Qualitative results

Sample

A total of 102 participants, who had expressed an interest in involvement in the qualitative study at the time of consenting to be in the ARTISAN trial, were contacted. Of these, 17 declined to participate and 54 did not respond.

A total of 31 participants consented and were interviewed from both arms of the trial, ARTISAN and ARTISAN Plus (Table 30). The participants were from 17 different trial sites in the UK; 16 participants were allocated to the ARTISAN arm, and 15 participants were allocated to the ARTISAN Plus arm. Most of the participants in the ARTISAN Plus arm were male (11 out of 15), while there was a balance between participants in the ARTISAN arm (8 male and 8 female). The interview participants’ median ages were 51 years (IQR 36) and 65 years (IQR 24.5) for the ARTISAN and ARTISAN Plus arms, respectively. Five participants in the ARTISAN arm and four in the ARTISAN Plus arm stated they were involved in sporting activities that needed high levels of physical activity.

Our findings illustrate participants’ experiences of receiving and interacting with rehabilitation services and participating in the ARTISAN trial.

Four dominant and inter-related topics were constructed based on the interview questions: (1) feelings about their shoulder rehabilitation outcome; (2) judgement of ARTISAN rehabilitation materials; (3) assessment of shoulder rehabilitation services provision; and (4) experiences of involvement in ARTISAN. Themes and subthemes emerged from the data in each of the four inter-related topics.

These themes and their subthemes are reported below, comparing and contrasting responses from both the experimental arm (ARTISAN Plus) and those from the control arm (ARTISAN) of the trial. Quotations are used as exemplars of themes, with each quote linked to a particular participant denoted by the arm of the trial they were involved in (AP = ARTISAN Plus arm; A = ARTISAN-only arm) followed by their ID number, their gender [male (m) or female (f)] and age in years (e.g. ‘A11, m, 31’).

Results

Topic 1: feelings about their shoulder rehabilitation outcome

This topic breaks down into a number of themes/subthemes and provides an insight into the assessment of participants’ feelings about their recovery, including movement and use of their shoulder and being able to get back to their previous activities or not.

Shoulder status (how they feel their shoulder is post rehabilitation)

Participants who received ARTISAN Plus reported improvement in returning to their normal life and working activities. Almost all of them expressed the status of their shoulder as ‘better’:

I feel good now, and then I can … I’m back to doing all the jobs I could do before.

I think I’m back at 100 now.

Probably getting up to 100%, I guess.

A few did still feel that they still had a little way to go:

I would say yeah, probably 70% now. Yeah, around about that. Yes, yeah.

Like, maybe more 60 than 50 in terms of movements.

This compared to the ARTISAN arm, where there were fewer participants who believed their shoulder was at a good level of movement:

… had almost complete range of movement.

It’s absolutely fine …

Satisfaction

Interestingly, most participants who had received ARTISAN Plus apparently liked to recommend it to the others with the same problem because they were very satisfied with the result from having multi-physiotherapy sessions.

Yeah, I would recommend, I would definitely recommend anybody to go do that what I did, yeah, definitely. Definitely, yeah.

The other source of satisfaction from the result for most of them was receiving positive reinforcement from the physiotherapist about outcomes and being told that they were doing the exercise correctly.

Only the reassurance that everything was going fine.

So, I suppose I needed those sorts of reassurances before I got into heavier physiotherapy.

On the other hand, most people in the ARTISAN arm have found the exercises as the most helpful part of rehabilitation to get back their abilities.

Yeah. I would … I would tell them, you need that physio exercise, yeah.

Setting short-term goals and identifying milestones was noted as helpful by one participant who received more physio sessions, helping them have a realistic view of their shoulder progression.

the goals were … because I think it kind of helps you set a realistic view of you know, going on to next session that if you could do this.

Topic 2: participants’ judgement about ARTISAN rehabilitation materials

All of the participants had the opportunity to use the provided rehabilitation training materials in addition to the support given by the physiotherapist in the session they all had with them. These materials seemed to be more important for the ARTISAN participants as they generally only had the one in-person session with the physiotherapist. However, it is also important to know to what extent the participants have used the materials and what their experience is in using them.

Material usefulness

Almost all participants in the ARTISAN arm reported using the booklets, while only half of the ARTISAN Plus arm reported using them. In addition, none of the ARTISAN Plus participants reported having used the videos and website, compared to around half of those in the ARTISAN arm. The ARTISAN Plus participants who had not used the materials believed that they had gained enough from their in-person visits with the physiotherapist; therefore, they did not feel the need to refer to the training materials:

Just after the first [physio] session, I had the chance to have a very quick look at the booklets, so, it was enough exercise and guidance from physiotherapist over the sessions … didn’t feel need them!

