted that recovery was individual but their definition of successful recovery was more to do with when the patient was happy with their level of function. Communication was emphasised as being important with the MDT and the patient, with psychological impact noted as being significant. Other factors influenced recovery from both system and individual perspectives. There were multiple barriers to using outcome measures with no single outcome measure being fit for purpose in this population.

The findings support current literature that the recovery process is complex and individual, with issues of poor communication with healthcare staff and multiple emotions experienced by patients [13,40–45]. The study also adds new insight into the lived experience at at a crucial early timepoint following soon after the injury and accident has occurred. Key new findings include that patients define recovery as returning to ‘normal’ soon after the injury has occurred. Crucially, this differs from the physiotherapist views which is more aligned to a medical model framework. Findings also highlight that patients spend considerable time in the early stages following injury to understand and reflect on their injuries and accident. This study has also found that recovery does not always follow align with physical injury healing times. This is the first study capturing physiotherapists’ views specifically to musculoskeletal trauma, providing greater insight into challenges currently faced within healthcare and their potential influence on patient care.

This study is unique including all severity of injuries, whereas the majority of previous literature focuses to more major injuries only [40,46,47]. Findings suggest that injury severity and using timepoints aligned with physical injury healing times to assess and progress rehabilitation may not be helpful. Instead, focusing on individual needs at point of contact and referring to specialist services for all musculoskeletal trauma regardless of injury severity would provide individualised patient centred care. Current NICE guidelines acknowledge that rehabilitation needs may not correlate with injury severity should focus on patient needs at the time of assessment [4]. However, these guidelines focus on the initial rehabilitation phase during the inpatient stay rather than at any point of contact following injury, leaving the current model of follow up aligned with physical injury healing times [4]. While appropriate for progressing weight bearing status following a lower limb fracture for example, this model of care is more focused to a medical model than holistic patient centered approach. This medicalised model approach therefore has the potential to lose focus on the emotional response to injury and recognising when this response is prolonged and unhelpful to recovery [15,48]. The findings support the importance of supporting patients both physically and emotionally, with previous studies demonstrating that psychological support is often limited [48]. Additionally, patients described the feeling of losing their ‘safety net’ upon discharge and the significant amount of time participants spent during the interviews discussing and processing the injuries and accident. The need for support following discharge has been reported previously from patients with musculoskeletal trauma both physically or emotionally [13,49,50]. Access to healthcare support was often not a positive experience shifting reliance to family and friends with previous literature supporting this finding [51]. Evidence suggests in both musculoskeletal trauma and other conditions such as traumatic brain injury that intensive rehabilitation can be effective for long-term recovery [52–55]. However, most studies focus on the inpatient stay rather than upon discharge. Additionally, due to limited resources within the NHS, intensive rehabilitation may not always be possible in all areas of the country and nations. The results highlight care provision shortcomings and discharge is described as quick with limited support. There is a need to investigate cost effective ways of supporting patients, especially within the first few months following injury when support is needed rather than just at point of physical injury healing time reviews, i.e., fracture clinic. Examples of novel ways in healthcare of supporting patients upon discharge include digital health interventions such as remote monitoring or telehealth [56,57] and could be considered in the future for this cohort of patients.

The complexity of recovery was highlighted in the physiotherapist focus groups with no consensus on the most appropriate outcome measure or what could be used to show recovery progress. Currently, there is no recommended core outcome set for the musculoskeletal trauma population, despite some having been developed for specific injuries such as open lower limb fractures [58], highlighting the challenges in developing suitable outcome measures for this population.

Coherence between patient and physiotherapist perspectives

This is the first study to explore and compare the views and perceptions of physiotherapists and patients specifically related to musculoskeletal trauma. Multiple themes illustrate consistencies across the patient interviews and physiotherapist focus groups. For example, factors influencing recovery such as psychological impact, fear of reinjury and the period of adjustment and acceptance were discussed in both focus groups and patient interviews as well as the system pressures affecting recovery. However, views on what successful recovery meant to patients, and what physiotherapists felt was important to patients differed. A significant difference highlighted is that communication was continually discussed within the focus groups as critical to recovery, whilst the patient interviews highlighted this was often not the case. Whether communication was between MDT members and the patient, or between MDT members it was highlighted as lack of consistency in messages to the patient. This could be due to multiple factors. Firstly, hospital pressures could impact the care patients received overall, and this could therefore potentially impact on communication to the patient. This has been reported in the literature in other conditions such as stroke [59]. Secondly, in the early stages of recovery patients are processing their injuries and experiencing potential side effects of medication and pain [6,60], which could affect how well the patient can understand and retain information in this early stage of recovery. Exploring how best to communicate key information to patients during the early stages of recovery and following discharge could allow better understanding and engagement in rehabilitation despite potential barriers such as high pain intensity.

