- i) Participant characteristics
A total of 19 eligible participants were invited to participate in the study. Of these, 12 people completed an interview and 7 people did not (4 participants were unable to be contacted; 2 declined to participate; and 1 had difficulty hearing over the phone) (Table 1). Data saturation was reached by the 12th interview, confirmed by no new categories or concepts emergent from the analysis of interview transcripts. Participants had sustained a variety of injuries, including limb fractures, whiplash, rib fractures, sternum fractures or mild traumatic brain injury (mTBI). Psychological impacts such as anxiety, depression and post-traumatic stress disorder (PTSD) were reported.
Table 1: Participant characteristics (n=12)
|
|
N
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Sex
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Male
|
5
|
|
Female
|
7
|
Age (at injury)
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65-69 years
|
4
|
|
70-74 years
|
5
|
|
75-79 years
|
1
|
|
80-84 years
|
1
|
|
85+ years
|
1
|
Marital status
|
Married / de facto
|
7
|
|
Divorced / widowed / separated
|
4
|
|
Never married
|
1
|
Education
|
Secondary
|
5
|
|
Technical / Other
|
1
|
|
Tertiary / University
|
6
|
Claimed
|
Yes
|
5
|
compensation
|
No
|
7
|
Living alone
|
Yes
|
4
|
|
No
|
7
|
|
Unknown
|
1
|
Role in crash
|
Driver
|
6
|
|
Passenger
|
2
|
|
Pedestrian
|
1
|
|
Cyclist
|
1
|
|
Motorcyclist
|
2
|
Hospitalisation
|
Yes (>12 hours)
|
7
|
|
Emergency Department only
|
3
|
|
No / not known
|
2
|
- 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).
Figure 1: Content analysis themes for recovery from RTI in older age – an ICF-based approach
Theme 1: Recovery is regaining independence
Regaining independence in pre-injury activities was a major facilitator of self-perceived recovery. Challenges to independence differed between individuals, types of injury and recovery phase. The initial acute recovery phase was characterised by dependence on others for self-care, such as eating, getting dressed and walking unaided. In the post-acute phase, returning to regular activities, including driving, were perceived as indicators of recovery. Whilst frustration was expressed regarding driving restrictions, being back in a vehicle also presented challenges.
Table 2: Illustrative quotes for Theme 1 - Recovery is regaining independence
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’.
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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’.
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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?’
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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”’.
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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’.
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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’.
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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’.
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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. 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'.
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Theme 2: Injury and disability in older age
Injury-related disability presented specific challenges in older age. Physical limitations and chronic pain had wide-ranging impacts on high-value activities such as caring for grandchildren, participation in weekly leisure and social activities and working life (which in some instances led to unplanned early retirement and financial concerns). The influence of older age on ongoing disability was raised.
Table 3: Illustrative quotes for Theme 2 – Injury and disability in older age
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’.
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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’.
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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’.
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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’.
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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]’.
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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’.
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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’.
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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’.
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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’.
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Theme 3: The burden of non-obvious disability
Late-onset physical disability, chronic pain and psychological injury were not readily apparent to others, but nonetheless had profound impacts on health and functioning.
Table 4: Illustrative quotes for Theme 3 – The burden of non-obvious disability
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’.
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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’.
|
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’.
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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’.
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Theme 4: The importance of support
Practical and emotional support from family and friends was perceived as very helpful to recovery. Participants expressed a great deal of gratitude for the support they received from family, friends, community members and health care professionals. However, communication barriers with medical doctors were also mentioned. Participants who engaged with the compensation system had mixed experiences.
Table 5: Illustrative quotes for Theme 4 – The importance of support
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’.
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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’
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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’.
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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?”’
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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)
‘[my GP is] a good doctor but he doesn’t seem to think that women are very useful [laughs]’
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’.
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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.’
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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’.
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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’.
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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’.
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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’.
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P2 (Male, 80-85 years, upper & lower limb injuries)
‘Where we live it’s quite well served by buses… if it 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'.
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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 6). 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 6).
Table 6: Illustrative quotes for Theme 5 – Positive personal approaches
P7 (Female, 65-69, mild traumatic brain injury)
‘They said [in the Emergency Department] the problem is I am too stoic. So that can really be against you [laughs]. It really can. I often resent wearing [helmets] but I feel like framing that one [laughs]’.
