NZ Journal of Physiotherapy - Vol 49 No 3 - Nov 2021 - WEB

2021 | VOLUME 49 | ISSUE 3: 113–156
ISSN 0303-7193 (PRINT)

ISSN 2230-4886 (ONLINE)
NEW ZEALAND
JOURNAL OF
PHYSIOTHERAPY
• Physiotherapists’ and GPs’

osteoarthritis treatment
knowledge and referral
decisions
• Täne Mäori experiences of
osteoarthritis
• Return to work after burn
injury
• Orthotics for people
affected by polio
www.pnz.org.nz/journal MOVEMENT FOR LIFE

CONTENTS
2021, VOLUME 49
ISSUE 3: 113–156
117 127 147

Guest editorial Research report Research report
Why does Aotearoa The lived experiences of Experiences and perceived
New Zealand need an ngä täne Mäori with hip effectiveness of carbon-
Oosteoarthritis Summit? and knee osteoarthritis fibre triplanar orthotics for
Daniel W. O’Brien, Te Whatarangi people affected by polio:
J. Haxby Abbott Dixon, Daniel W. A qualitative descriptive
O’Brien, Gareth Terry, study
118
Research report Jennifer N. Baldwin, Rachelle A. Martin,
New Zealand Tom Ruakere, Toni Anne C. Fitzpatrick,
physiotherapists’ and Mekkelholt, Peter J. William M. M. Levack
general practitioners’ Larmer
treatment knowledge and
referral decisions for knee
134
osteoarthritis: A vignette- Literature review
based study Supporting people
Daniel W. O’Brien, experiencing a burn
Richard J. Siegert, injury to return to work
Sandra Bassett, Jennifer or meaningful activity:
N. Baldwin, Valerie Qualitative systematic
Wright-St Clair review and thematic
synthesis
Jessica van Bentum,
Julia Nicholson,
Natasha Bale, Joanna
K. Fadyl
New Zealand Journal of Physiotherapy Physiotherapy New Zealand

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DIRECTORY
NEW ZEALAND JOURNAL

OF PHYSIOTHERAPY
Honorary Editorial Jo Nunnerley Mark Laslett Barbara Singer
Committee PhD, MHealSc PhD, DipMT, DipMDT, PhD, MSc,
(Rehabilitation), BSc(Hons) FNZCP, Musculoskeletal GradDipNeuroSc,
Stephanie Woodley
Physiotherapy Specialist Registered with DipPT
PhD, MSc, BPhty
Burwood Academy of the Physiotherapy Board of School of Medical & Health
Department of Anatomy New Zealand
Independent Living and Sciences
University of Otago
Department of Orthopaedic PhysioSouth @ Moorhouse Edith Cowan University
New Zealand
Surgery and Musculoskeletal Medical Centre Perth
Editor
Medicine, University of Otago New Zealand Australia
Richard Ellis New Zealand
Sue Lord Margot Skinner
PhD, PGDip, BPhty Associate Editor
PhD, MSc, DipPT PhD, MPhEd, DipPhty,
Department of Physiotherapy Meredith Perry FNZCP, MPNZ (HonLife)
Neurorehabilitation Group
School of Clinical Sciences PhD, MManipTh, BPhty Health and Rehabilitation Centre for Health Activity
Auckland University of
Centre for Health Activity Research Institute and Rehabilitation Research
Technology
and Rehabilitation Research School of Clinical Sciences School of Physiotherapy
New Zealand
School of Physiotherapy Auckland University of University of Otago
Associate Editor
University of Otago Technology New Zealand
Rachelle Martin New Zealand New Zealand
PhD, MHSc(Dist), DipPhys Associate Editor
Peter McNair Physiotherapy
Department of Medicine Nusratnaaz Shaikh PhD, MPhEd (Dist), New Zealand
University of Otago PhD, MSc, BPhty DipPhysEd, DipPT
New Zealand Ben Hinchcliff
Department of Physiotherapy Department of Physiotherapy
Burwood Academy of National President
School of Clinical Sciences and Health and Rehabilitation
Independent Living
Auckland University of Research Institute Sandra Kirby
Associate Editor
Technology School of Clinical Sciences Chief Executive
Sarah Mooney New Zealand Auckland University of
DHSc, MSc, BSc(Hons) Associate Editor Technology Erica George
Counties Manukau Health New Zealand Communications and
Editorial Advisory Board Marketing Advisor
Department of Physiotherapy David Baxter Stephan Milosavljevic
School of Clinical Sciences TD, DPhil, MBA, BSc (Hons) PhD, MPhty, BAppSc Madeleine Collinge
Auckland University of Copy Editor
Centre for Health Activity and School of Physical Therapy
Technology
Rehabilitation University of Saskatchewan
New Zealand Level 6
School of Physiotherapy Saskatoon
Associate Editor 342 Lambton Quay
University of Otago Canada
Wellington 6011
Suzie Mudge New Zealand
Peter O’Sullivan PO Box 27386
PhD, MHSc, DipPhys
Leigh Hale PhD, PGradDipMTh, Marion Square
Centre for Person Centred PhD, MSc, BSc(Physio), DipPhysio FACP Wellington 6141
Research FNZCP New Zealand
School of Physiotherapy
Health and Rehabilitation Centre for Health Activity and Curtin University of
Research Institute Rehabilitation Research Phone: +64 4 801 6500
Technology
School of Clinical Sciences School of Physiotherapy [email protected]
Australia
Auckland University of University of Otago pnz.org.nz/journal
Technology New Zealand Jennifer L Rowland
New Zealand PhD, PT, MPH
Associate Editor Jean Hay-Smith Baylor College of Medicine
PhD, MSc, DipPhys Houston
Women and Children’s Texas
Health, and Rehabilitation USA
Research and Teaching Unit
University of Otago
New Zealand
GUEST EDITORIAL
Why does Aotearoa New Zealand need an Osteoarthritis

Summit?
In July this year, at the University of Auckland, a steering Physiotherapists have an essential role to play in the
committee for the newly formed initiative ‘Osteoarthritis management of OA in Aotearoa New Zealand. It is a role that
Aotearoa New Zealand’ hosted a gathering we called the spans the complete spectrum of care, ranging from sports
‘Taupuni Hao Huatau Kaiköiwi Osteoarthritis Basecamp’. This injury prevention programmes for our youth to physical activity
one-day event included national and international presenters promotion, traumatic injury rehabilitation, early symptom
and attendees from across the spectrum of healthcare, from management, and pre- and post-operative rehabilitation.
a broad range of clinical practitioners to health funders to Furthermore, physiotherapists are well placed to contribute to
researchers. The cause that drew people to the event was research in all these areas and more. We had great professional
a desire to see better management for people living with engagement from physiotherapists at the Basecamp event
osteoarthritis (OA) in Aotearoa New Zealand. During the and hope to have even greater representation at the Aotearoa
event, we undertook two workshops to prioritise OA care New Zealand Osteoarthritis Summit in July 2022. For anyone
delivery and research. One message that came through very interested in being involved in this kaupapa, you can go to the
clearly from these workshops is that people want cohesion in summit website: https://events.otago.ac.nz/2021-osteoarthritis-
the organisation and delivery of healthcare for people with basecamp/wellington-summit
OA. A finding supported by previous papers calling for the
implementation of a Model of Care to guide service delivery for
OA in Aotearoa New Zealand (Baldwin et al., 2017; O’Brien et Daniel W. O’Brien PhD
al., 2021).
Senior Lecturer, Department of Physiotherapy; Active Living and
The purpose of the Aotearoa New Zealand Osteoarthritis Rehabilitation: Aotearoa New Zealand, Health and Rehabilitation
Summit initiative is to facilitate strategic planning for a national Research Institute, School of Clinical Sciences, Auckland
response to the growing burden of OA and to galvanise University of Technology, Auckland, New Zealand.
action to address this burden. It takes inspiration from the
Email: [email protected]
successful series of Osteoarthritis Summits in Australia, led by
the prominent rheumatologist and world-leading OA expert
Professor David Hunter (Hunter et al., 2019). The kaupapa
J. Haxby Abbott PhD, FNZCP
aims to connect the OA research and innovative health delivery
community, foster increased collaboration in OA research Professor, Department of Surgical Sciences; Director of the
and innovative health delivery in Aotearoa New Zealand, and Centre for Musculoskeletal Outcomes Research, University of
facilitate a cohesive approach to OA research and innovative Otago, Dunedin, New Zealand.
health delivery in Aotearoa New Zealand from basic science
to translational research and implementation by forming an
OA research network and facilitating interdisciplinary and
inter-institutional collaboration. The fundamental objectives of
https://doi.org/10.15619/NZJP/49.3.01
the kaupapa in Aotearoa New Zealand are to (1) co-create a
National Model of Care for OA and (2) develop a list of national
priorities in OA research and innovative health delivery.
REFERENCES
Clinical services must be collaborative and responsive to Baldwin, J., Briggs, A. M., Bagg, W., & Larmer, P. J. (2017). An osteoarthritis
the needs of all New Zealanders with OA. In a paper within model of care should be a national priority for New Zealand. New Zealand
this issue of the Journal (Dixon et al., 2021), we explore the Medical Journal, 130(1467), 78–86.
experiences of living with OA for ngä täne Mäori (Mäori men) Dixon, T.-W., O’Brien, D., Terry, G., Baldwin, J. N., Ruakere, T., Mekkelholt,
and discuss some strategies to improve engagement. While this T., & Larmer P. J. (2021). The lived experiences of Mäori täne with hip
and knee osteoarthritis. New Zealand Journal of Physiotherapy, 49(3),
paper focuses on the experiences of ngä täne Mäori, some of
127–133. https://doi.org/10.15619/NZJP/49.3.03
the lessons learnt could have a broader impact. For example, we
Hunter, D. J., Nicolson, P. J. A., Little, C. B., Robbins, S. R., Wang, X., &
could examine the importance of whakawhanaungatanga, the
Bennell, K. L. (2019). Developing strategic priorities in osteoarthritis
value of relationship building with your patient (or community) research: Proceedings and recommendations arising from the 2017
so you can better serve their needs. We are hopeful that this Australian Osteoarthritis Summit. BMC Musculoskeletal Disorders, 20, 74.
notion of understanding the community’s needs will underpin https://doi.org/10.1186/s12891-019-2455-x
the Ministry of Health’s development of the new Regional O’Brien, D. W., Pigg, W., Ellis, R., Baldwin, J. N., Quicke, J. G., Evans, N., &
Networks and Mäori Health Authority as part of the planned Dziedzic, K. S. (2021). An evidence-informed model of care for people
with lower limb osteoarthritis in New Zealand. New Zealand Journal of
health reform in 2022. Furthermore, Dixon et al. (2021)
Physiotherapy, 49(1), 24–30. https://doi.org/10.15619/NZJP/49.1.04
highlight how research can inform clinical practice.
NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 117

