Discussion
The main findings in this qualitative study comprised one theme, reflecting three main categories. Overall, the time after an ACL injury treated with rehabilitation alone was characterised by uncertainty. Patients did not receive clear answers to questions and felt unable to trust their knee and did not know what the future might hold. Most patients experienced persistent knee symptoms, whereas a few patients could return to a normal life without knee impairment.
Theme: is the grass greener on the other side? context characterised by uncertainty
The theme of this study, ‘Is the grass greener on the other side? Context characterised by uncertainty’, interprets the state of mind of the interviewed patients when they reflected on the past, present and future. Several patients were worried about their knee function after injury and what consequences the ACL injury could have in the long term. Early reconstruction after ACL injury entails superior patient-reported outcome compared with both rehabilitations alone and later ACL reconstruction.5 6 These findings are inconclusive, since there are studies reporting no differences between patients treated with rehabilitation alone or reconstruction in patient-reported outcomes in the long term (10–20 years) after ACL injury.19 20 On the other hand, patients treated with ACL reconstruction can report persistent symptoms and dissatisfaction with treatment.21 A lack of information from the healthcare system with regard to treatment options resulted in the absence of proper guidance and patients, therefore, experienced being confused, frustrated and uncertain. Patients in this study reported wondering whether or not a decision about late ACL reconstruction could improve their knee function and reduce limitations. Clinically, patients might interpret one of the two treatment options, rehabilitation alone or ACL reconstruction, or the lack of clear information, as one treatment leading to a complete resolution of symptoms or impairments. Clinicians should stay up to date with the literature be aware that there is no superior option at this stage,22 and treatment decisions should be made with patient preferences and needs in mind.
Uncertainty was a central aspect of patients’ experiences of rehabilitation alone as a treatment after an ACL injury. Uncertainty refers to a psychological state of ignorance, but, rather than mere ignorance, to the ‘conscious awareness or experience of ignoring something’.23 To be aware of ignoring something, that is, being uncertain, has the potential to influence the emotions and thoughts a patient might have in relation to a certain event in which the ignorance is taking place. There can be different sources of uncertainty, but two important sources related to the findings in this study are (1) probability, which arises from the unpredictability or indeterminacy of the future, and (2) ambiguity, which arises from limitations in the reliability, credibility or adequacy of the information.24 Uncertainty is mostly regarded as being negatively charged.23 In response to uncertainty, patients can experience negatively charged affective feelings, such as anger, anxiety or sadness, and uncertainty during an emotional event has been reported to make unpleasant events more unpleasant.25 From a healthcare perspective, negatively charged affective feelings can influence treatment outcomes and patient satisfaction.26 One specific outcome that can be affected is the patient’s confidence in their ability to perform a physical task (self-efficacy).27 Experiencing uncertainty might lead to patients having lower levels of knee-related self-efficacy, where lower levels of self-efficacy have been linked to a lower level of performed physical activity.28 Not being confident in one’s self-efficacy might lead to patients being afraid of the moment and possibly developing kinesiophobia, which can negatively affect rehabilitation after ACL injury.29 Taken together, patients’ uncertainty can lead to a cascade of negative affects, and the healthcare system’s inability to provide patients with adequate and credible information can negatively influence treatment outcomes. Consequently, the healthcare system needs to improve the amount, quality and credibility of information with regard to treatment options and outcomes given to patients who suffer an ACL injury.
In Sweden, where this study was performed, patients who suffer an ACL injury are commonly assessed by a physiotherapist and eventually referred to an orthopaedic surgeon. Physiotherapists treating patients after ACL injury might feel uncertain since evidence on treatment after an ACL injury is under constant development and far from certain.30 As research advances, it is up to researchers and healthcare professionals (eg, treating physiotherapists, surgeons) to create and update clinical practice guidelines to provide patients with clarity about their treatment options.
Main category: past: the ACL injury and its consequences
Patients described their first encounter with healthcare providers as unconvincing. The overall experience was a lack of professional assertiveness, and patients were instead met with vagueness regarding the outcomes of the different treatment choices. Several patients experienced not being a part of the treatment decision-making process. In contrast, some patients reported reading scientific studies and consulting with friends to make a proper decision. For some patients, the rehabilitation was tough and mentally challenging. Social support, intended as a forum to discuss and share experiences and resources of informational (education) or emotional type, has been previously stated to play an important role for patients to take part in successful rehabilitation.30 31 In line with this statement, patients in this study explained that the support and presence of physiotherapists were important to maintain rehabilitation when motivation was low. It is, therefore, important for physiotherapists who work with patients who suffer an ACL injury to provide proper support during rehabilitation.
