Two separate conceptual models are presented, one each for patients in the MOTIFS and CaU groups in order to clarify the context in which MOTIFS training is perceived, and not to compare differences. Themes are presented in descending order of prevalence, from most to fewest references, and are marked in accordance with the corresponding figure, which shows major and more detailed subordinate themes. Selected participant quotations are presented in text as (P#) in order to illustrate the complex reality of participant experiences in the context of the generated conceptual models. Themes with fewer than three references are specified to indicate that they may not represent a distinct pattern.
Motor Imagery to Facilitate Sensorimotor Re-Learning
Three major themes were identified from patients in the MOTIFS group (figure 1):
‘Rehabilitation training is strongly influenced by psychological factors’: patients described psychological responses to injury and/or rehabilitation, including both positive and negative factors, and perceived concrete strategies to influence these.
‘Interaction between biopsychosocial aspects of injury and rehabilitation training’: physical and psychological factors were perceived to interact, in which physical, psychological and social aspects influenced one another during rehabilitation.
‘Physical rehabilitation aims to prepare patients for return to activity’: patients described perspectives on physical aspects of rehabilitation, including readiness to return to activity, and treatment and/or interventional strategies.
Figure 1Conceptual model generated from interview responses of patients in the Motor Imagery to Facilitate Sensorimotor Re-Learning (MOTIFS) group including major and more detailed subordinate themes. PT, physical therapist.
Major theme: ‘Rehabilitation training is strongly influenced by psychological factors’
Patients described psychological aspects, providing unique perspectives on rehabilitation training, as those in this group were speaking from the experience of using MOTIFS training. Patients referred to psychological reactions and responses to rehabilitation, characterised by perceptions and feelings which arose as a result of training-related factors. Negative responses or barriers (figure 1—MOTIFS 1a) were described as the hardest part, resulting in a negative physical self-image, which may have resulted in feeling "totally handicapped" (P03). Absence from activity ("I’ve been away from floorball for so long, you almost forget how it can be" [P01]) and a lack of enjoyment and motivation ("certain times can feel hard and unmotivated and boring" [P04]) were perceived causes of this. Fear was also a perceived barrier to psychological readiness ("You were afraid for your knee, so it was hard to get into like, soccer-mindset. It was more, like, 'don’t step wrong-mindset’"[P10]). These results indicate that rehabilitation constitutes a negative change from patients’ usual lives.
Patients also discussed perspectives on return to activity (MOTIFS 1b), including feeling "scared for my knee. That the same thing will happen again" (P02). Desire to return may depend on perceived significance of the activity, as one participant described feeling "such freedom when I play soccer" (P02), and others perceived enjoyment and athletic identity as strengthening their desire to return to activity ("floorball has been such a big part of my life […] so I chose to fight my way back" [P01]). This implies that psychological aspects play a large role in determining how a knee-injured person views returning to activity following an injury.
Undergoing rehabilitation training also included positive responses and facilitators (MOTIFS 1c) to completing rehabilitation training. One participant perceived rehabilitation as a "kind of a social thing, too" (P04), possibly resulting from having a common focus on using MOTIFS to create sport-specific rehabilitation ("we were very focused on soccer, there were […] a couple others that were also soccer players" [P10]). Another believed self-confidence facilitated training and alleviated psychological barriers, because discussions with the PT in MOTIFS training provided evidence that "I’ve made it once, so I can do it twice, so [rehabilitation] is nothing scary" (P01). Positive motivation was psychologically important to rehabilitation compliance, as MOTIFS clearly connects to participant desires and interests ("I’ve always known I could […] go far in soccer. So I’ve never doubted- I know I have to give 100% [in rehabilitation]" [P10]). Patients indicated that, despite changes from normal preinjury physical and psychological states, rehabilitation included positive aspects which aid in encouraging effective rehabilitation training.
Psychological strategies were described that alleviated negative reactions and/or strengthened positive reactions. Using MOTIFS to integrate imagery was a psychological strategy (MOTIFS 2a), perceived as new and sometimes difficult, because imagery requires that one "really […] think about how you do things, like how I normally do it on the field’"(P03). One participant clarified that imagery gets easier over time and two "thought it was fun" (P10). Imagery was implemented using "a stick and a ball in the [clinical] environment […] to get into the mindset of ‘this can happen on the floorball court,’ and to see it in front of me" (P01) in order to "practice in my mind, […] so I get myself to the right place at the right time and play smart" (P10). Patients perceived that imaging sport-specific movements created training which was "specific to floorball […], so you could definitely say that [MOTIFS] is preparation to play for real again, with these exercises we’ve done with different directional changes" (P04).