RESEARCH REPORT
New Zealand Physiotherapists’ and General Practitioners’

Treatment Knowledge and Referral Decisions for Knee
Osteoarthritis: A Vignette-based Study
Daniel W. O’Brien PhD
Senior Lecturer, Department of Physiotherapy; Active Living and Rehabilitation: Aotearoa New Zealand, Health and Rehabilitation
Research Institute, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
Richard J. Siegert PhD

Department of Psychology and Rehabilitation, Auckland University of Technology, Auckland, New Zealand
Sandra Bassett PhD*

Department of Physiotherapy, Auckland University of Technology, Auckland, New Zealand
Jennifer N. Baldwin PhD

Postdoctoral Fellow, Priority Research Centre in Physical Activity & Nutrition, Faculty of Health and Medicine, The University of
Newcastle, Australia
Valerie Wright-St Clair PhD*

Professor, Department of Occupational Therapy, Auckland University of Technology, Auckland, New Zealand
*Has retired since completion of this study.
ABSTRACT
Physiotherapists’ and general practitioners’ (GPs) treatment knowledge affects the management of people with knee osteoarthritis
(OA), but little is known about the OA referral decisions and treatment knowledge of these clinicians in New Zealand. Data
were collected from New Zealand registered physiotherapists and GPs (n = 272) using an online vignette-based questionnaire.
Approximately two-thirds (63%, n = 172) of participants stated they would likely refer the hypothetical patient with knee OA to
another profession. Participants indicated they would refer the woman between the two professions (73%, n = 57 GPs would
refer to a physiotherapist; 47%, n = 92 physiotherapists would refer to a GP). However, few participants indicated they would
refer the woman to other health professionals (such as 19%, n = 52 would refer to a dietitian). The majority of participants
reported they would recommend education (98%, n = 267), therapeutic exercises (92%, n = 251) and weight-loss advice (87%,
n = 237) as treatments for knee OA. These results indicate that first-line knee OA treatment knowledge of New Zealand GPs and
physiotherapists are generally in keeping within international guidelines. However, promoting interprofessional collaboration with
other health professions, such as dietetics, and providing education regarding treatments not recommended for OA is needed to
meet all first-line treatment recommendations.
O’Brien, D. W., Siegert, R. J., Bassett, S., Baldwin, J. N., & Wright-St Clair, V. (2021). New Zealand physiotherapists’ and
general practitioners’ treatment knowledge and referral decisions for knee osteoarthritis: A vignette-based study. New
Zealand Journal of Physiotherapy, 49(3), 118–126. https://doi.org/10.15619/NZJP/49.3.02
Key Words: General Practitioners, Knee Joint, Knowledge, Osteoarthritis, Physiotherapists, Treatment
INTRODUCTION should be multi-faceted and reflect the different ways the

disease can affect the individual, including physically, socially
Osteoarthritis (OA) is a chronic musculoskeletal condition
and psychologically (Brosseau et al., 2016; Larmer et al., 2014;
that can affect a person’s physical, spiritual, social and mental
National Institute for Health and Care Excellence, 2015).
wellbeing (Ackerman et al., 2015; Hochberg et al., 2015;
McGruer et al., 2019). Hip and knee joint OA is currently ranked International management guidelines advocate for a staged
as the 11th highest contributor to disability worldwide (Cross et approach to treatment progressing from first-line (exercise,
al., 2014). In New Zealand, OA affects nearly one in 10 people, education and weight loss if appropriate) to second-line
and it was estimated that in 2018 arthritis cost the country treatments (pharmaceutical, aids or bracing and injection
approximately $12.2 billion (Deloitte Access Economics, 2018). therapy) and third-line treatments (joint replacement surgery)
International evidence-based practice guidelines recommend (McAlindon et al., 2014; National Institute for Health and
that OA treatment options progress from conservative Care Excellence, 2015). A large component of the first-line
interventions (such as dietary changes and exercise) to invasive conservative management of OA occurs in primary care; in
treatments (e.g., joint replacement surgery) (Allen et al., 2016; New Zealand, this care is typically provided by physiotherapists
Bennell, 2013; Hunter, 2017). Furthermore, OA treatment and general practitioners (GPs) (Baldwin et al., 2017). Recent
118 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

research indicates that GPs are generally the first point of care the criteria that you typically used to decide that a person has
for most New Zealanders with OA (Jolly et al., 2017; Larmer OA of the knee joint?
et al., 2019). Furthermore, research suggests that first-line
The vignette used in the current study describes a ‘typical’
management approaches such as education, exercise and
person presenting in a primary care setting for treatment of
weight loss (if appropriate) are under-utilised internationally
their knee OA, as well as a series of practice-based questions
(Bennell et al., 2014; Healey et al., 2018; Hunter, 2011, 2017).
(Appendix A). The original vignette was based on the research
The reasons for this are unclear but may include problems such
records of an anonymous patient who had clinical knee OA,
as negative patient beliefs about these interventions, poor
and the questions were based on those used by Holden et al.
adherence or under-prescription by clinicians (O’Brien, 2018).
(2008), altered for use with both physiotherapists and GPs.
Internationally, research has suggested that some clinicians’
The questions sought to understand how the practitioner
views contrast with international guidelines, and treatments
believed they would manage the person. Before the survey
offered frequently do not reflect the recommendations. Recent
was administered, all questions were tested for face validity
studies in New Zealand indicate similar findings from a patient’s
and readability. Three clinical researchers with experience in OA
perspective (Jolly et al., 2017; Larmer et al., 2019; McGruer
research and survey design read the questionnaire and provided
et al., 2019). However, little is currently known about OA
feedback about survey length, appropriateness for the New
treatment knowledge and referral decisions from a clinician’s
Zealand context and readability.
perspective and to what extent this knowledge and behaviour
align with international practice guidelines. Procedure
The anonymised survey was advertised through several
There are several different methods for exploring clinical
channels: physiotherapy continuing education courses, the
practice. Clinical vignette is one method for measuring
Physiotherapy New Zealand Conference, the Royal New Zealand
clinical knowledge and self-reported behaviour, and has been
College of General Practitioners e-newsletters and the local
previously used in this population (Holden et al., 2008). Clinical
primary healthcare organisation. Data were collected between 1
vignettes are cost-effective and allow for data to be collected
September and 1 December 2016 via SurveyMonkey® (https://
efficiently from a wide range of clinicians (Evans et al., 2015;
www.surveymonkey.com). Participants were required to read the
Peabody et al., 2004). However, caution should be applied
online participant information sheet and respond to the items in
when considering the findings, as clinical vignettes are prone to
the questionnaire. Submission of the questionnaire constituted
response bias (participants providing answers they believe the
informed consent to participate. No identifying information was
researcher wants to hear or believe are ‘correct’) and may not
collected, and participants could not be identified or traced.
reflect actual clinical practice (Evans et al., 2015).
Data analysis
This study aimed to investigate the referral decisions and
All data were analysed using SPSS version 24.0 (IBM, USA), with
treatment knowledge of physiotherapists and GPs about New
the alpha level set at p < 0.05. The use of the online platform
Zealanders with knee OA.
limited missing data because participants were directed by
METHODS automatic prompts to complete any missed item or question.
Only complete data sets were analysed. It was not possible to
Study design
calculate the total return rate for the survey, as participants
This study was a cross-sectional, observational study with data
completed the study online and it was unknown how many
collected via online questionnaires. Ethical approval to conduct
potential participants saw the study advertisement but chose
this study was obtained from the Auckland University of
not to participate.
Technology Ethics Committee (reference number 16/284).
Demographic and occupational characteristics
Participants
All data describing demographic and professional characteristics
Clinicians were eligible to participate if they were registered and
were categorical. For each category, the total number of scores
practising in New Zealand as either a physiotherapist or GP, had
was described using descriptive statistics. Data from GPs and
treated a patient with knee OA in the past 6 months, were living
physiotherapists were presented together and separately to
in New Zealand at the time of data collection and had sufficient
allow comparison between the two professions. Categories
English language skills to complete the survey.
that represented a small number of participants were collapsed
Measures/questionnaires into a single category, called ‘Other’. Group equivalency
The survey comprised two sections: 1) demographic and between the two professions for demographic and occupational
occupational characteristics and 2) referral decisions and characteristics data were assessed with chi-square tests (Pallant,
treatment knowledge about knee joint OA. 2011). The Yates correction for continuity was reported where
data were represented as a two-by-two assessment (Pallant,
Section 1 collected demographic data about the participant,
2011).
such as occupation and gender, as well as data about
occupational characteristics, such as duration of practice Clinical vignette data
and geographical location of the practice. Additionally, the All data were categorical, so the total number of scores for each
occupational characteristics included questions about OA- category were counted and converted to a percentage score
specific practice such as, ‘In your current job, how many patients of the total number of people who answered the question.
do you see in your clinic/department with OA?’ and ‘What are Data from GPs and physiotherapists were presented as a single

group and separately to allow comparison between the two General OA patient referral decisions
professions. Group equivalence of the vignette question data Table 2 shows that GPs saw significantly more people with
between the two professions was assessed by Chi-Square knee OA more frequently than physiotherapists (X2 (3) = 27.67,
tests. Where data represented a two-by-two test, the Yates’ p = 0.0001). Additionally, a significantly higher percentage of
Continuity Correction was reported (Pallant, 2011). GPs indicated that they would commonly refer people with
OA to other health professionals (X2 (1) = 16.39, p = 0.0001).
RESULTS
Most commonly, participants indicated that they would refer
Demographic and occupational characteristics patients with OA to orthopaedic surgeons, radiographers/
In total, 295 clinicians participated in this study and completed sonographers and Green Prescription. Significantly more GPs
the demographic and occupational characteristics section of indicated that they referred patients to these professions than
the survey (Table 1). The dropout rate from those who started physiotherapists did (orthopaedic surgeons: X2 (1) = 26.95, p >
the survey was 7.8%, and 272 participants completed the 0.000; radiographers/sonographers: X2 (1) = 32.48, p = 0.0001;
clinical vignette. Approximately 70% of participants were Green Prescription: X2 (1) = 11.61, p = 0.001). Conversely, a
physiotherapists. More female (62.4%) than male participants much smaller number of participants indicated that they usually
completed the survey, irrespective of profession. The duration referred patients with OA to other professions such as dietitians
of practice ranged from less than five years to over 20 years in or psychologists.
both professional groups. Significantly more physiotherapists
Vignette referral decisions and treatment knowledge
than GPs had completed pre-registration qualifications in New
Data from 272 participants were analysed (Table 3), and the
Zealand (X2 (1) = 7.65, p = 0.0001). Participants from both
results of the vignette questions are presented for the whole
professions came from a range of geographical and employment
sample and the individual professions. The findings show that
settings. Significantly more GPs worked in private practice,
significantly more GPs indicated that they would refer the
whereas more physiotherapists worked in the public system.
person described in the vignette to another clinician (X2 (1) =
Table 1
Participants’ Demographic and Occupational Characteristics (N = 295)
All GPs Physiotherapists