Main category: present: having knee-related symptoms
Previous RCTs7 8 have determined that there is no significant difference in terms of self-reported knee function, level of physical activity or the prevalence of subsequent OA 2–5 years after an ACL injury between patients treated with rehabilitation alone and patients treated with ACL reconstruction and subsequent rehabilitation. In this study, there were occasional exceptions, where patients reported that they did not suffer from knee symptoms and that their knee function was good enough for what was needed. On the other hand, many patients said that their knee was a constant reminder of their injury and that symptoms were a daily struggle. In line with previous research, patients treated with rehabilitation alone experienced poorer self-reported knee function.4 Physical and psychological stress can affect the training and rehabilitation of the knee.32 Uncertainty and undetailed guidance reflect hesitation and doubt on the part of healthcare providers and might increase patients’ psychological stress. It is plausible that this uncertainty will remain with the patient throughout the treatment process and that the healthcare professional’s hesitant behaviour fuels the psychological impairments. It is important that the healthcare professional has a great knowledge of rehabilitation alone as a treatment after an ACL injury, has confidence in the treatment provided to the patient and is clear when providing information and expectations relating to injury and treatment. Knowing how to take care of patients’ psychological state of mind after an ACL injury is also important. The great preponderance of codes in the subcategory ‘The knee, a symptomatic obstacle’ highlights that many patients do not have a satisfactory present knee function. Therefore, future studies to understand whether clearer information changes patients’ uncertainty and which subgroup of patients who suffer an ACL injury might benefit from rehabilitation alone as a treatment are needed.
Main category: the future and what might happen
The uncertainty experienced by patients in the past and the present was perceived in relation to the future. Patients experienced not knowing what could happen in the future, whether they would ever regain proper knee function and whether they would be able to participate in physical activities without limitations imposed by their knee. Further uncertainty was experienced about the future’s unpredictability, specifically in the possible development of knee OA. Whether OA would occur cannot be predicted by healthcare providers, and, as a result, uncertainty about unpredictable outcomes can probably not be answered. However, a recent umbrella meta-analysis showed that an ACL injury increases the risk of developing knee OA.33 Moreover, surgical treatment does not appear to reduce knee OA prevalence compared with rehabilitation alone as treatment.33 With regard to the presence of uncertainty for future knee OA, the implementation of a virtual knee-health programme aimed to minimise impact of knee OA for people at risk of post-traumatic OA after a sport-related knee injury, has been reported to satisfy an unmet need.34 Accordingly, the uncertainty for future knee OA has been highlighted in other geographical setting than those included in this study. Taken together, patients end up feeling the same way as they initially experienced treatment from the healthcare system, ‘wait and see’; hoping for symptom resolution but experiencing uncertainty.
Methodological discussion/limitations
Qualitative research plays an important role in bridging the gap between research and practice, as patients’ voices are given a chance to be included to create new understanding. When including the patient as the main stakeholder, quantitative and qualitative research is needed to explore various aspects of health-related issues.12
Qualitative content analysis can provide access to each participant’s subjective construction of a certain event, and was deemed suitable to realise our aim and individual interviews were, therefore, chosen as a data collection method. The description according to Graneheim and Lundman13 14 implies that data are derived via an interaction between the researcher, the participants and the analysed text. Researchers work, therefore, through own bias and preconceptions during the analysis. In order to account for the interaction between researchers and data, own bias and preconceptions were discussed in the method section, and the six authors participated in the analysis via regular meetings, where findings were continuously discussed. According to the description formulated by Graneheim and Lundman13 trustworthiness can be further divided into credibility, dependability and transferability. To establish credibility, researchers need to accurately describe the research participants. Accordingly, patient demographics were reported in table 2, and each involved research background and demographics were briefly discussed in the method, according to COREQs. To provide credibility in the analytical process, examples of the analytical process are provided in table 1, ranging from codes to main categories. Dependability refers to the certainty of how the analytical process has been carried out and the stability of data over time. To ensure dependability, the interview guide was worked on before the study started and not changed afterwards. The goal with this project was not to achieve transferability but rather to capture experiences of individuals who rarely have the opportunity to share their experience, since outcomes after rehabilitation alone as treatment after ACL injury has not been as thoroughly studied as outcomes after ACL reconstruction. Consequently, the transferability of the results should be interpreted with caution.
Another possible limitation could be the brevity of some interviews. Despite time not merely reflecting the richness of the interview, the length of the interview can influence the amount of information collected. In our sample, two interviews lasted 10 min, one lasted 14, and all the other interviews lasted well above 20 min. Common for the short interviews was that informants were rather satisfied with their knee function in relation to the patient’s current knee demands.
Lastly, we used a convenience sample, which might not entirely reflect the variety of experiences of patients treated with rehabilitation alone after ACL reconstruction. Future studies could apply more selective inclusion criteria to produce specific results for certain subgroups of patients who suffer an ACL injury and are treated with rehabilitation alone.
Summary
With few exceptions, patients’ experiences after an ACL injury treated with rehabilitation alone are characterised by uncertainty regarding their physical function, psychological impairments and possible future limitation of knee function. Uncertainty is experienced by patients in the past, the present and the future. Patients experience the knee as a symptomatic obstacle and need to adapt their physical activity to the presence of knee symptoms.