Goal setting in connection with MOTIFS training was perceived to positively influence motivation (MOTIFS 2b) through goal-directed and activity-specific discussions ("in a month I’ll be able to run, in a month I can play floorball" [P01]; "I’m reminded all the time of why I am doing [rehabilitation]" [P01]). Two patients saw on-field MOTIFS training as an environmental psychological strategy (MOTIFS 2c), which provided a method of coping with difficulties. Having no strategy was a possibility (MOTIFS 2d), with one participant describing that "I didn’t really have any strategy not to think about it, because [the knee] was always reminding me" (P03) in the beginning of rehabilitation. However, MOTIFS exercises were "more similar to sport than the [CaU] exercises were. And then – you got to feel it – handball – in some way, even though it wasn’t for real" (P03), leading to a perception that MOTIFS "prepar[ed] me more than I think I normally would" (P03). Overall, MOTIFS training was perceived as a method of preparing for return to activity.
Major theme: ‘Interaction between biopsychosocial aspects of injury and rehabilitation training’
When discussing rehabilitation, patients clearly referred to the way in which physical, psychological and social factors are inter-related. This resulted in conceptually different perspectives than either physical or psychological reactions.
Patients indicated that both psychological and physical factors can be influenced by social and environmental aspects in their lives. PT-specific interactions (MOTIFS 3a) during MOTIFS training were important because PTs "were fun and they could joke around, and it wasn’t just like ’doctors’ […], it was fun" (P10). Support such as adapting communication and knowledge transfer strategies using "the simple names, so to speak, not those complicated names, […] like Greek names" (P02) influenced physical and psychological aspects of rehabilitation. This was perceived to help manage rehabilitation expectations, understanding that "this is what’s going to happen in a few months, next time we’ll do this" (P01) and connected them to the PT and exercise design ("because [PT] has also played handball, so we discussed, like, what are- what kind of situations can happen" [P03]). Participant responses highlighted the important impact the PT had on physical and psychological rehabilitation experiences.
Patients experienced other sources of social influence (MOTIFS 3b), perceived as coming from friends and family "that have said like ‘you’ve come so far, so you have no reason to give up’" (P01), which can impact training quality or frequency. However, negative support also occurred ("[my teacher] said if you want to continue with soccer and if something happens to your knee again, it’s not going to be like before. You might not even be able to work." [P02]). This shows that a person’s social network, including PT, sport and private life influences, can impact rehabilitation perspectives and behaviours.
Two patients felt that sport-specific MOTIFS training provided necessary physical and psychological return to sport or activity (MOTIFS 4a) preparation ("you don’t get the same feeling [in CaU], and then you maybe don’t do it in the same way." [P03]; ‘"[MOTIFS] helps more in the head, to get back in the mindset […], it’s helped both physically and mentally’"[P01]). MOTIFS integrates activity-specific rehabilitation training, which "helped me think back on it and actually get into those situations, and also prepares my knee" (P01). Patients suggested a need to rehabilitate sport skills by training "individual technique, and a little that you need to get back that you have lost during the injury period" (P01). Physical-based factors (MOTIFS 4b) including exercise difficulty ("some sessions were a little bad because it was hard to do them" [P02]; "I liked it because it was challenging" [P10]) and pain may have influenced rehabilitation perceptions ("I’ve been limping the whole time, so it has always been a reminder" [P02]). Psychologically based factors (MOTIFS 4c) were also perceived to influence rehabilitation, including frustration and reduced confidence because "you know that you can do things - I can walk, I can extend my leg, but then it, like, doesn’t work" (P03). However, progression increased trust in one’s knee ("after a while, I see that my knee is pretty good, it’s holding well" [P02]). This theme indicates that patients are aware of the interaction between psychological impacts on physical training and that they perceived that MOTIFS training addressed this.