Characteristic
n % n % n %
Participants 295 100 87 30 208 70

Gender
Male 111 38 39 54 72 35
Female 184 62 48 55 136 65
Duration in practice
< 5 years 60 20 9 10 51 25
6–10 years 63 21 20 23 43 21
11–15 years 38 13 11 13 27 13
16–20 years 38 13 8 9 30 14
> 20 years 96 33 39 45 57 27
Location of pre-registration qualification
In New Zealand 217 74 54 62 163 78
Elsewhere 78 26 33 38 45 22
Location of clinical practice
City 197 67 54 62 143 69
Town 63 21 17 20 46 22
Rural 35 12 16 18 19 9
Employment setting
Public 51 7 4 5 47 23
Private 218 74 74 85 144 69
Both 15 5 6 7 9 4
Other a 11 4 3 3 8 4
Note. For clarity, percentages are rounded to the nearest whole number. GP = general practitioner.
a
Other employment settings included: aged care (n = 1), community care service (n = 2), hospice care (n = 1), Mäori health trust (n = 2), occupational
health service (n = 1), primary health organisations (n = 2) and university clinic (n = 2).

Table 2
Participants’ OA Patient Referral Decisions
All GPs Physiotherapists

Characteristic (n = 295) (n = 87) (n = 208)
n % n % n %
Frequency of treating patients with hip and/or knee

osteoarthritis
≥ 1 per day 81 28 35 40 46 22
1–3 per week 121 41 43 49 78 38
1–3 per month 66 22 8 9 58 28
1–3 in the past 6 months 27 13 1 1 26 13
Usually refer patients with osteoarthritis to a(n)
Orthopaedic surgeon a 190 64 76 87 114 55
Radiographer/sonographer a 130 44 61 70 69 33
Green Prescription a 120 41 49 65 71 34
Dietitian 57 19 18 21 39 19
Occupational therapist 44 15 14 16 30 14
Personal trainer a 39 13 4 5 35 17
Orthotist 37 12 8 9 29 14
Psychologist 15 5 3 3 12 6
Physiotherapist N/A 64 74 N/A
GP N/A N/A 93 45
Other b 31 11 5 6 26 13
Note. For clarity, percentages are rounded to the nearest whole number. GP = general practitioner; N/A = not applicable.
a
Indicates a statistically significant difference between the GPs and physiotherapists.
b
Other practitioners that participants indicated they would refer to included arthritis nurse educator (n = 1), community exercise programme (n = 7),
hydrotherapy (n = 2), osteopath (n = 2), personal trainer (n = 4), podiatry (n = 7), practice nurse (n = 6) and sports doctor (n = 2).
15.54, p = 0.0001). Both physiotherapists and GPs indicated practice. Significantly more physiotherapists expected to see the
that they would most commonly refer the person described person described in the case study more times for her OA (X2 (4)
in the vignette to the other group’s profession, respectively. = 76.04, p = 0.0001).
Considerably fewer participants indicated that they would
DISCUSSION
consider referring the patient to another profession such
as a dietitian, orthopaedic surgeon or pharmacist. Very few The findings of this study suggest that first-line knee OA
participants indicated they would refer the patient to a pain treatment knowledge held by the GPs and physiotherapists
specialist (2%) or a psychologist (< 1%). in this study are in line with core treatments recommended in
best-practice guidelines (McAlindon et al., 2014 [Osteoarthritis
Most indicated they would provide advice and education
Research Society International]; National Institute for Health and
(98%) and therapeutic exercise (92%). In contrast, very few
Care Excellence, 2015), and is influenced by their respective
participants indicated that they would suggest intra-articular
professional scopes of practice. While both groups suggested
injection (7%) or opioid-based analgesics (2%). GPs’ and
they would commonly refer patients with OA to the other
physiotherapists’ answers differed significantly for many (8 of
group (i.e., GPs to physiotherapists or vice versa), referral to
11) of their chosen treatment modalities for the person. Most of
other health professions appear limited and may indicate the
these significant differences reflect differences between scopes
need for a Model of OA Care in New Zealand to facilitate better
of practice of each profession.
collaboration between healthcare professionals (Baldwin et
Almost every participant (99%) indicated that they would al., 2017). Furthermore, this limited collaboration is reflected
provide the patient with advice as part of their treatment (Table in patients’ experience of OA treatment in New Zealand (Jolly
3). The highest number of participants indicated that they would et al., 2017; Larmer et al., 2019; McGruer et al., 2019). It was
give the person advice about weight loss (87%), pacing activities interesting to note that some participants indicated they would
(81%) and analgesic use (72%). Significant differences occurred consider applying treatment modalities or advice that is not
between the two professions for six of the 11 advice categories; supported by best practice guidelines, such as acupuncture and
again, these differences reflected differences in scopes of rest (National Institute for Health and Care Excellence, 2015).

Table 3
Vignette Beliefs And Referral Decisions
All participants GPs Physiotherapists

Characteristic (n = 272) (n = 78) (n = 194)
Answered ‘Yes’
n % n % n %
Would you be likely to refer this patient to another health 172 63 64 82 108 56
care professional? a
Would you refer this woman to a...?
Dietitian 52 19 14 18 38 20
Orthopaedic surgeon 38 14 8 10 30 16
Pharmacist 32 12 5 6 27 14
Support group 28 10 9 12 19 10
Podiatrist a 24 9 2 3 22 11
Rheumatologist 17 6 2 3 15 5
Acupuncturist 10 4 1 1 9 5
Exercise physiologist 10 4 4 5 6 3
Occupational therapist 10 4 3 4 7 4
Pain clinic 6 2 0 0 5 3
Osteopath 1 >1 0 0 1 >1
Psychologist 1 >1 0 0 1 >1
Chiropractor 0 0 0 0 0 0
GP N/A N/A 92 47
Physiotherapist N/A 57 73 N/A
Once you have made your diagnosis, would you suggest...?
Advice and education 267 98 75 96 192 99
Therapeutic exercises a 251 92 63 81 188 96
Ice or heat a 138 51 20 26 118 61
Manual therapy a 137 50 6 8 131 67
Prescription of simple analgesics a 126 46 76 97 50 25
Strapping or bracing a 89 33 7 9 82 42
Acupuncture a 70 26 4 5 66 34
Prescription of non-steroidal anti-inflammatory drugs a 67 25 39 50 28 14
Rest a 30 11 8 10 22 11
An intra-articular injection of steroids or similar a 20 7 16 21 4 2
Prescription of opioid-based analgesics a 6 2 5 6 1 >1
Would you offer any advice as part of your treatment? 270 99 78 100 192 99
Would you offer any advice about...?
Weight loss 237 87 69 89 168 86
Pacing activities a 220 81 42 54 178 91
Analgesics a 196 72 65 83 131 67
Heat or ice a 159 58 28 36 131 67
Increasing level of activity a 150 55 32 41 118 61
Using a walking aid 132 48 32 41 100 51
Nutrition 105 39 27 35 78 40
The use of knee supports a 90 33 18 23 72 37
Rest 48 18 9 12 39 20
Avoiding painful movements 40 15 12 15 28 14
Reducing activity levels a 28 10 2 3 26 13
How often would you be likely to see this woman?
Once a 6 2 4 5 2 1
2–3 times 86 32 52 67 34 18
4–5 times 91 34 18 23 73 38
6–7 times 50 18 1 1 49 25
> 7 times 39 14 3 4 36 19
Note. For clarity, percentages are rounded to the nearest whole number. GP = general practitioner; N/A = not applicable.
a
Indicates a statistically significant difference between the GPs and physiotherapists.