I had time, was off from work, almost at home, and was keen on going through the booklets, but only booklets, no website, and videos, so I think it was quite helpful.

I got those stuff [training materials] … but yeah! I don’t remember using them! Yeah, didn’t look at them at all.

[I] got the booklet and everything, I went on the website, saw the videos and, yeah.

Problems with study materials provided

The main reported source of difficulty in using the materials provided was in the ARTISAN arm, where there were problems reported accessing the video and internet-based materials. A few of the participants from ARTISAN also reported some problems with the booklets provided. These problems were very low in the ARTISAN Plus arm.

There was but I don’t have the internet at my house …

I couldn’t quite find … I couldn’t follow the instructions on those. And I couldn’t log into the website. So, I couldn’t get any additional information. I had a booklet. I didn’t find them all easy to follow. There was a couple … I mean they did run through it with me, the fracture clinic, but they more demonstrated it I would say. But I didn’t find everything in the booklet that easy to follow. I did with the hospital physiotherapist, I actually had to do it because my arm was in better shape.

I think there was one [picture] that wasn’t quite clear, but I checked it out with her the next time I went.

I suppose the booklet, umm, is in some ways misinterpreted because it is not in 3D, you know, so surely for a picture … a picture does not always give you the right angle or the right, umm, motion to use

Material comprehensiveness and consistency

The content of the materials was consistent with what had been provided in face-to-face rehabilitation sessions, in the view of most participants. The materials were also reported to be comprehensive and to meet the needs of the participants in both arms.

From the ARTISAN participants:

It was very good because you get … further on, you’ve sort of got more exercises to do. So, you really need that leaflet to show you the different exercises you need to do.

Yeah, well, the exercises we did were the exercises in the pamphlet that I was given which I said to you, and, hmmm, the physio, she did them all with me … two or three times.

From the ARTISAN Plus participants:

It was just giving me alternatives to do. It’s the same kind of stress on the shoulder, but it was a different exercise. But more or less, there were those like, you know…

She [the physiotherapist] did. She did go through the booklet with it and marked certain things, you know, like she wrote in the book the few exercises that I should be doing

Topic 3: participants’ assessment of rehabilitation service provision

This topic reflects participants’ feelings about the provision of physiotherapy/rehabilitation in terms of the accessibility to the providing rehab centres, physiotherapist performance and then the form of sessions provided. This part of the participants’ experiences reflects insights about the obstacles that can influence the participants getting to the centres, and to what extent participants believe the physiotherapists have been engaged in their rehabilitation/treatment process. Finally, it has an implication about the impact of participating in group physiotherapy sessions as a possible form of rehabilitation provision.

Accessibility to the rehabilitation services

Several of the participants in ARTISAN Plus experienced some physical difficulties in attending the rehabilitation sessions, such as problems with driving, finding a car parking space and a considerable distance to the physio clinic or hospital from their home.

Taking into account quite a long distance to travel and the roads aren’t that great, I have to be taken in by my wife – obviously I was not driving.

Sort of two hours right around the hospital so if I wasn’t close it would be more difficult

Most of the people in this group stated that there were no difficulties to attend the physio sessions. They also mentioned that the health centres were flexible in providing suitable slots for appointments. In addition, there were positive comments about public transport and employers who were supportive.

Nothing whatsoever because I was able to get a time slot that suited me, which was earlyish morning. And there was no delay, you know. There was … it was all perfectly right for me.

No, no. Well, they were quite supportive at work.

No, you can get a bus to the hospital.

Most of the participants in the ARTISAN group reported not having experienced any obstacles or obstacle to accessing rehabilitation services:

I didn’t [have trouble to attend], but I walked (there).

That’s fine.

However, some obstacles remained for a small number of ARTISAN participants:

I couldn’t drive. I got some free transport from the transport people. And then … and that stopped when I was told that … they had to tell me I must get on a bus because they have to keep it for people that are more seriously ill than me. And I was, therefore, trying to sort that out, and eventually, I got a friend to take me, across the road … (After requiring additional physio sessions for frozen shoulder.)

Parking. It’s terrible up there.