Another noteworthy finding is that injury severity was seen as being a factor which can influence recovery and what patients could achieve, with physiotherapists feeling the injury severity should dictate rehabilitation following injury. This contrasts with patients’ views who wanted to return to ‘normal’ regardless of injury severity. This aligns with findings in a study focused to shoulder problems, where patient definitions of successful recovery varied and focused to meaningful activities, whilst physiotherapist definitions were focused on when the patient could ‘manage’ on their own [19]. Although direct comparisons cannot be made as this study was focused to shoulder problems, it highlights differing views between patient and physiotherapist around recovery and highlights a wider problem within physiotherapy practice. However, it is unclear why patient and physiotherapist views do differ. A potential explanation could be the influence of preconceived ideas or unconscious bias which have been formed through education and clinical experience [61,62]. This could explain why physiotherapists perceive they are addressing patient needs but patient experience differs. Unconscious bias can influence how healthcare interact with patients and influence decision making with detrimental effects [61–63]. Whilst existing research on unconscious bias often focuses on ethnicity, gender, age etc [61], little is known about it’s impact on injury perceptions and clinical decision making. Further research is needed around unconscious bias in clinical decision making, and how to support clinicians in managing patients following musculoskeletal trauma. Developing of a framework which could assist clinicians in how they can manage difficult conversations and potentially manage any known pre-conceived ideas such as injury severity could be useful.

Strengths and limitations

A strength of this study is that it incorporates both patient and physiotherapist views, providing greater insight into the early stages of recovery from a service level as well as patient experience. This study also explores the breadth of injury severities rather than focusing on major injuries. Interviews were conducted at an early timepoint (5–44 days post injury) to capture participants’ initial thought processes on their recovery as it is occurred making this research novel. Further research is now required to compliment these findings at later timepoints in a longitudinal approach to understand the recovery journey in its entirety. Alongside the patient views, this study has captured physiotherapists views allowing a more comprehensive understanding of recovery and rehabilitation following musculoskeletal trauma.

Patient and public involvement has been integral to this study from inception with strategies to ensure trustworthiness, such as participants reviewing transcripts following interviews and focus groups. Although participants could have reviewed the synthesised findings to further enhance the trustworthiness of the data, this was a pragmatic decision a-priori following discussion with PPI groups to avoid overburdening participants during this difficult period of transition following the injury.

A limitation of this study was the physiotherapists were only from an inpatient setting. While some of these clinicians did have outpatient experience, this was not their current focus. Considerable efforts were made to recruit outpatient staff, but due to the timing of the study, staff capacity to participate was restricted. This was discussed within the Study Steering Group and Study Management Group, leading to the pragmatic decision to stop recruiting for the focus groups. Future studies incorporating outpatient physiotherapists’ views on recovery would be beneficial. Additionally, although focus groups are useful for generating discussion and gaining different viewpoints, there is the risk that dominant voices within the group could limit alternative views, and could be seen as a limitation of this method. However, every effort was made to reduce thus risk, including having a moderator for the focus group and setting out expectations at the beginning of the group that we are all views were of interest.

Another limitation is that while every effort was made to complete the interviews within four weeks of injury, this was sometimes not possible for all participants due to medical procedures, and the patient preference to complete the interview at home upon discharge for privacy. From the analysis completed, this did not impact the results and themes presented and provided additional insight into the few weeks following discharge, which might not have been captured otherwise. Future studies should consider capturing data within six weeks of injury to allow adequate participation and rich data. Additionally, it is recognised that this is a challenging time for participants, reflected in that two participants withdrawing from the first interview due to feeling unable to discuss their accident/injuries. While these additional insights are not reflected within this study, they highlight the importance of support and guidance for patients in the early stage of recovery.

Finally, all interviews and focus groups were conducted face to face online, with one interview being conducted via the telephone. Face to face interviews in person were not possible due to the COVID pandemic. However, video calling allowed observation of body language and collection rich, insightful data. Although one telephone interview was conducted without observing body language, this participant could not access video calling technology. It was decided a-priori to include telephone interviews as an option to be inclusive and representative of the population.

Conclusions

The early stages of recovery are complex and individual to the patient. Recovery does not follow injury healing trajectories and is irrespective of injury severity, age or gender. Considerable time in the early stages following injury is processing the injuries and accident with a clear definition of successful recovery is returning to normal. Multiple influences impact on the early stages of recovery. Differences in key messages between the patients and physiotherapists have been highlighted. This highlights the need for effective communication and a development of a framework which would support all members of the multi-disciplinary team in supporting patients in their recovery. Future studies exploring patient views of their recovery at later stages of their journey are now required.

Supporting information

S1 File. Supplementary File 1: Interview and Focus Group Audit Trail.

https://doi.org/10.1371/journal.pone.0323575.s001

(DOCX)

S2 File. Supplementary File 2: COREQ Checklist.

https://doi.org/10.1371/journal.pone.0323575.s002

Acknowledgments

With thanks to Carla Jarrett (PPI representative) who has shaped this study and contributed to the study steering group. With thanks to Dr David Keene for chairing the Study Steering Group.