Demographic characteristics al. (2017) found that the current primary care funding model
Participants included clinicians with a range of different in New Zealand has led to the fragmentation of care for people
experience levels, frequency of treating people with knee OA, living with chronic multi-morbidity. Third, the findings may be
employment settings and geographical locations. However, the due to inadequate or limited communication between health
small sample sizes (approximately 4% of New Zealand registered professionals. If GPs and physiotherapists do not regularly
physiotherapists and 1% of GPs completed the survey) means practise with clinicians from these professions, they may
that the findings cannot be considered representative of the not consider including these professions in an integrated or
treatment knowledge or self-reported referral behaviour of each collaborative approach to OA treatment (Hall, 2005; Westby &
profession. Considerably more physiotherapists participated Backman, 2010).
in the study than GPs. Previous research has referred to the
Vignette referral decisions and treatment knowledge
challenges of recruiting GPs to studies of this nature, citing
The results show that the participants supported first-line
causes for low research recruitment rates as survey fatigue and
treatment practices in keeping with current best-practice
high workloads (Cottrell et al., 2015, 2017). It is possible that
recommendations for the treatment of people with knee OA
the length of the survey in the current study was a barrier to
(Fransen et al., 2015; McAlindon et al., 2014; Merashly &
GP participation and future research needs to address these
Uthman, 2012). Advice and education and therapeutic exercise
challenges to enhance recruitment of GPs.
were the most popular interventions considered appropriate for
OA patient referral decisions the person described in the vignette, findings that are similar
Participants most commonly reported the three professions or to previous research using this vignette (Holden et al., 2008).
services they refer people with OA to as radiology, orthopaedic Moreover, this finding suggests that participants perceive
surgery and Green Prescription (a publicly funded community- value in therapeutic exercise for people with moderate knee
based exercise and activity service). These findings are not OA. The most popular advice categories were weight loss,
surprising. First, X-ray is still considered a critical diagnostic tool pacing activities and the use of analgesics. Again, these results
by some clinicians, despite current contradictory evidence and imply that participants were conscious of the known benefits
recommendations that suggest that imaging is unnecessary of these interventions (Atukorala et al., 2016; Bliddal et al.,
(National Institute for Health and Care Excellence, 2015). 2014; Mills et al., 2019; Poitras et al., 2010). Several significant
Imaging correlates poorly with symptoms and, in some cases, differences were seen in the recommended treatments and
is harmful because it reinforces a purely mechanical view of advice given between the two professional groups (GPs and
the disease (Bunzli et al., 2019; O’Brien et al., 2019). Second, physiotherapists). However, most of these differences can
surgical joint replacement is common and effective for reducing be explained by differences in the scope of practice of each
pain (Hochberg et al., 2015; Leskinen et al., 2012). profession. For example, significantly more GPs advocated
prescription of medication, whereas more physiotherapists
In contrast, only a few participants indicated they would
advocated treatment such as pacing, therapeutic exercises or
refer people with knee OA to dietitians, psychologists and
manual therapy.
occupational therapists. A high body-mass index score is a
known risk factor for developing OA and an aggravating factor There were three areas where the findings suggest knowledge
with OA (Barrow et al., 2019; Hochberg et al., 2015). Therefore, that differed from clinical best practice. First, a notable
it would seem logical that referral to dietitians to help with percentage of participants indicated they would recommend
weight loss, when appropriate, would be beneficial. Similarly, management approaches (acupuncture [26%] and rest [18%])
many people with OA describe the impact of the disease on not supported by current evidence (McAlindon et al., 2014
their mental and emotional wellbeing (Bijsterbosch et al., 2009; [Osteoarthritis Research Society International]; National Institute
Brembo et al., 2016; Sharma et al., 2016). Thus, engaging the for Health and Care Excellence, 2015). These findings may
services of a psychologist could be beneficial for these people. suggest that further professional training is needed among
Limitations of activities of daily living and mobility are common, GPs and physiotherapists to ensure consistent, best-evidence
as is chronic fatigue (Hegarty et al., 2016; Murphy et al., management is provided to people with OA in New Zealand.
2013; Palmer, 2012). Hence, a benefit may be obtained from
Second, very few participants specified that they would refer the
occupational therapy services to facilitate pacing and coping and
person to a dietitian, despite 86.9% of participants indicating
the prescription of functional aids (Stukstette et al., 2012).
the importance of providing advice about weight loss. Obesity
Three factors may explain the findings of clinicians’ referral is a known risk factor for developing knee OA (Barrow et al.,
practices. First, GPs and physiotherapists may see little efficacy 2019; Silverwood et al., 2015). Furthermore, weight loss is
in these services or have a limited understanding of what these known to reduce disease progression in people with knee OA
professions could offer people with OA. This limited knowledge (Van Manen et al., 2012). Therefore, this result is somewhat
is known to affect the referral of people with OA to conservative surprising, and the reason for this finding is unclear. Possible
treatment programmes (Chevalier et al., 2004). Second, the explanations for these findings may relate to the limited funding
current funding model in New Zealand does not typically of dietetic services in New Zealand, the perception that any
facilitate referral for people with OA to these services because healthcare professional can provide weight-loss advice, or that
patients have to pay for these services. Cost and funding models effective weight loss is too challenging for people with knee OA.
are known to affect how clinicians in primary care services Again, this finding suggests that considerably more research is
practise and refer (Stokes et al., 2017). Furthermore, Stokes et needed in this area of OA treatment.

Third, 14% of participants indicated that they would refer the DISCLOSURES
patient to an orthopaedic surgeon, despite limited conservative
No funding was obtained for this study. There are no conflicts
treatment options being trialled first. While this is a relatively
of interest that may be perceived to interfere with or bias this
small percentage, it is still notable given that surgery is only
study.
considered appropriate after all conservative treatments
have been attempted (National Institute for Health and Care PERMISSIONS
Excellence, 2015). Furthermore, 64% of participants indicated
This study was granted ethical consent by the Auckland
they usually referred people with OA to an orthopaedic
University of Technology Ethics Committee (reference number
surgeon. The reason for these findings is not apparent, but the
16/284). There was no mechanism of identifying people who
results may reflect a perception that joint replacement surgery
participated in the study, and the participant information
is inevitable for people with OA or the limited state-funded
explained that by submitting the questionnaire electronically,
conservative treatment services available to people with OA in
they were consenting for the data to be used for the study. No
New Zealand (Baldwin et al., 2017; Bunzli et al., 2019; O’Brien
additional permissions are required for this manuscript.
et al., 2019).
ACKNOWLEDGEMENTS
Strengths and limitations
A strength of the study was the adaptation and use of an The primary author would like to acknowledge the ongoing
existing clinical vignette (Holden et al., 2008), which allowed for support of Arthritis New Zealand and the Auckland University of
comparison with previous research. Technology with this research.
The study had several limitations. Twice as many physiotherapists ADDRESS FOR CORRESPONDENCE
as GPs completed the survey. Therefore, the findings may be
Daniel O’Brien, Department of Physiotherapy, School of Clinical
biased towards physiotherapists’ beliefs and may not represent
Sciences, Auckland University of Technology, North Shore
GPs’ beliefs. The sample size was relatively small, meaning the
Campus, Akoranga Drive, Northcote, Auckland, New Zealand.
findings may not represent the knowledge or practice decisions
of the wider population of physiotherapists and GPs in New Email: [email protected]
Zealand. The high survey dropout rate (7.8%) may reflect survey
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Appendix A
CLINICAL VIGNETTE (CASE STUDY) morning and after staying in one position for too long. She finds
some relief from an anti-inflammatory gel and takes up to three
A 66-year-old woman presents to your clinic with a 6-year
200-mg ibuprofen tablets per day.
history of left knee pain, which was of insidious onset and has
gradually worsened over time. She is a retired shop manager Despite not having a radiograph, she feels her problem is due
and usually enjoys gardening, but this has become difficult due to arthritis, as her father had this. This is the first time that she
to her knee problem. Her general health is good, despite being has consulted with a health professional about the problem,
overweight and having mild hypertension. She also has pain in and she is optimistic about its outcome. On examination, the
both hands. left knee has a mild effusion and a valgus alignment. Flexion is
limited and the quadriceps femoris muscles are weak. The joint
Today, she rates the intensity of her knee pain as 6 out of 10.
line is tender on palpation. No other examination findings are
Descending stairs, bending and rising from sitting all aggravate
remarkable.
her knee pain. She has some difficulty walking and has started
to use a cane outdoors. Her knee is stiff first thing in the

RESEARCH REPORT
The Lived Experiences of Ngä Täne Mäori with Hip and Knee
Osteoarthritis
Te Whatarangi Dixon BHSc
Physiotherapist, Queen Elizabeth Hospital, Rotorua, New Zealand
Daniel W. O’Brien PhD

Senior Lecturer, Department of Physiotherapy; Active Living and Rehabilitation: Aotearoa New Zealand, Health and Rehabilitation
Research Institute, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
Gareth Terry PhD

Centre for Person Centred Research, Auckland University of Technology, Auckland, New Zealand
Jennifer N. Baldwin PhD

Postdoctoral Fellow, Priority Research Centre in Physical Activity & Nutrition, Faculty of Health and Medicine, The University of
Newcastle, Australia
Tom Ruakere DHSc

School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
Toni Mekkelholt BHSc

Physiotherapist, Whakatane Hospital, Whakatane, New Zealand
Peter J. Larmer DHSc

Head of School, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
ABSTRACT
Osteoarthritis (OA) is a debilitating condition affecting an individual’s quality of life in multiple ways. However, little is known about
the experiences of täne (men) Mäori living with OA in Aotearoa New Zealand. We aimed to explore the lived experiences of ngä
täne Mäori with OA. This qualitative study was guided by tikanga and kaupapa Mäori philosophies. Interviews were conducted in a
semi-structured method, with seven täne Mäori living with OA. Key themes were identified and developed from the data through
thematic analysis, and were informed by Tä Mason Durie’s Mäori health frameworks, Te Whare Tapa Whä and Te Pae Mähutonga.
Four themes developed from the data and were named: (1) The interface of masculine embodiment and mana, (2) Taha whānau and
connection as central to ngä täne Mäori wellbeing, (3) The benefits of taha wairua (spiritual wellbeing), and (4) Te urutau kia uru
ki te punaha tiaki hauora: Adapting to access the health-care system. OA places a significant burden on ngä täne Mäori and their
whänau, impacting on all aspects of hauora (health). The unique lived experiences and impact on wider whänau of Mäori living with
OA indicates the need to consider te ao Mäori (Mäori world view) when developing clinical services and a Model of Care for OA.
Dixon, T.-W., O’Brien, D. W., Terry, G., Baldwin, J. N., Ruakere, T., Mekkelholt, T. & Larmer, P. J. (2021). The lived
experiences of ngä täne Mäori with hip and knee osteoarthritis. New Zealand Journal of Physiotherapy, 49(3), 127–133.
https://doi.org/10.15619/NZJP/49.3.03
Key Words: Aotearoa New Zealand, Beliefs, Experiences, Täne (men) Mäori, Osteoarthritis
INTRODUCTION greater preoperative comorbidities and have more postoperative

complications than non-Mäori (Pai et al., 2010; Singleton et al.,
Osteoarthritis (OA) is a common joint disease that affects
2013).
the health and wellbeing of approximately one in 10 people
living in Aotearoa New Zealand and costs the country an OA can affect all aspects of a person’s sense of hauora (health)
estimated $12 billion annually (Deloitte Access Economics, including taha hinengaro (mental and emotional), taha tinana
2018). People with OA often experience pain, joint stiffness (physical) and taha whänau (social) (Durie, 2004; Gignac et al.,
and weakness, which can affect their mobility, independence, 2008; Hawker et al., 2011; Jolly et al., 2017; Kao & Tsai, 2012;
function and mental wellbeing (Hall et al., 2008). Research McGruer et al., 2019; Smythe et al., 2012; Smythe & White,
suggests that ngä täne (men) Mäori suffer higher incidence 2017). International guidelines state that management of the
and prevalence rates of OA than non-Mäori males (Ministry disease should be patient-centred and address the multifaceted
of Health, 2019), although Jansen et al. (2009) state Mäori nature of the condition (National Institute for Health and Care
may be underestimated in statistics. Mäori are more likely to Excellence, 2021). Furthermore, a call has been made for a
undergo total joint replacements at a younger age, present with New Zealand Model of Care for OA that details how, when,