The physiotherapists’ performance

The physiotherapist was considered a valuable source of motivation in improving the injured shoulder by participants in both arms of the trial. All participants expressed that their physiotherapists went through the exercises and correct movement in detail as much as they could. Giving feedback and setting short- and long-term goals by physiotherapists had a positive impact on the participants’ feelings, especially for ARTISAN Plus:

It gave us confidence.

I don’t know who he [the physiotherapist] was, but it was a good job.

She [the physiotherapist] pretty much answered the questions anyway as we went along, you know.

The participants in the ARTISAN arm also found an excellent experience with their physiotherapists:

She [the physiotherapist] was a really, really, really good physio. Very straightforward, practical, on to work, which I really like.

He’s … he [the physiotherapist] was very, very positive attitude so that’s about all really. No, they’re all very positive about what to do next. (Participant who was given additional physio session by the clinician.)

Single, group and multiple physio sessions

Almost all participants in the ARTISAN group found the physio session helpful and informative; a few expressed that they may have preferred having multiple physio sessions. A number noted that they felt they benefited from a single session:

Yes, was helpful. He [the physiotherapist] gave me a booklet, he gave me lots of things and did say that if I had problems, then I was to go back.

It was informative. They gave me a few exercises to do, and they scanned through all different movements to see where I was sort of suffering with it.

One ARTISAN participant noted that she experienced group-based physio sessions (outside of that provided by the trial). She was keen on attending these sessions because she thought it was an excellent opportunity to get peer support, to understand the limitations and develop coping strategies for dealing with issues that may arise:

Although everybody is different, it was nice to talk to other people and other people have different things, but it was still nice to speak to someone in the same situation as you.

Others in the ARTISAN arm had sought out additional treatments or programmes apart from the training materials to increase their chance of returning to their previous sports activities:

I’m lucky enough that the club that I play rugby for has a physio that they employ as well, he recommended the [name of a local programme], so I went along, did some of those exercises on that, and that was good, got to all progressions that I was trying to get back to, and the exercise that was provided from like the ARTISAN from the hospital was kind of due to get me back to general life, it probably would’ve been perfectly fine, but yeah, I want to go back to rugby so I know I needed to get my shoulder back to like full strength.

Almost to the year, it was almost to the year and my shoulder was absolutely killing. I couldn’t drive. It almost felt like, well, I didn’t know what was wrong with it. It felt like a frozen shoulder, and I ended up in the … I ended up going to a chiropractor.

Most participants with ARTISAN Plus multi-physio sessions pointed out that they had enough chances to visit their physiotherapist to assess their shoulder movement, achieve their goals and receive instructions on doing the exercises correctly:

If I was doing something wrong, they could correct me.

The most emphasised point in this group was getting reassurance and feedback from the physiotherapist:

Well, I suppose it’s … the fact that you can do a certain exercise over a period of time, then you get some feedback with a consultant to tell you how you’re doing.

Several of them expressed that communication with a professional member such as a physiotherapist psychologically impacts the rehabilitation journey:

It certainly helped mentally. It gave you support. You felt that somebody was interested in trying to help, which was as much benefit as the physical side of it.

A participant from the ARTISAN arm who received additional physiotherapy sessions highlighted again the reassurance of having the contact with a therapist:

The other benefit really was the reassurance because I think one of the things that you did … that you worry about is, you know, it’s going to dislocate again.

Topic 4: ARTISAN trial processes from the participants’ viewpoint

This topic addresses the experiences of participants’ involvement in the ARTISAN trial, exploring their experiences of trial procedures and materials.

Questionnaires

Comments on the questionnaire were mixed, with some participants noting that they were clear and easy to complete and others noting problems such as confusing terminology, difficulty in understanding, and from some there were recall issues related to remembering their status in a few previous weeks for both arms:

That was fine.

It was straightforward.

This was … some of it was a bit confusing, some of the terminologies around the, before your accident and after your accident, a little bit unclear.

I think that there is a problem in how the questions are asked because it’s not very clear at which timescale they have directed the questions. I think there is a problem there.

I wasn’t quite sure, you know, like, it was saying it would say, like, in the last … and I think sometimes because your pain goes up and down, doesn’t it.

Comments to improve the study

A number of the younger interviewees from the ARTISAN Plus arm liked the idea of virtual rehabilitation sessions:

I think [virtual physio sessions] would be a lot less time-consuming for both sides… and it’s just reassuring that you know that what you are actually doing, you are doing it correctly.