Major theme: ‘Physical rehabilitation aims to prepare patients for return to activity’
Rehabilitation was described as including a significant physical aspect, and patients discussed their thoughts on this. Patients perceived treatment, training and progression as including physical training strategies (MOTIFS 5a) focusing on range of motion ("bending the leg and extending the leg" [P03]), strength ("a bench that you lay on and just try to lift up your hips" [P10]) and hop ability ("jumping sideways, jump for distance" [P04]). The chosen strategy was perceived to be determined by evaluations (MOTIFS 5b), including discussions of symptoms ("how was it with your knee while you were sleeping and stuff" [P02]), and one participant described evaluations of side-to-side differences "in my hamstrings that should be a certain percent of the other hamstrings" (P04). Progression was perceived as being unclear in terms of overall timeframe (MOTIFS 5c), but could include prehabilitation exercises ("strength training to build up the muscles before – since it was a little uncertain how long it would take to get the operation" [P04]). Other interventions that were perceived to help regain function were described, (MOTIFS 5d) including orthotics ("I got one of these, like, robot legs, a brace" [P03]), cortisone, and operation. One participant described a lack of physical readiness to return (MOTIFS 6a), citing lack of physical ability and symptoms ("sometimes I have a clicking sound in my knee" [P02]), which relied in part on the PT’s opinion (MOTIFS 6b).
Care as usual
Two major themes were identified from patients in the CaU group (figure 2):
‘Rehabilitation training is strongly influenced by negative psychological factors’: patients perceived positive and negative psychological perspectives and described strategies used to address these.
‘Physical rehabilitation is a phase-based progression towards recovering physical function’: patients described their rehabilitation training and progression, as well as perspectives on physical barriers and the injury itself.
Figure 2Conceptual model generated from interview responses of patients in the care-as-usual group including major and more detailed subordinate themes. PT, physical therapist.
Two themes (‘return to activity’ and ‘caregiver–patient interaction’) exhibited cross-over between both major themes, resulting in separate presentation of these themes. An interesting aspect of this conceptual model is the reflection of participants’ lived experiences of rehabilitation as being characterised by dualistic descriptors rather than articulating a holistic interaction between physical, psychological and social aspects.
Major theme: ‘Rehabilitation training is strongly influenced by negative psychological factors’
When discussing negative perspectives on rehabilitation, negative factors and rehabilitation barriers were described. Fear (figure 2—CaU 1a) and reinjury anxiety ("I know I have arthritis in my knee. I know that the more times I injure myself, the closer I get to getting a knee replacement" [P08]) were perceived to negatively influence return to activity:
it will of course be scary to start playing soccer again. I’m not going to sit here and say anything else… because it is the psychological part that will mostly… put a stop to going into a duel
(P06)
Negative physical self-image (CaU 1b) and faltering motivation (CaU 1c) were perceived to be a result of lack of progress ("I had to get to know [my knee] again. Both how it looked, because it was so thin [laughing] but mostly how it worked" [P11]; "it’s pretty hard to see a light at the end of the tunnel" [P12]). Negative treatment perspectives (CaU 1d), such as boring exercises (CaU 1f) resulted from being "extremely basic when you just- when you like extend and lift a leg, it feels like ‘this is nonsense’" [P08]). The subsequent frustration and lowered motivation may be due to uncertainty (CaU 1g) resulting from inadequate guidance, because "it’s pretty much my feeling. And who knows if my feeling is right" (P08). It may also be due to absence from activity (CaU 1h), because "I found other sports that I thought were really fun. (…), but that I couldn’t participate in fully because I was like waiting for my knee to be good enough" (P11), suggesting symptoms (CaU 1i) were barriers ("I still feel it now when I work, too, […] I feel a bit of cartilage and stuff" [P12]). One participant described refusing to address psychological factors (CaU 1j), feeling that negative psychological reactions "didn’t exist for me, I thought 'that’s for other people, but it won’t get me'" (P07). Others perceived feeling "super depressed" (P05; CaU 1k). The overall negative perceptions suggest that this is a dominating factor which influences rehabilitation experiences.
Positive perspectives on rehabilitation included motivation (CaU 2 a) and self-confidence, perceived as helpful because “you know that, if I just keep training well enough like this- it will work out” (P06). Positive perspectives can also include enjoyment (CaU 2b) and overall positive treatment perspectives (CaU 2c) including that it "felt good" (P05). One participant believed "it was also kind of nice to get away from [sport] a little bit" (P07; CaU 2d). These results indicate that patients recognise the importance of psychological factors in influencing perspectives on rehabilitation.
Patients perceived using self-initiated psychological strategies including goal setting (CaU 3a), while others had no strategy (CaU 3b), claiming that "you never get any tools for the mental bit" (P08). Training monitoring (CaU 3c) and social support (CaU 3d) were described as strategies to find motivation (CaU 3e) and set training goals ("jogging, that’s been [the goal] – when you look at where I need strength and stability" [P08]; "it was more and more fun, and you felt that you got the leg going and you got stronger" [P12]). However, one participant "didn’t think [monitoring] gave so much" (P05), resulting in giving up that strategy. One patient also described using self-talk "to convince myself that [my knee] will hold […] you try to- I don’t know… push it in your head that you can do these things" (P08). Patients perceived the importance of being able to influence psychological factors, but the strategies are vague and vary in their efficacy.