where and with whom the management of OA should happen research process, results, researchers and participants (Jones
(Baldwin et al., 2017; O’Brien et al., 2021). et al., 2006). The questions were open-ended (see Appendix
A), aiming to explore the participants’ personal experience of
Mäori perspectives have historically been under-reported
OA and their experience of health services. Five of the seven
in research in Aotearoa New Zealand and few studies have
participants asked that their interviews not be recorded – two
employed kaupapa Mäori methods that facilitate mana-
of the participants did not want their voices to be loaded onto
enhancing practice (Smith, 1999). McGruer et al. (2019)
any shared networks and no reason was given for the other
explored the lived experience of ngä wähine (females) Mäori
three participants. Interviews that were not digitally recorded
with OA, and found that OA inflicts a substantial burden on
were instead transcribed by TD, from extensive notes written
the physical, mental, spiritual and family wellbeing of Mäori.
during the interview, then further developed and transcribed
The authors argue that primary care practitioners must consider
immediately following the interview to aid in the retention of
spiritual and family wellbeing when providing care for Mäori
important details. The remaining two interviews were recorded
with OA (McGruer et al., 2019). However, it is unclear if the
and transcribed verbatim.
findings also represent ngä täne Mäori. Therefore, we aimed to
explore the perceptions and lived experiences of ngä täne Mäori Data analysis
living with OA in Aotearoa New Zealand. Analysis was guided by the six steps outlined by Terry et al.
(2017) for reflexive thematic analysis. Consideration of te ao
METHODS
Mäori informed and shaped the process of developing themes
Study design throughout the research process. The first step involved
This study used a qualitative method and was informed by the familiarisation, making casual notes on the content of the
kaupapa Mäori philosophical framework for research (Smith, interviews. Inductive codes were then generated, informed
1999). by the research question at both semantic and latent levels
(the latter often using concepts from mätauranga Mäori to
Kaupapa Māori philosophical framework
inform codes). From this, themes were developed, tested and
The kaupapa Mäori research model is Mäori-centred, with
reviewed by returning to the interviews to determine whether
outcomes aiming to benefit Mäori. Kaupapa Mäori research
they accurately gauged the data collected, then the final report
is defined as “to engage in a dialogue about setting new
was produced. Each of the six phases of thematic analysis were
directions for the priorities, policies, and practices of research
carried out by the primary researcher, with findings presented
for, by and with Mäori” (Smith, 1999, p. 183). It places Mäori
to the wider research team. Following this, the themes were
values, customs and protocols at the centre of the research
refined by a second member of the research team (GT) and
methods, and is vital in attaining an accurate interpretation of
again presented to the research team to ensure that meaning
te ao Mäori to ensure mana-enhancing approaches to research
had been retained.
practice (Jones et al., 2006).
Theme development was informed by the Mäori health
Participants
frameworks, Te Whare Tapa Whä and Te Pae Mähutonga. Te
The study was advertised via social media and flyers as well
Whare Tapa Whä (Durie, 1998) uses the four walls of a whare
as through the primary researcher’s (TD) whänau, community
(house) that represent the elements that symbolise good health
contacts and snowball sampling. Participants were recruited
and wellbeing. Te Pae Mähutonga is a health promotional
from the Bay of Plenty region. Participants were included if they
framework, also proposed by Durie (2004). A constellation, Te
identified as täne Mäori, were over the age of 35 years and met
Pae Mähutonga or Southern Cross, has traditionally guided
the American College of Rheumatology criteria for hip or knee
Mäori on their ocean voyages. The stars that make up Te Pae
OA; knee, hip or groin pain; stiffness for less than 30 min; knee
Mähutonga symbolically represent the components of Durie’s
crepitus; bony tenderness and enlargement of the knee; and no
(2004) health promotion framework: Mauriora, Waiora, Toiora,
unusual, palpable warmth (Kolasinski et al., 2020). Participants
Te Oranga, Nga Manukura and Te Mana Whakahaere, which
were excluded if they had difficulty verbally communicating in
served historically as a guide for generations of Mäori.
either English or te reo Mäori; had suffered a significant injury in
the past 3 months; had had a total joint replacement; or had a RESULTS AND DISCUSSION
disability or medical condition other than OA that substantially
Seven täne Mäori participated in the study and their ages
affected their daily function.
ranged from 49 to 75 years. Five participants had knee OA and
Procedures two had hip OA. Symptom duration ranged from 6 months
Participants were interviewed face to face by TD in a location of to 40 years. Four participants lived rurally and three lived in
the participant’s choosing. Upon starting, karakia (ritual chant an urban area. All participants indicated taking medication for
or prayer) was undertaken, the consent form was filled out their OA and four stated that they used rongoa (traditional
and whakawhanaungatanga (process of building relationships) Mäori medicine) to treat their OA. Four themes developed
established. The interviews followed a semi-structured style in from the data and were named: (1) The interface of masculine
both English and te reo Mäori. TD utilised the domains of te embodiment and mana, (2) Taha whänau and connection as
ao Mäori to ensure tikanga (Mäori customs) where karakia, central to ngä täne Mäori wellbeing, (3) The benefits of taha
whakawhanaungatanga, manaakitanga (process of showing wairua (spiritual wellbeing), and (4) Te urutau kia uru ki te
respect), aroha (love and compassion) and pono (honesty) punaha tiaki hauora: Adapting to access the health-care system.
were included. These tikanga practices safeguarded the

Theme 1: The interface of masculine embodiment In contrast, some ngä täne Mäori articulated their mana or
and mana masculinity as not defined by their physical capacity alone, and
This theme explored the different beliefs ngä täne Mäori were more willing to be vulnerable and accepting of change:
expressed regarding their mana, in relation to their ‘manliness’ “Having ailments is a natural thing. Your maleness isn’t judged
or masculinity, and how this was impacted by OA. Central on whether you’re limp winged or have any other physical
to this theme was the relationship of masculine identity to defect” (Participant 3).
both taha tinana and taha hinengaro, and the inseparability
Despite these differences in ngä täne Mäori, there was a distinct
of these within te ao Mäori. Taha hinengaro allows people to
sense that they were answerable to these masculinity concerns,
think, communicate and feel, generating awareness of the self
whether or not they identified strongly with them. This meant
(Durie, 1998) – but this includes experiences and expressions
that ngä täne Mäori would often make reference to manhood
of the physical body. Within Western men’s health literature,
and masculinity when speaking about OA and its impacts,
this interface has been understood as experiential embodiment
whether or not this was raised by the interviewer.
(Robertson et al., 2010). This is an area underexplored within
Western biomedicine, where the body and mind are often Much of this körero related to changes in toiora (role
treated as separate (Robertson et al., 2010), something that expectations and changes) and the modelling of skills and
can impact ngä täne Mäori negatively. For the men in this study, behaviour to their whänau. This often meant that the elements
taha hinengaro seemed to be a primary point of reference of their identities that gave them a sense of meaning were
for understanding the experience of OA. However, how this increasingly being located in the past, rather than the present.
manifested in their roles and responsibilities (toiora) as täne
I really miss my hunting … that’s what I miss the most.
Mäori was also referred to throughout the interviews.
Getting my boys and the dogs, then just spending a day or
Frequently, the sensation of whakamä (an event or experience two out in the bush with them. It’s priceless those moments
that brings shame or embarrassment) was present for ngä täne … They’re memories I will cherish forever; it’s the time I spent
Mäori when talking about their experiences of OA (Te Karu, with my boys bringing them up and teaching them the life
2013): skills that were passed down to me. It’s whakapapa really my
boy. (Participant 6)
It’s just annoying to be honest. A lot of things have changed
… The things I used to be able to do, I just can’t … I can’t This kind of embodiment has been described as pragmatic
run anymore, I can walk but I struggle to keep up with embodiment – or the ways the body enables certain roles
people … It’s tough because I’m still relatively young … It just (father, worker, rugby player) to be taken up (Robertson et
bothers me feeling like people are looking at me with pity. al., 2010). For ngä täne Mäori like Participant 6, this was
(Participant 5) inextricably tied to their bodies. For some ngä täne Mäori, their
roles had changed as they aged, and so the need for physical
Participants commonly expressed attitudes associated with the
expression of masculinity was lessened: “When I go and help
dominant ideals and values of Aotearoa New Zealand: strong,
with the marae and that, it doesn’t really affect me. Although,
hard-working, rising above adversity and, most notably, humility
I’ve got to sit down a bit … I still partake in that sort of thing it
(Phillips & Hulme, 1987). Participants spoke of being a “man’s
hasn’t stopped me doing that” (Participant 4).
man”, and having a “she’ll be right” attitude, drawing on the
powerful imaginary figure of the ‘kiwi bloke’, who epitomises For those whose identities were tied up in their physicality, this
what an Aotearoa New Zealand man should look like and aspire was something that seemed to be a longstanding component of
to be (Terry & Braun, 2009). A predominant feature of this their lives. Ngä täne Mäori spoke of the comparisons between
whakamä was the reluctance to be vulnerable. Ngä täne Mäori the freedom of youth and their current experience of their
seemed to struggle with a concern for burdening others and the bodies:
disempowering feeling of pity from whänau and friends. This
It’s all part of life. I was just a kid, I still am young at heart
had significant effects on their mana. Mana as an expression
even though I’m an old fart and can’t do much anymore …
of spiritual power and potentiality within a person (Tate, 2010),
We would go up the hills and roll down them, run down
seemed at risk due to their experiences. This was spoken about
to the beach and build huts and play rugby in the mud.
by some of ngä täne Mäori specifically in relation to their
(Participant 6)
masculinity:
These conversations and comparisons seemed to be confronting
I can’t bring myself to get too emotionally involved, I’ve
for some participants. This could indicate a reliance on their
always been a man’s man and just gotten on with life. My
bodies for a positive sense of self. Several ngä täne Mäori
kids are all doing really well with my moko’s [mokopuna/
had not previously considered, or had and disregarded, the
grandchildren] so I don’t want to be annoying them.
implications of their physical ailments on their mental wellbeing.
(Participant 2)
This may highlight a challenge when supporting ngä täne Mäori
I’ve never really thought about it … I’m definitely a man’s to express their vulnerabilities.
man, I’ve always just done things a certain way and was
I do sometimes get a little bit, well maybe more than a little
brought up with my dad’s ‘life isn’t fair’ way. I don’t really
bit … How do I put it? Not depressed. Oh, actually a little
talk about these things because we were basically raised to
bit of that I think … You know, putting up with the pain. It’s
be staunch and all. (Participant 5)