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Citation: Middlebrook N, Heneghan NR, Moffatt M, Silvester L, Falla D, Rushton AB, et al. (2025) Experiences, views and perceptions of recovery following musculoskeletal trauma of patients and physiotherapists: a qualitative study. PLoS One 20(5): e0323575. https://doi.org/10.1371/journal.pone.0323575

About the Authors:

Nicola Middlebrook

Roles: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Validation, Visualization, Writing – original draft, Writing – review & editing

E-mail: [email protected]

Affiliation: Department of Health Professions, Faculty of Health and Education, Manchester Metropolitan University, Manchester, United Kingdom

ORICD: https://orcid.org/0000-0003-2154-5723

Nicola R. Heneghan

Roles: Conceptualization, Formal analysis, Funding acquisition, Methodology, Validation, Writing – original draft, Writing – review & editing

Affiliation: School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom

Maria Moffatt

Roles: Data curation, Formal analysis, Project administration, Validation, Writing – original draft, Writing – review & editing

Affiliation: School of Allied Health Professions and Nursing, Institution of Population Health, University of Liverpool, Liverpool, United Kingdom

ORICD: https://orcid.org/0000-0002-8385-7418

Lucy Silvester

Roles: Formal analysis, Project administration, Validation, Writing – original draft, Writing – review & editing

Affiliation: Institute for Applied & Translational Technologies in Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom

Deborah Falla

Roles: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Validation, Writing – original draft, Writing – review & editing

Affiliation: Western University, School of Physical Therapy, London, Ontario, Canada

ORICD: https://orcid.org/0000-0003-1689-6190

Alison B. Rushton

Roles: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Validation, Writing – original draft, Writing – review & editing

Affiliation: Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom

ORICD: https://orcid.org/0000-0001-8114-7669

Andrew A. Soundy

Roles: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliation: School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom

ORICD: https://orcid.org/0000-0002-5118-5872

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[/RAW_REF_TEXT]

[/RAW_REF_TEXT]

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[/RAW_REF_TEXT]

References

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15. Sim A, McNeilage AG, Gholamrezaei A, Rebbeck T, Ashton-James C. Impact of healthcare interventions on distress following acute musculoskeletal/orthopaedic injury: a scoping review of systematic reviews. BMJ Open. 2024;14(7):e085778. pmid:39025825

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17. Nota SPFT, Bot AGJ, Ring D, Kloen P. Disability and depression after orthopaedic trauma. Injury. 2015;46(2):207–12. pmid:25015790

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20. Middlebrook N, Heneghan NR, Falla D, Silvester L, Rushton AB, Soundy AA. Successful recovery following musculoskeletal trauma: protocol for a qualitative study of patients’ and physiotherapists’ perceptions. BMC Musculoskelet Disord. 2021;22(1):163. pmid:33568110

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22. Krueger RA. Analyzing & reporting focus group results [electronic resource]./ Richard A. Krueger. London: London: SAGE; 1997.

23. Krueger RA. Focus groups: a practical guide for applied research. Sage Publications. 2014.

24. Spiers J, Riley R. Analysing one dataset with two qualitative methods: The distress of general practitioners, a thematic and interpretative phenomenological analysis. Qualitative Research in Psychology. 2018;16(2):276–90.

25. Larkin M, Watts S, Clifton E. Giving voice and making sense in interpretative phenomenological analysis. Qualitative Research in Psychology. 2006;3(2):102–20.

26. O.Nyumba T, Wilson K, Derrick CJ, Mukherjee N. The use of focus group discussion methodology: Insights from two decades of application in conservation. Methods Ecol Evol. 2018;9(1):20–32.

27. Palmer M, Larkin M, de Visser R, Fadden G. Developing an Interpretative Phenomenological Approach to Focus Group Data. Qualitative Research in Psychology. 2010;7(2):99–121.

28. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. pmid:17872937

29. Karendal B. Effect of heparin or saline dilution of blood on PCO2 and pH. Ups J Med Sci. 1975;80(3):175–7. pmid:1888

30. Smith J, Osborn M. Interpretative phenomenological analysis. In: Smith J, editor. Qualitative psychology: a practice guide to methods. 2nd ed. ed. London: Sage. 2007.

31. Brocki JM, Wearden AJ. A critical evaluation of the use of interpretative phenomenological analysis (IPA) in health psychology. Psychology & Health. 2006;21(1):87–108.

32. Ritchie J, Ormston R, McNaughton NC, Lewis J. Qualitative Research Practice: A Guide for Social Science Students and Researchers. London: SAGE Publications Ltd; 2013.

33. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing. 1972;1(4):233–8. pmid:4669880

34. WHO. International Classification of Functioning, Disability and Health: ICF: World Health Organization 2001. Available from: https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health#:~:text=ICF%20is%20the%20WHO%20framework,and%20measure%20health%20and%20disability.

35. Rodham K, Fox F, Doran N. Exploring analytical trustworthiness and the process of reaching consensus in interpretative phenomenological analysis: lost in transcription. International Journal of Social Research Methodology. 2013;18(1):59–71.

36. Biggerstaff D, Thompson AR. Interpretative Phenomenological Analysis (IPA): A Qualitative Methodology of Choice in Healthcare Research. Qualitative Research in Psychology. 2008;5(3):214–24.

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