ii) Overview of recovery experiences
Recovery experiences, trajectories and outcomes were diverse, reflecting the different types of injuries in the study cohort; pre-injury health status, and individual lifestyles and priorities.
Some participants fully recovered from their injuries:
P4 (Female, 70-74 years, fractured sternum)
‘I’ve always felt pretty good… [so]... once I got over the cracked sternum, my life carried on like usual’.
However, for other participants, their injury and recovery experience were life-changing, and resulted in major disruptions to their lives:
P10 (Female, 65-69 years, multiple arm fractures)
‘Well, it is all very traumatic having had many surgeries, which was terrifying. I would be in hospital, a long way away from the family… that was a real big problem… I lost my car, it was written off. So, the day that I had the accident I was going to my new unit I had just rented... so I paid rent for six months on a house I never lived in... so it was all pretty crappy'.
The degree of disability reported by participants varied. One participant described major limitation in activities following bilateral soft tissue leg injuries, despite this being a ‘minor’ severity injury:
P5 (Female, 70-74 years, leg injuries)
‘I didn’t do hardly any chores or anything in the house because I couldn’t move properly. I had to learn to walk again. It took me all my time to - just to do my daily things, like getting up and walking, going to the bathroom to get up and have my shower’.
Recovery issues and priorities changed over time. In general, participants were most concerned with pain management and self-care during the acute recovery phase:
P6 (Female, 70-74 years, fractured ribs)
‘My GP said it’s [the fracture] on your ribs, they’ll just heal between six to eight weeks. And that’s what happened. I did go on a lot of medication, it was very painful... But then with the time that went by I got better’.
After the acute recovery phase had passed, participants’ priorities turned to resuming pre-injury daily life. Major barriers to further recovery at this time included chronic pain and persistent psychological symptoms.
iii) Perspectives and themes
Five themes were identified in relation to the ICF conceptual model: recovery is regaining independence; injury and disability in older age; the burden of non-obvious disability; the importance of support and positive personal approaches (Figure 1).
Theme 1: Recovery is regaining independence
The majority of participants equated recovery with regaining pre-injury levels of independence, especially with their self-care (including mobility), and being permitted / able to drive again. Thus, regaining independence was a major facilitator of recovery.
Self-care
Participants’ experiences of being dependent on others for self-care varied significantly. For some, it was a temporary phase that was a necessary, albeit inconvenient recovery phase:
P11 (Male, 85-89 years, upper limb dislocation)
‘I had of course to feed myself with my left hand, do everything with my left hand as I had no capacity in my right hand. But look, I got through that… really it was just a matter of letting it heal… I suppose it was worse for my wife who had to do the driving and do the shopping and things like that’.
However, for others loss of independence in self-care was a longer-term reality that completely disrupted their lives, such as changing living arrangements and a profound sense of loss of control and choice:
P10 (Female, 65-69 years, multiple arm fractures)
‘I couldn’t live on my own because I couldn’t do anything for myself... I couldn’t cut my food, I couldn’t drive… I couldn’t do anything, so I had to go and live with [my daughter] permanently which wasn’t my choice’.
Participants did not wish others to complete tasks for them, and preferred to obtain only as much assistance as necessary for them to continue on with completing tasks:
P1 (Male, 70-74 years, whiplash)
‘I don’t have enough strength in my arm to be able to start the lawnmower, so unless someone comes and starts it for me the lawn doesn’t get mowed, you know?’
For some participants, being able to walk independently was a fundamental skill and overlapped with personal factors such as determination and resilience:
P5 (Female, 70-74 years, leg injuries)
‘I got up and had my shower each day, very slow, I could hardly walk… I said [to the nurses], “No, I want be independent, I’ve got to use my legs”’.
P5 (Female, 70-74 years, leg injuries)
‘I walked around the shops today... [for] maybe an hour and half… I mean the walking’s not helping but I think it is helping somewhere inside because it is exercise every day. You need to be able to walk and do those things’.