hard to say … You know, when I feel and look at my bad I am. Their opinions are the only opinions that matter most to
knee I think, Jesus what’s going on. (Participant 4) me. If anything, they help me through each and every day”
(Participant 7).
Taha tinana considers our autonomy over our physical health
and how we manage the challenges presented to this and Ngä täne Mäori in this study discussed how their roles had
is strongly related to our mental wellbeing (taha hinengaro). changed within their whänau and society due to ageing. It
Turning to whänau for support in times of need is common; so, is a natural human instinct to seek acceptance and to have a
it is essential we consider the nuances of taha whänau and the place of belonging within society (Oetzel et al., 2019). Hence,
role of connection. the endeavours of te oranga is to find that sense or place of
belonging, in order to participate in society (Durie, 2004). Ngä
Theme 2: Taha whänau and connection as central to ngä
täne Mäori felt their ability to participate in society or with
täne Mäori wellbeing
whänau had become limited due to their OA. These limitations
Whänau in te ao Mäori is tremendously important. Durie (1998)
include the changing dynamics as a päpä (father) or koroua
argues the concept of whänau is unique, as it organises Mäori
(grandfather), and the inability to work full-time or at all, drive,
culture and is foundational to Mäori identity. There are two
stand at the marae or simply hang the washing.
elements that characterise taha whänau. First, whänau is the
principal support system. Second, self-reliance and an insistence I used to be able to help the boys at mahi [work], but now I
on independence, not turning to whänau for support in times have to drive the truck around to all the areas and just wait
of need, is viewed as immaturity rather than strength. As Durie for them as we go through each paddock or bush … I can’t
(1998) states, “Interdependence rather than independence is go out hunting like I used to as well, because my knee just
the healthier goal” (p. 72). This idea is extended to connection hurts too much. (Participant 1)
to whenua (land) and whakapapa (genealogy), and the support
When speaking of these changes, ngä täne Mäori allowed
these offer ngä täne Mäori and their sense-making concerning
out a part of their compartmentalised emotions. These were
OA.
raw, special moments, which showed they had the capacity to
‘Mauri’, means life force, in things or objects both living and express their vulnerabilities: “I tell you what though, the thing
inanimate. In essence, ‘mauri ora’ expresses the importance I really miss is actually being able to run around with the kids”
of a healthy cultural identity, to realise inner potential and to (Participant 5).
seek one’s identity and facilitation into te ao Mäori (Durie 1999;
The main thing I miss the most is being able to ride my horse
2004). For many Mäori, urbanisation has limited access into
… I can’t ride him like I used to … My knee bloody kills me
te ao Mäori. Many Mäori have become alienated, as cultural
when there in the stirrups, it just jars-up and crunches with
ties have been damaged through the confiscation of whenua,
every stride. It’s the worst pain. (Participant 1)
generational loss of te reo Mäori, colonised suppression and
institutionalised racism (Jones et al., 2006). The loss of cultural Ngä täne Mäori have struggled with the changes brought on
identity and its impacts on wellbeing were evident among some by OA, including choosing to be independent from whänau,
participants in the dataset: living and working alongside whänau or seeking a spiritual
connection. Hence, taha wairua needs to be discussed, as Mäori
I was brought up in the city but we used to go out to the
culture is infused intimately with the spiritual world.
farm back home all the time when I was growing up … I was
beaten when I was younger for speaking Mäori even though Theme 3: The benefits of taha wairua (spiritual wellbeing)
it’s my native tongue. (Participant 2) Taha wairua encapsulates the unspoken energies that surround
us. It is intertwined with the past, present and future and
All participants discussed how important their whänau were and
provides the important connections Mäori have with their
the crucial role they played in their lives. However, several ngä
whakapapa and te ao Mäori (Durie, 1998). Waiora is one’s
täne Mäori struggled or were reluctant to engage emotionally
capacity to balance and harmonise one’s relationship with one’s
with whänau about their OA. This could indicate the breakdown
environment. Durie (1999, 2004) emphasises the significance
in mauri ora, with some ngä täne Mäori unwilling to open up
of environmental protection and the relationship with te ao
in fear of becoming a burden on others, emphasising again the
Mäori, and how it is crucial for the health and wellbeing of
challenge ngä täne Mäori have with vulnerability: “I don’t really
Mäori. The two important factors required to bring balance
talk about it with them … It’s just become the norm now really,
with the spiritual realm are tikanga and ähuatanga Mäori. If
me being a cripple. My kids and I joke about it so it’s not too
tikanga Mäori are ‘Mäori customs’ then ähuatanga Mäori are
depressing” (Participant 5).
‘Mäori traditions’, and co-exist with one another. Ähuatanga
Some ngä täne Mäori appeared to have strong connections Mäori in particular is key, as it encompasses the characteristics
with whänau and whakapapa, speaking of their whänau as of Mäoritanga that connect the deep emotional and spiritual
Durie (1998) describes: “family is the primary support system bonds unique to Mäori (Mead, 2003).
for Mäori, providing care and nurturance, in physical terms
Typically, Mäori are raised under tikanga and ähuatanga Mäori.
as well as culturally and emotionally” (p. 86). Muriwai et al.
Our results suggest that rural ngä täne Mäori appear to have
(2015) further argue that those who strongly identify solely as
a stronger connection to their wairua compared to urban ngä
Mäori, with strong cultural adeptness, have lower psychological
täne Mäori, which could be due to the effects of urbanisation:
distress. Our data supports this notion, for instance: “My
“I’d go for drives to the bush where I used to go hunting … to
whänau support me 100 percent, they are the reason I am who

listen to all of Täne-mahuta’s children singing their songs and let Our people are not used to talking about their mamae [pain].
my thoughts drift away. Sometimes I’d fall asleep” (Participant Perhaps, our medical professionals would need to learn how
1). to get that information out of us rather than write ‘now okay
we’ll give you this for that, and this for that. All right, thank
In comparison, Participant 7 was from an urban setting: “Never
you very much. See you later, good day.’ Then they walk out
tried rongoa … I wasn’t brought up around that stuff. If we
and pay $50 for that service. (Participant 3)
were sick or got injured we went to the doctors, that’s just the
way it was” (Participant 7). OA has made a significant impact on ngä täne Mäori. To others,
they present the dominant ideals that are perceived to epitomise
Some urban-raised ngä täne Mäori mournfully expressed they
what an Aotearoa New Zealand ngä täne Mäori should be.
had not been back to their papakäinga (ancestral homelands)
However, many spoke about struggling to come to terms with
in many years, which resulted in them feeling disconnected
their condition(s) and become accepting of these changes,
from their whenua, iwi and tïpuna (ancestors): “If I’m feeling a
in private. Durie (1998) advises considering all dimensions
bit down about something, all my whänau live back home so I
collectively and not independently. But this is difficult to achieve
don’t really have that many people to talk to. I’m divorced now
with ngä täne Mäori with ill-health or injury. Throughout each
and the kids are all grown up” (Participant 2).
dimension, a major issue became evident: the inability for some
Urbanisation has profoundly impacted the upbringing of participants to accept change and unwillingness to express their
Mäori and their access to te ao Mäori. Many Mäori who feel vulnerabilities.
disconnected from their wairua become more socially isolated
Strengths and limitations
and have experienced generational marginalisation in the
A strength of the study was the guidance of kaupapa Mäori
Aotearoa New Zealand healthcare system (Jansen et al., 2009).
throughout the research process; the key utilisation of the
Participants in this study have experienced different types
Mäori health frameworks informed the data analysis and
of healthcare treatment; hence, it is critical to discuss these
theme development. Having the primary researcher (TD) and
experiences.
a second member (TR) of the research team identify as Mäori
Theme 4: Te urutau kia uru ki te punaha tiaki hauora: and understand tikanga and kaupapa Mäori protocols was
Adapting to access the health-care system fundamental to implementation of concepts of te ao Mäori. A
Numerous studies have argued Mäori marginalisation in the limitation of this study was the small sample size, which should
Aotearoa New Zealand health-care system, and the disparity be considered when interpreting the results. Additionally, only
between the biomedical/Western and Mäori models of health two of the seven interviews were digitally recorded at the
(Elers, 2014; Wilkins, 2009). Ngä täne Mäori in this study request of participants. Therefore, some communications may
reported contrasting experiences of the healthcare system. have been lost due to recall limitations.
Ngä täne Mäori with a stronger sense of identity, support
Clinical and research implications
and belonging appeared to have had positive experiences –
Physiotherapists and researchers should consider the process
especially if their medical professionals’ practices matched their
of whanaungatanga as a method of building rapport when
expectations:
undertaking research with or treating ngä täne Mäori. This
Oh, the good thing they do here is they treat you like change could be something as simple as committing time at the
whänau. They always make sure we are okay, they would beginning of the session to understanding what is important to
contact you and make you feel at home here, which [I think your patient/participant and sharing something about yourself.
is] different to what it’s like in the cities. (Participant 4) For more guidance, please see Person and whänau centred care
/ seeing the patient as a person / ethnicity Mäori (Darlow &
However, others reported stories of institutional racism and
Williams, 2018) on the Physiotherapy New Zealand website.
marginalisation, for instance:
CONCLUSION
I grew up in a pohara [poor] neighbourhood and the doctors
treated us like we were from a third world country … I got This is the first kaupapa Mäori-informed study of the lived
annoyed one time when my mum was sick. The doctors saw experience of hip and knee OA by ngä täne Mäori in Aotearoa
all the päkehä patients who arrived after us … I was 12 or New Zealand. The findings emphasise the multifaceted and
13 at the time and I threw my marbles at him when he came integrated nature of hauora Mäori. The physical and emotional
out and we left. We moved to another doctor after that and burden of OA has impacted on ngä täne Mäori perceptions
we’ve had the same family doctor ever since. (Participant 7) of themselves, and caused some to question their masculinity.
Furthermore, OA impacts the relationships and roles of ngä täne
Furthermore, some discussed the disconnect between the
Mäori within both their whänau and in society. The unique lived
päkehä/biomedical approach, which traditionally they felt
experiences and wider whänau impacts of ngä täne Mäori living
focused on the physical symptoms of health, and the holistic
with OA supports the need to consider the necessities of te ao
approach of te ao Mäori. This divide in Aotearoa New Zealand
Mäori into clinical practice and future OA models of care.
healthcare institutions was perfectly summarised by Participants
1 and 3: “Never really been a big fan of doctors boy. Everything KEY POINTS
to do with the päkehä way of life is just different to our life. Not
1. OA can affect the ability for ngä täne Mäori participation
to say one is better than the other, just different” (Participant 1).
with whänau, which can in turn impact their sense of self-
worth and mana.