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P9 (Male, 65-69 years, chest injuries)
‘I know they [ribs] are there but I wouldn’t class it as pain… in the end you just do things that you know you can do. I can’t work as hard as I could, but I do what I have to do... I just discourage people giving me big hugs’.
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P2 (Male, 80-85 years, upper & lower limb injuries)
‘At the time I thought things weren’t too bad. And it’s interesting to me that I totally underestimated how much this had affected me. On the other hand, having laid in hospital beds for a while and looked at other people, I’m not too bad’.
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P9 (Male, 65-69 years, chest injuries)
‘I don’t employ anyone. There were lots of jobs I could do even straight away… at certain times, different times [my injuries] affect me a fair bit but basically, I’m back to full work’.
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P9 (Male, 65-69 years, chest injuries)
So-called pain killers, I just went off them as quick as I could a long way short of what some people would because I just got the shits with [the] up and down feeling… [you don’t need] pain killers you just do things that doesn’t hurt… I’ve never been a great believer in pain killers.
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P10 (Female, 65-69 years, multiple arm fractures)
‘For the first time I was just going to make sure I had my own place and yeah so pretty exciting. I got all new furniture and everything and I never lived there… I am back now and have family all around me now… so it worked well, I suppose’.
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P10 (Female, 65-69 years, multiple arm fractures)
‘It is just sort of like watching and being aware. You are always aware… so it’s always on your mind but it won’t stop running my life. [We] have to live, don’t we? At least I didn’t have any other serious injuries. I just have lots of scars up my arm, that's all'.
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P10 (Female, 65-69 years, multiple arm fractures)
‘I mean I do a lot of walking, but you are always very cautious of not tripping. So, it hasn’t stopped me from doing anything that I want to do. Not anymore’.
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- iv) Summary of key findings
Table 7: Themes, facilitators and barriers of RTI recovery in older age, based on ICF concepts
ICF concept
|
Themes
|
|
Example
|
Functioning, activities and participation
|
1. Recovery is regaining independence
|
Facilitators: Returning to driving; regaining independence in self-care, mobility & transportation; resuming usual daily activities
|
P5 (Female, 70-74 years, leg injuries)
‘After I got my licence and I was able to drive around it, like, got back to normal almost straight away’.
|
|
|
Barriers: Lack of independence with self-care and transportation
|
P5 (Female, 70-74 years, bilateral leg injuries)
‘I had to rely on him [my husband] to drive me anywhere and everywhere. It’s terrible when you’ve been independent, you know… so I was very relieved that I actually got my licence back again’.
|
|
2. Injury and disability in older age
|
Barriers: Activity limitations and social participation restrictions with usual daily activities and pre-injury lifestyle
|
P1 (Male, 70-74 years, whiplash):
‘I used to go and play golf three times a week and I would play tennis on a Sunday. Since the time of the accident I haven’t been able to do any of that’.
|
|
3. The burden of non-obvious disability
|
Barriers: Chronic pain; persistent psychological symptoms; passive coping strategies; reduced pre- and/or post-injury mental health
|
P10 (Female, 65-69 years, multiple arm fractures)
‘[The main issue] I think it’s the pain. It’s really just that. It hurts. I think it’s going to hurt for the rest of my life. The same as I suppose having something [like] arthritis or whatever, it is something you have to live with isn’t it?’
|
|
|
|
|
Environmental factors
|
4. The importance of support
|
Facilitators: Practical support from family and friends; timely and effective treatment
|
P5 (Female, 70-74 years, leg injuries)
‘My husband’s a fantastic partner. He’s absolutely been beautiful to me. He’s just been brilliant. Without him, I wouldn’t have been here, I would have been in care or something, you know’.
|
|
|
Barriers: Reluctant to raise concerns with GP; unclear recovery expectations
|
P5 (Female, 70-74 years, leg injuries) ‘I got to my doctor [GP] and he says, “Don’t worry about your legs.” I do worry about my legs because I’m getting older and my legs support me. If your legs aren’t good, well, you’re not going to be moving around, are you?’
|
|
|
|
|
Personal factors
|
5. Positive personal approaches
|
Facilitators: Resilience, determination; active coping strategies; physical fitness; goal-oriented; sense of humour; reflective
|
P11 (Male, 85-89 years, upper limb dislocation)
‘I think I’m pretty lucky because I’ve always had a very active lifestyle…and so I’m now back to swimming... I’ve made a very, very good recovery. A lot of determination going into recovering to where I was before, but if you don’t do it, well, you’ll pay for it’.
|