Some participants who had a single session raised a few remarks regarding home-based physio sessions and developing an online format of questionnaires to improve the process because posting them needs more time:

I know, I mean, something I appreciate that if people can come up with even with the tiniest suggestion of what could have been easier for them and that is the only thing that could have made it easier for me was having it online rather than, well, it wasn’t inconvenient on paper, but it was just that it would have been a bit quicker

Participants’ satisfaction with the ARTISAN trial

The study’s introduction and familiarisation with the process have been identified as a factor in the participants’ satisfaction. Almost all participants appreciated a chance to ask for details about the study from ARTISAN members since the participants stated:

She was very clear.

I was able to ask questions, but I didn’t need to.

Participants in the ARTISAN arm were aware of having the right to go back to the usual care as an interviewee detailed

… you know, it’s not a punishment to … to not get help if you feel like you don’t … if … even though you’ve been randomised to one session only, you’re more than welcome to do so if you feel like you need more than that. That … is that … if that’s OK.

Participants’ motivation

All participants, regardless of their background and allocated arm, expressed that the most important motivating factor to attend the study was the excellent sense of the applicability of the study for helping injured people in the future:

Well, I think if it can help other people experiencing that thing.

Summary

The overall aim of the interview study was to explore the participants’ experience of receiving the trial treatments and facilitators and obstacles to adhering to them, and this has been achieved. We have interviewed a representative sample of trial participants from both treatment arms of the trial who have openly shared their experiences. These experiences include participants’ feelings about their recovery after their rehabilitation journey.

More of the ARTISAN Plus participants reported having had a better experience, based on their expectations after the rehabilitation sessions, compared to the ARTISAN participants. It appears that the main route of the discrepancy in this regard relates to the levels of physical activities that the participant wanted to return to (e.g. sports). Participants in the ARTISAN group did seem to want more physiotherapy sessions. However, it is important to know that, even among those who do engage in sporting activities, in the ARTISAN Plus group, some are still reporting that they are not reaching their pre-injury levels of activity.

A number of the younger participants in the ARTISAN group have sought out additional treatment options (e.g. exercise programmes, chiropractic sessions) in addition to what was provided to increase their chance of returning to pre-injury levels of activities. ARTISAN Plus participants, it seems, were less likely to go for additional treatments outside of those provided.

The interviews give us an insight into the participants’ motivations and experiences in their rehabilitation journey. Involving them in the improvement journey seems to have a positive influence on their sense of improvement. Regardless of the participant’s allocated group, gender, age and history of doing exercise, the physiotherapist’s advice and efforts to give reassurance appear to play a crucial role in the participants’ mindset and confidence.

Alongside the sense of reassurance, communicating with the participants and giving them some ideas about their rehabilitation journey ahead would be motivating for the participants to be more involved in the treatment process, subsequently giving a better experience for the treatment outcomes. This is more obvious among participants of older ages. This also could be as easy as telling the participants about the physiotherapy session length, durations and expectations from each single and whole session.

Those participants who have consulted with the materials have found them helpful regardless of their background factors (sex, age and history of doing sport) and allocated arms. Both groups of participants have used the booklets and expressed good experiences with them.

The participants raised some minor points regarding the difficulty with the booklets and that the online materials were sometimes difficult to access. However, the participants in the ARTISAN Plus group seem to have had a better chance to resolve this kind of problem because of having more contact with their therapist. Participants in both groups report using the videos and website less than the booklets. This is more obvious among the senior groups and females. Lack of internet access was an issue for some. However, for those who have viewed the video, it has given them a better idea of how to do the exercises correctly. The latter is more apparent among those participants at younger ages and with less severe injuries.

In terms of the trial process, almost all participants, across both groups, have had a positive experience regarding the staff communications, responsiveness and explaining the ambiguities. Some do report that paper-based questionnaires are not very convenient to deal with due to their injuries and the volume of the questions. Younger participants seem to have found the questionnaires more convenient and easier to do regardless of their group allocation.

While it is a strength of this qualitative study that it includes participants representing both arms of the trial from multiple sites across the UK, there are a number of limitations. This was a one-off single interview undertaken with consenting participants 12 months after they received their treatment. Recall at these times was an issue with some participants. While the interviewers mitigated this by restructuring questions and using prompts, it may have impacted on the quality of the data. During the analysis of the data, it became very clear that the qualitative sample as a whole were responding very positively. In addition, in both groups there were those who liked things and those who did not. We can only interview those who are willing to participate, and it may be that the sample who agreed were very positive overall about the trial. Therefore, we took a very cautious approach to reporting the findings descriptively, comparing and contrasting outcomes within and across the groups.