2. OA affects ngä täne Mäori relationships and roles within Jansen, P., Bacal, K., & Crengle, S. (2009). He ritenga whakaaro: Māori
both their whänau and in society. experiences of health services. Mauri Ora Associates. https://www.moh.
govt.nz/notebook/nbbooks.nsf/0/2A6CAF401ABBEFB9CC2575F4000B6D0
3. Physiotherapists should consider the process of C/$file/He-Ritenga-Whakaaro.pdf
whanaungatanga to build rapport when treating ngä täne Jolly, J., Bassett, S. F., O’Brien, D., Parkinson, C., & Larmer, P. J. (2017). An
Mäori. exploration of the sequence and nature of treatment options available
to people living with osteoarthritis of the hip and/or knee within a New
DISCLOSURES Zealand context. New Zealand Journal of Physiotherapy, 45(2), 90–95.
Jones, R., Crengle, S., & McCreanor, T. (2006). How tikanga guides and
There are no conflicts of interest that may be perceived to
protects the research process: Insights from the hauora täne project. Social
interfere with or bias this study. Policy Journal of New Zealand Te Puna Whakaaro, 29, 60–77. https://
www.msd.govt.nz/documents/about-msd-and-our-work/publications-
PERMISSIONS resources/journals-and-magazines/social-policy-journal/spj29/29-
pages-60-77.pdf
This study was granted ethical approval by the Auckland
University of Technology Ethics Committee (reference number Kao, M.-H., & Tsai, Y.-F. (2012). Living experiences of middle-aged adults
with early knee osteoarthritis in prediagnostic phase. Disability and
18/389).
Rehabilitation, 34(21), 1827–1834. https://doi.org/10.3109/09638288.20
ACKNOWLEDGEMENTS 12.665127
Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J.,
The authors would like to acknowledge the support of Person- Callahan, L., Copenhaver, C., Dodge, C., Felson, D., Gellar, K., Harvey,
Centred Research (AUT) for funding the summer student W. F., Hawker, G., Herzig, E., Kwoh, C. K., Nelson, A. E., Samuels, J.,
scholarship that underpinned this project. Scanzello, C., White, D., … Reston, J. (2020). 2019 American College
of Rheumatology/Arthritis Foundation guideline for the management of
ADDRESS FOR CORRESPONDENCE osteoarthritis of the hand, hip, and knee. Arthritis & Rheumatology, 72(2),
220–233. https://doi.org/10.1002/art.41142
Daniel O’Brien, Department of Physiotherapy, School of Clinical
McGruer, N., Baldwin, J. N., Ruakere, B. T., & Larmer, P. J. (2019). Mäori lived
Sciences, Auckland University of Technology, Auckland, New experience of osteoarthritis: A qualitative study guided by kaupapa Mäori
Zealand. principles. Journal of Primary Health Care, 11(2), 128–137. https://doi.
org/10.1071/HC18079
Mead, M. (2003). Tikanga Mäori: Living by Mäori values. Huia Publications.
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APPENDIX A
INDICATIVE QUESTIONS
Can you start by telling me about the history of your [knee/hip] pain?
What, if anything, has been the impact of your [knee/hip] pain on your life?
What, if anything, have you done about your [knee/hip] pain?
How do you manage your knee/hip pain on a day-to-day basis?
Has your [knee/hip] pain affected your relationships with other members of your whänau? If so, how?
Has your [knee/hip] pain impacted on your [physical/ mental/ spiritual] health and wellbeing? If so, how?
How do you feel about your [knee/hip] pain, now and into the future?
What is your knowledge of osteoarthritis in terms of the condition itself?
What are your thoughts about medication/pain relief in relation to your knee/hip pain? (Talk about different kinds of medication and
how they are used).
What sorts of traditional/complementary/alternative approaches do you use? How have you found these?
There are a number of ideas about Kiwi masculinity (being stoic, self-reliant, etc.). How do you relate to these?
How does being a guy influence some of your thinking about pain and management of pain?
What has been your experience of doctors and other health practitioners (broadly defined) prior to OA?
Has the experience of having OA impacted on how you relate to doctors and other health practitioners? If so, how?

LITERATURE REVIEW
Supporting People Experiencing a Burn Injury to Return to

Work or Meaningful Activity: Qualitative Systematic Review and
Thematic Synthesis
Jessica van Bentum BHSc (Physiotherapy)
Julia Nicholson BHSc (Physiotherapy)

Natasha Bale PGCert (Health Science), BHSc (Physiotherapy)

Waikato Burns Unit, Waikato District Health Board, Hamilton, New Zealand
Joanna K. Fadyl PhD, MSc, BSc (Psychology)

ABSTRACT
Qualitative studies contain in-depth information about facilitators and barriers to successful rehabilitation. This systematic review
synthesised findings across qualitative studies to inform vocational rehabilitation practices for people who have experienced burn
injury. PRISMA guidelines were used to determine inclusion criteria for the review and develop a comprehensive search strategy. Four
databases were searched and results screened. Included studies investigated experiences of return to work (RTW) or meaningful
activity in a burn injury population. Quality of included articles was examined using the CASP framework for qualitative research.
Thematic synthesis was used to analyse the qualitative results. Six studies met inclusion criteria. Five analytic themes were identified
regarding experiences of vocational support and ability to RTW after burn injury: addressing the complex impact of burn injury;
personal connections as vital support; skilled and specialised healthcare as central to RTW; value of knowledge; and considering the
work environment. No included studies investigated meaningful activity other than paid work. Findings support structured vocational
rehabilitation, psychological interventions, social support, intensive rehabilitation and patient, clinician and workplace education as
key in facilitating RTW after burn injury. Additionally, coordinated care is likely to improve vocational outcomes. Research is needed
on supporting return to meaningful activity.
Van Bentum, J., Nicholson, J., Bale, N. & Fadyl, J. K. (2021). Supporting people experiencing a burn injury to return
to work or meaningful activity: Qualitative systematic review and thematic synthesis. New Zealand Journal of
Physiotherapy, 49(3), 134–146. https://doi.org/10.15619/NZJP/49.3.04
Key Words: Burns, Qualitative research, Rehabilitation, Systematic Review, Vocational
INTRODUCTION than 10% total body surface area (TBSA) (Tracy et al., 2020).
In New Zealand, the current criteria for a person who has
Survival rates following burn injury have notably improved
experienced an acute burn injury to attend a regional burn
worldwide due to medical and surgical advances (Espinoza et
unit includes, but is not limited to, a TBSA greater than 10%
al., 2019). Quality of life following burn care is now the focus
in an adult or 5% in a child, burns to specific areas such as
of most burns research (Espinoza et al., 2019). Return to work
face, hands or perineum, electrical or chemical burns, or burns
(RTW) is a key rehabilitation goal and is identified as a valid
with inhalation injuries (Counties Manukau Health, 2021).
indicator of post-burn injury physical and psychosocial health
The current criteria for admission to the national burn unit
(Espinoza et al., 2019). RTW is defined here as engaging in work
includes, but is not limited to, burns greater than 30% TBSA,
in any capacity after health-related impairment. Achievement of
full thickness burns to face, hands, genatalia or perineum,
RTW or meaningful activity helps people who have experienced
significant inhalation injury, and significant electrical or chemical
burn injury regain a sense of normality and is an indicator of
burns. Specialised burn-experienced physiotherapists are part
community reintegration (Johnson et al., 2016; Mason et al.,
of the treating multidisciplinary team (MDT) at the national
2012).
burns unit and the regional burn units. The rehabilitation
The Burn Registry of Australia and New Zealand (BRANZ) pathway may differ between individuals, depending on the
recorded 437 admissions to Aotearoa New Zealand inpatient severity and mechanism of the injury, patient demographics and
burns units between 2018 and 2019 (Tracy et al., 2020). Scald, existing co-morbidities, resources available at their hospital of
contact and flame burns remain the most common mechanism admission, and support provided by the Accident Compensation
of injury and the vast majority of injuries happen in the person’s Corporation (ACC). ACC guidelines state that burn injury
own home (Tracy et al., 2020).The trend of severity of burn rehabilitation must be carried out in a designated District Health
injuries remains stable, with the majority of injuries being less Board (DHB) facility but do not provide specific rehabilitation

processes, therefore permitting the treating therapist to provide published since 2005 that specifically investigated RTW after
rehabilitation and RTW strategies at their discretion (Accident burn injury (Wiechman et al., 2015). This study, conducted in
Compensation Corporation, 2016). the USA, compared an expanded delivery model of burn care
to standardised outpatient care, and there were some concerns
A 2012 systematic review by Mason and colleagues estimated
about risk of bias. At present, the most productive avenue is
that 28% of individuals experiencing burn injury never RTW.
to examine experiences reported in the qualitative literature to
Although New Zealand statistics were not included in this
identify promising interventions for further testing. The authors
review, it is reasonable to infer that New Zealand burns patients
aimed to address this need through a systematic review of
face similar challenges to what is reported in this review (Mason
qualitative literature related to supporting RTW or meaningful
et al., 2012). In New Zealand, 99% of burns patients’ health-
activity after burn injury. Meaningful activity was defined as any
related costs are funded by ACC, which is a no-fault personal
physical, social or leisure activities important to a person.
insurance scheme for accidental injuries (Tracy et al., 2019).
ACC funds medical costs, post-discharge support and also Qualitative studies are designed to explore complex lived
vocational rehabilitation and 80% wage compensation. Wage experiences and social processes, and therefore they are specific
compensation and vocational rehabilitation continues until the to the context in which they were conducted. When multiple
person is work-able, determined by a RTW or an assessment qualitative studies are synthesised, it is possible to retain the
that the person could work in a suitable job according to nuanced understanding of a phenomenon that is enabled by
both medical and vocational criteria (New Zealand Accident qualitative research, while generating insights that cut across
Compensation Act, 2001). According to ACC statistics, weekly the different study contexts (Flemming et al., 2019). This type
wage compensation costs for people with burn injuries between of review can also be used to identify possible interventions
2018 and 2019 were $5,315,779 (personal communication, for future testing (Levack, 2012). There are several methods of
April 6, 2020). Therefore, burn injuries pose not only significant conducting synthesis of qualitative studies. For this study, we
healthcare costs, but delayed RTW following injury also creates selected thematic synthesis (Thomas & Harden, 2008) based on
an additional economic load due to productivity loss and guidelines published in the Cochrane handbook for systematic
compensation claims. reviews of interventions (Higgins et al., 2019) – an approach
appropriate for the type of research question, and capable of
Returning to work requires people with burn injury to overcome
producing well-developed themes.
persistent injury-related challenges including tissue contractures,
pain, weakness, psychological issues, scarring and insecurities METHODS
over altered physical appearances (Mason et al., 2012). A
The research question this review addressed was: What does
2010 systematic review reported time to RTW following burn
qualitative research evidence indicate is useful to support an
injury in the USA, China, Australia and Sweden as ranging
individual experiencing burn injury to RTW or meaningful
from 4.7 weeks to two years (Quinn et al., 2010). This research
activity?
illustrates the variable and often lengthy RTW experience.
Vocational rehabilitation (VR) employs a MDT approach aimed Definition of terms for database search and screening for
at optimising RTW among individuals experiencing a health- inclusion
related impairment (Escorpizo et al., 2011). In New Zealand, We employed a pre-planned database search strategy across
physiotherapists are involved in VR for people with burn four databases, specifying keywords and subject terms adapted
injury both in early intervention as staff on burns units and as for each database. The key definitions that structured our search
specialised VR providers. This often involves teamwork among are outlined below. Specific keywords used are presented in
occupational therapists, VR counsellors, psychologists, social Table 1.
workers, case-managers and medical staff (Esselman, 2011;
Table 1
Gobelet et al., 2007). Physiotherapy contribution is crucial;
therefore, research in this field is significant to physiotherapy Search Terms
practice. However, with limited research on effective practices
specifically in relation to VR, it can be challenging for Population "burn* patient*" OR "burn* injur*" OR
physiotherapists to decide on best use of time and resources. terms "burn* rehabilitat*" OR "burn* model*" OR
Comprehensive VR programmes are individualised and include "burn* care" OR "burn* survivor*"
interventions like vocational training, guidance, education, goal Intervention "return to work" OR "rtw" OR "return to
setting, job placement and vocational counselling (Gobelet et terms employment" OR employment OR "work
al., 2007). Successful VR has obvious benefits for people with reintegration" OR "work re-entry" OR "work
burn injury while generating positive social and economic effects resumption" OR "vocational rehabilitat*"
through the prevention of long-term sickness and disability OR "meaningful activit*" OR "meaningful
(Waddell et al., 2008). occupation*"
Despite the importance of social and work reintegration Note. Population and intervention terms were combined in the search
following burn injury, there is limited literature or guidelines with AND.
detailing intervention protocols that facilitate RTW. Therefore,
supports likely differ between burns units. Additionally, the Included populations
clinical trial evidence in this area is still extremely limited. The review included studies where participants were 16 years
Our search identified only one randomised controlled trial of age or older, who had experienced burn injury. A burn injury