Major theme: ‘Physical rehabilitation is a phase-based progression towards recovering physical function’
Patients described a perspective that training followed a phase-based progression. Early phases (CaU 4a) included muscle activation, range of motion and strength training, in order to "feel that the leg could do something, […] that there was some connection between my head and the knee" (P11) and includes "a lot […] leg exercises, like in machines and stuff" (P07). Later phases (CaU 4b) included hop and strength training ("(h)exbar was one, Bulgarian split squats was one" [P06]), with two patients doing balance training. Training intensity and movement type became "more intensive, finally full running […] a lot of rushes forwards and fast braking" (P12), seen as increased activity–specificity.
The rehabilitation process and progression (CaU 5a) was perceived to be determined by evaluations, including strength or cutting movements to "test things more towards soccer" (P07). Compliance (CaU 5b) to PT-supervised training was thought to ensure proper execution ("the stuff that was challenging we did in the clinic" [P06]), but may lack sport specificity and variation ("When we were going to adjust something ([…)], then we just increased weight, or that I hopped a bit further. But the exercises didn’t change very often" [P09]). These results may indicate an understanding of the physical requirements and goals of rehabilitation training.
Physical barriers to rehabilitation were perceived to include physical symptoms (CaU 6a) such as swelling, fatigue and pain ("when I get winded […] I feel that I have pretty bad control of my knee" [P07]), and two patients perceived limitations in sport and daily life activities (CaU 6b and c), feeling that "I haven’t been able to do anything, until the end when you can start passing a little" (P06). One participant felt limited by pre-existing individual factors (CaU 6d). Patients referred to the injury, diagnosis and timeline of rehabilitation ("I waited almost 6 months for my operation" [P12]; CaU 7a–c). These physical barriers indicated a focus on negative factors of rehabilitation over which patients may feel little control, possibly resulting in feeling helpless regarding these.
Major theme cross-over
Two themes were determined to exhibit cross-over between psychological and physical themes. This resulted from discussions of both physical and psychological concepts without explicitly distinguishing between them.
A positive caregiver–patient interaction was perceived as important, showing whether the PT (CaU 8a) cared and communicated well ("[PT] has had other patients at the same time, so I’ve trained mostly alone. […] I feel like I’ve been there and done what I was supposed to, but I didn’t get the right follow-up on it" [P08]; "they did a really good job and tried to give me as much information and stuff as possible" [P12]). This helped return to sport expectation management, which "is nothing we have discussed in depth, it’s just 'when can I start playing?’" (P06) and increased perceived PT competence and feeling "safe because I felt in some way like he knew his stuff" (P09), leading to positive perceptions. One participant perceived primary care (CaU 8b) as disappointing ("I met a newly graduated physical therapist and the first thing he says to me is ‘oh, you’re my first knee patient, how exciting!’ How trust inspiring [sarcastically]" [P05]). The importance of this interaction was seen as physically and psychologically important, but patients did not express a distinction between these aspects, possibly indicating they did not consciously make this connection.
Not feeling ready to return to activity (CaU 9a) included acceptance of replacement activities due to changing perceived activity-specific abilities and need fulfilment ("I don’t need to play soccer. Partly because I don’t have time, and I don’t miss it as much because I’ve found another sport that fits me just as well" [P09]). Readiness needs (CaU 9b) included time, exposure or regaining skills and confidence ("[PT] tried to find situations that I thought were scary. And then challenged me quite a bit in those situations" [P11]). Two patients distinguished readiness to return to their specified activity from other activities, citing expertise as a factor:
we […] are beginners, so there’s not the same tempo in paddleball. […] And my knee can handle that. And soccer I’ve played long enough that, and I, I have always lived on my quickness, so it’s, it’s a lot more- a lot harder, quicker loading. […] If I were a good paddleball player, I don’t think that would work for me either.
(P07)
Patients perceived readiness to return to activity as both physical and psychological, with one referring to feeling ready (CaU 9c) "as soon as I get the OK" (P05), suggesting PT dependence. These results suggest that patients desired activity, but accepted an inability to return to their preinjury activity.