One participant experienced a (non-traumatic) re-injury, and having coped well following their initial injury, found this unexpected loss of independence confronting, challenging and frustrating:
P2 (Male, 80-85 years, upper & lower limb injuries)
‘I hadn’t normally until very recently needed help. I was showering, dressing and that sort of thing. But since… the pain and problems have come back… the last fortnight I actually do need a bit of help dressing. Now that’s never happened before in my life’.
P2 (Male, 80-85 years, upper & lower limb injuries)
‘When you’ve been just picking up things for 85 years, you know, suddenly to say, “Now don’t pick that up, or don’t reach for that” it’s very, very difficult'.
Driving
Restrictions on driving were difficult to deal with, and returning to driving was synonymous with recovery:
P3 (Male, 70-74 years, head injury)
‘I still couldn’t drive for about three weeks. They just wanted to make sure that everything was okay… in case there was a recurrence or something, which is fair enough. But it annoyed me because I wanted to drive’.
Another participant was hesitant to drive after their crash, yet saw the value in taking an active approach to regain their driving independence:
P4 (Female, 70-74 years, fractured sternum)
‘I felt hesitant the first time because where I lived, I always have to go through this roundabout. So, the very first time, yes, I was a bit hesitant, but I thought, no, I’ve got to do it. So, I’m just probably a little bit more careful or cautious could I say. But after that I was fine’.
Theme 2: Injury and disability in older age
Participants experienced disruptions to daily activities and social participation as a consequence of their injury.
Daily activities and social participation
Several participants reported physical, psychological, cognitive and/or pain-related difficulties. For some, but not all participants, recovery from injury as an older person presented specific challenges:
P2 (Male, 80-85 years, arm / leg injuries)
‘I was already suffering from a neuropathy… and also Parkinson’s and so this has really exacerbated it, compounded it… I’m typing [on the computer] instead of writing… fortunately the brain is still reasonably accessible.’
P1 (Male, 70-74 years, whiplash)
‘It’s getting harder to do [social activities and sport] because, I mean I do catch up with them, like for a barbecue and things like that, but it’s not the same sort of situation where we used to go out and we – we play a round of golf and have two beers and come home and things like that’.
Residual physical limitations were mostly acceptable, provided functioning returned to sufficient levels to complete pre-injury tasks, even if slight limitations remained; and adapting or modifying ways of doing things were common. Recovering the majority of pre-injury physical functions and fitness was a major facilitator of recovery, and was seen as a milestone in recovery that brought a sense of happiness and satisfaction:
P11 (Male, 85-89 years, upper limb dislocation)
‘Really, I mean, I’m now doing everything… I’m not terribly good on managing a crowbar these days and digging a deep hole, but otherwise I’m doing everything’.
Chronic pain
Chronic pain impacted heavily on health-related quality of life where activities of high value to the individual were affected, for example, caring for grandchildren:
P10 (Female, 65-69 years, multiple arm fractures)
So you can't hit my arm and it's really painful… I couldn't drive for six months… I couldn’t lift the grandchildren… that was a huge problem and it still extremely hurts when I lift them on my arm’.
In contrast, a participant felt that pain in older age was something to be accepted:
P6 (Female, 70-74 years, fractured ribs)
‘I do have pain, but you know, I am at an age now, that you can’t do without any pain, but I would say it’s got nothing to do with that [the injury]’.
Work, retirement and economic self-sufficiency
Whilst some participants were retired, two female participants, both of whom lived alone, each experienced negative impacts on work. One participant described accelerated retirement as they were physically unable to resume their usual work in two different roles and carer for grandchildren:
P10 (Female, 65-69 years, multiple arm fractures)
‘I am not quite sure what retirement means. I tend to do more than I ever did but I have retired… [the injury] accelerated it. Yeah, I wouldn’t have [retired] because I was actually working with my daughter and minding the children and doing other things and that stopped me from doing that’.
Whilst the other participant resigned from their job. Whilst there were other factors at play here, returning to work with physical and significant psychological symptoms appeared to one catalyst for suddenly resigning:
P12 (Female, 65-69 years, fractured sternum, whiplash, psychological impact)
‘I had a mortgage and I’m on my own, so I had to go back earlier... It just got to the point where I felt totally burnt out’.
Financial concerns around paying off a mortgage were also an issue:
P12 (Female, 65-69 years, fractured sternum, whiplash, psychological impact)
‘When I went back to work after my accident, the fear was, oh my God, I have to pay this mortgage off, and I’m going to pay it, it’s not much, but I had to pay it off, and I did’.
Other symptoms
One participant expressed concern that her ongoing symptoms could in fact be due to age-related cognitive decline:
P8 (Female, 75-79 years, head injury, arm movement limitation)
‘When I’m doing something, I can remember what I’m doing, but given half an hour, nowadays, I’ve forgotten it... that’s why I thought I had Alzheimers and I wanted the test’.
Theme 3: The burden of non-obvious disability
Persistent psychological symptoms
Psychological symptoms were common and varied, ranging from temporary to persistent, and from transport-related to more general in nature.
P1 (Male, 70-74 years, whiplash)
‘I also don’t drive a car anymore. I’m just paranoid about driving a car and I won’t sit in the back of a car’.
P5 (Female, 70-74 years, leg injuries)
‘I was scared when my husband was driving. I don’t know whether it was me or - I don’t know… I was quite scared’.
P7 (Female, 65-69 years, mild traumatic brain injury)
I really don't like thinking about it, you know. It’s had a psychological impact … quite probably a significant psychological impact’
Two participants reported long-standing consequences from soft tissue injuries that had not been major concerns at the time of injury or shortly thereafter:
P8 (Female, 75-79 years, head injury, arm movement limitation)
Oh, one of the things that’s really important and I don’t know why or anything but since the injury my right shoulder, I can’t lift my arms very well. Yeah, that didn’t appear to be injured in the accident’.
For one of the participants, they had closed their claim, however their symptoms persisted:
P12 (Female, 65-69 years, fractured sternum, whiplash, psychological impact)
‘When I came home, I had a bit of stiffness in my neck… I didn’t really worry about it too much... I thought no, my neck will settle down. But I found over the last two years it’s [my neck] gradually getting worse’
Theme 4: The importance of support
Family, friends and community members
Practical and emotional support from family was highly valued and appreciated, and an important facilitator of recovery:
P10 (Female, 65-69 years, multiple arm fractures)
‘It’s good to have support, that’s the main thing. I feel sorry for people that don’t have support… I have a daughter who was wonderful… so, I had that support with her and I had some nice friends around that gave me support. That helped a lot’.
Some participants were concerned about the carer burden for their spouse:
P2 (Male, 80-85 years, upper & lower limb injuries)
‘It has been a big change [for my wife]. Obviously, it’s been a worry... she does drive me around more than she used to... [and] she’s been helping me with getting my shirt on and everything’
Friends were also valuable sources of practical, and much appreciated support:
P4 (Female, 70-74 years, fractured sternum)
‘I suffer from benign vertigo and I’d been bending over, packing a lot of boxes and I kept having minor attacks of it… I had a friend, they would stand me up beside a chair with a box on it and they’d put everything on the table so I wouldn’t have to bend over and I wouldn’t have to lift… it was really lovely’.
Participants were very positive about assistance offered by community members as they were out and about:
P2 (Male, 80-85 years, upper & lower limb injuries)
‘I’ve found people very, very helpful actually... on one occasion someone came up to me and said, “I’ve seen you standing there for a while. Do you need any help?”’
Health professionals
Overall participants were satisfied with the care they received in the Emergency Department or as an admitted patient, especially from the nursing staff. One participant expressed frustration that her questions to hospital doctors about her injured legs were repeatedly dismissed:
P5 (Female, 70-74 years, leg injuries)
‘[I injured] my legs which [the doctors] never, ever did a thing for in hospital. All they were worrying about was the other injuries that weren’t visible… they said “Don’t worry about [your legs], that’s your last problem”. I thought it is not the last problem, if there’s nothing wrong with my heart, I need my legs… I think if I’d had treatment on my legs earlier I wouldn’t be in this pain and suffering now’.
Some participants described difficulties seeking and obtaining support from their General Practitioner for ongoing health concerns related to their injury:
P7 (Female, 65-69, mild traumatic brain injury)
‘[Psychologically] I think there’s stuff lingering there. Yeah, I think there’s an aftermath. [I’d prefer to] just not think about it. There’s nothing he [GP] could do. [Laughs] there’s nothing he would do’.
P8 (Female, 75-79 years, mild traumatic brain injury, arm movement limitation)
‘Oh, one of the things that’s really important and I don’t know why or anything but since the injury my right shoulder, I can’t lift my arms very well. Yeah, that didn’t appear to be injured in the accident… [my GP is] a good doctor but he doesn’t seem to think that women are very useful [laughs]’
On the other hand, participants who sought therapy or treatment with other health professionals found it to be beneficial:
P1 (Male, 70-74 years, whiplash)
‘just after the accident I had quite a few falls... I went to Stepping On and did that program and I’ve only had one fall since then’.
P2 (Male, 80-85 years, arm / leg injuries):
‘it did affect my attitude crossing the road, and particularly in crowds…. the insurance company has paid for some counselling…… so I’m not too bad there.’
Compensation system
Our study included participants regardless of their compensation status, that is, those who lodged a claim, those who did not lodge a claim but were eligible to, and those who did not meet the criteria for lodging a claim. To avoid pre-conceived ideas by the interviewer, the compensation status was not sought prior to the interview. However, if the participant mentioned they had lodged a claim they were encouraged to discuss this further if they wished. Of the few participants who mentioned they had a claim, most mentioned in passing that their claim had been accepted. One participants’ experience was a protracted, inefficient and frustrating claims process that was yet to be resolved, despite ongoing chronic pain that had been previously successfully managed with regular physiotherapy:
P1 (Male, 70-74 years, whiplash)
‘It was just an annoying pain continuously……the insurance company agreed to physio, and then they cut the physio out and I’ve been in pain ever since… my solicitor said everything should be straight forward, that they were making a claim and I should get money to go and continue with physio’.
Dislike of medicolegal assessments was expressed.
P1 (Male, 70-74 years, whiplash)
‘[One thing that I will say, I’m very annoyed with the other driver’s insurance company]...[they] sent me to see another orthopaedic surgeon and he said there was problems on… not the left hand side but the right hand side, which was totally not right… and now… I got a letter …… I’ve got to see another orthopaedic surgeon. And then a psychologist’.
Another participant raised the issue of out-of-pocket expenses for taxis that were not directly related to medical appointments, but had become necessary due to the physical limitations that were a consequence of their injury:
P2 (Male, 80-85 years, arm / leg injuries)
‘When I’m out socially I find I’m using taxis quite a lot. Which is a bit of an expense. So anything to do with the accident I can claim back. But going off to do a bit of ordinary shopping I can’t obviously’.
Transportation services
Participants who used public transport regularly were happy with the availability of services:
P1 (Male, 70-74 years, whiplash)
‘It’s all public transport or my wife will drive me or my step-daughter or my daughter will come and pick me up... if they are not available I just get public transport. It’s only about a six minute walk to the railway station. And there’s plenty of buses around’.
P2 (Male, 80-85 years, upper & lower limb injuries)
‘Where we live it’s quite well served by buses’
One participant did encounter challenges using public transport with a physical disability, however was solution-focused and kept a sense of humour about their experience:
P2 (Male, 80-85 years, upper & lower limb injuries)
‘if it [the bus] stops at the normal stops it’s not a big problem. But the other day... I ended up being hauled into the bus by the bus driver and pushed into the bus by a passer-by... yes, it’s not too good for morale that. But it does work'.
Theme 5: Positive personal approaches
Positive personal and / or psychological resources were important facilitators of recovery that also served as coping mechanisms in managing the experience of the injury itself and the recovery process (Table 2). The most prominent resources from the participants’ perspectives were determination: both to recover and to not let the injury stop them from living life; resilience; pragmatism; active coping strategies, e.g. adoption of physical and psychological adaptations and ‘work-arounds’ in order to regain functioning; being physically active; focusing on incidental positive outcomes (e.g. moving closer to family); selflessness; stoicism; realistic optimism; not taking oneself too seriously; a good sense of humour; being goal-directed; taking responsibility for one’s own recovery and health, and a positive attitude towards life in general (Table 2).