was defined according to the BRANZ definition, encompassing senior author, and involved consideration of full study reports.
contact with hot objects, hot liquids or steam, chemicals, The screening process was managed using Rayyan software
electrical current, fire or flame, radiation, radiant heat, flashes (Ouzzani et al., 2016).
of energy produced by explosive material or friction-type
Quality assessment
movement of a surface against the skin (Tracy et al., 2019).
Two review authors (JvB, JN) independently assessed for
Included interventions and related outcomes methodological quality using the Critical Appraisal Skills
Included interventions involved any type of support aiming to Programme qualitative checklist (Public Health Resource Unit,
assist people who have experienced burn injury to remain in or 2002). Section A (six items) assesses the study design as it
RTW or meaningful activity. Studies were excluded if there was affects validity of results. Section B (three items) addresses the
a lack of discussion of or focus on RTW or meaningful activity. reporting of results directly. Section C addresses external validity.
RTW was defined as engaging in work in any capacity after As with screening, uncertainties and disagreements were
health-related impairment and return to meaningful activity was discussed with the senior author and resolved by consensus.
defined as engaging in any physical, social or leisure activities Each item was scored ‘yes’, ‘no’ or ‘can’t tell’. Where an item
important to that person. scored ‘can’t tell’ and it was critical to our inclusion criteria for
quality (see quality inclusion criteria above), study authors were
Included study designs
contacted for clarification.
All qualitative study designs except qualitative systematic reviews
were considered eligible for inclusion. Relevant study designs Data extraction
included, but were not limited to, grounded theory, qualitative Two authors (JvB, JN) independently extracted key information
descriptive, ethnography, critical, post-structural or Indigenous from all included studies including full citation, authors,
methodologies. Other qualitative systematic reviews including year published, country, sample size, methodology (such as
evidence synthesis were excluded due to potential double-up of grounded theory), intervention (where relevant) and study
study data with original studies. findings. Extracted data was compared and any disagreements
were handled in the same way as for screening and quality
Timeframe
assessment. The data for analysis for each study was the
A 15-year search timeframe was chosen for study eligibility to
extracted text from the ‘results’ or ‘findings’ and ‘discussion’
ensure appropriate relevancy accounting for changes in job
sections.
market conditions and policy environments over that time.
Thematic synthesis
Sources of research reports
Included qualitative data was synthesised using methods of
We searched four databases in February 2020 for peer reviewed
thematic synthesis outlined by Thomas and Harden (2008).
articles published between 1 January 2005 and 27 February
Thematic synthesis is an established method used to inform
2020. The databases were CINAHL, MEDLINE, SPORTDiscuss and
practice recommendations through development of analytic
Scopus. We also conducted a manual search of reference lists of
themes, which presents data in an accessible form. This method
included articles.
was selected as it meets the review’s objective of identifying
Study quality patterns within existing qualitative literature to make informed
As thematic synthesis synthesises the findings across studies, conclusions.
it was important that all data included for synthesis was
The first stage involved two authors (JN, JvB) independently
considered trustworthy. To this end, studies included for data
coding the results, quotations and discussions of each study,
extraction were required to meet critical methodological quality
line by line, according to meaning and context. Codes
criteria. These criteria were appropriate methodology, design
were placed into Google Docs for cross-review. Codes were
and data collection, and sufficiently rigorous analysis, including
checked alongside the original text to confirm consistency of
a clear statement of findings – each mapping onto a specific
interpretation and to identify whether additional levels of coding
question in the critical appraisal tool (see below).
were required (Thomas & Harden, 2008).
Study screening
The second stage involved identifying similarities and differences
The team involved in study screening and subsequent quality
between codes to develop descriptive themes that capture
assessment included two final-year trainee physiotherapists (JvB,
and describe patterns in the data (Thomas & Harden, 2008).
JN), a senior burns physiotherapist (NB), and an experienced
Codes with the same meaning were combined into new codes.
qualitative researcher with expertise in both qualitative synthesis
All codes were then placed into Miro (www.miro.com), an
and vocational rehabilitation (JF). Initially, two review authors
online whiteboard. Similar codes were arranged together into
(JvB, JN) independently considered the titles and abstracts
hierarchical tree structures. From this, the study team developed
from the studies identified and screened for relevance to
five descriptive themes.
the research questions. All studies that had any possibility of
meeting inclusion criteria for topic and population at title and The final stage involved generating analytic themes that
abstract screening were included for full text screening, and expanded beyond the original data and addressed the review
methodology/study type was not screened until full text stage. question. The team discussed each theme with the aim of
The same two authors conducted full text screening, also describing an overarching meaning in the context of inferences
independently before discussing consensus. Disagreement or for appropriate support. At this stage, ideas became more
uncertainty about relevance for inclusion was discussed with the abstract and analytic themes superseded the prior descriptive

themes. Both the in-depth knowledge of the descriptive themes list search revealed one additional article. After removal of 176
from the prior work and the depth of experience within the duplicates, title and abstracting screening excluded 185 articles.
research team in relation to burns rehabilitation and vocational Of the 64 articles that were screened at full text, six met the
rehabilitation were crucial to this stage of analysis. Results inclusion criteria.
presented below are the result of the analytic theme stage of
Study and participant characteristics
analysis. That is, they go beyond the findings of the original
Characteristics, strengths and limitations of the included
study into interpretation only possible with synthesis of multiple
studies are detailed in Table 2. Included studies involved
studies. Where reported results related to specific studies, these
participants recruited from specialist burns centres or outpatient
are referenced. Where the interpretation is a synthesis that goes
rehabilitation sites in Canada, Sweden and Australia (Johnson et
beyond this, we have not referenced original studies.
al., 2016; Mansfield et al., 2014; Nguyen et al., 2016; Stergiou-
RESULTS Kita et al., 2014). Very specific patient populations limited
the transferability of results to the wider burns population. A
Search results
common strength among studies was relevant quotation usage
Figure 1 shows the screening outcomes. Initial database
to verify results.
searches returned 424 journal articles. The manual reference
Figure 1
Screening for Inclusion
Articles identified in baseline search (n = 424)
Articles identified in manual

search of references (n = 1)
Removal of duplicates (n = 176)
Titles of articles screened (n = 249)
Articles excluded through title

screening (n = 100)
Abstracts of articles screened (n = 149)
Articles excluded through

abstract screening (n = 85)
Potentially relevant articles retrieved

for full text evaluation (n = 64)
Articles excluded through full-

text screening (n = 58)
• Not in English (n = 3)
• Outside publishing date
timeframe (n = 20)
• Outcome not related to
support to return to work or
meaningful activity (n = 25)
• Wrong study design (n = 10)
Articles included in review (n = 6)

Table 2
Study Characteristics
Methodology and
Author Aims Participants Strengths/limitations
country
Öster et al. Qualitative Exploration of burn n = 39 Strengths

(2010) descriptive patients’ perception Burn injury patients Participants chose interview location
(content analysis) of factors seen as previously Neutral, experienced interviewer
facilitators or barriers employed or Moderate sample size
Sweden in the process of studying Effective use of quotations to verify results
returning to work after Limitations
a severe burn injury Only included previously employed
participants
Participants interviewed up to six years after
RTW
Two participants interviewed together
Mansfield et Qualitative Assessment of how n = 13 Strengths

al. (2014) descriptive worker, job, workplace, Burn survivors who Provides specialised insight into electrical
(thematic injury, compensation, experienced injuries
analysis) and support elements a workplace Detailed data analysis protocol
interact and influence electrical injury Effective use of quotations to verify results
Canada the RTW process Limitations
Small sample size
Specific type of burn injury
Impairment information was self-reported
Authors do not outline strengths and
limitations of the study
Stergiou- Qualitative Aimed at gaining n = 13 Strengths

Kita et al. descriptive an understanding Burn survivors who Provides specialised insight into electrical
(2014) (thematic of workers’ RTW experienced injuries
analysis) experiences including a workplace Detailed data analysis protocol
challenges and electrical injury Effective use of quotations to verify results
Canada beneficial support and attempted to Limitations
RTW Small sample size
Specific type of burn injury
Impairment information was self-reported
Johnson et al. Heideggerian Interprets information on n = 18 Strengths

(2016) phenomenology the lived experience Burn patients and Perspectives from patients and carers
of hospitalisation and family members Effective use of quotations to verify results
Australia recovery following burn following hospital Limitations
injury discharge Only recruited from one state in Australia
Only included English speaking participants
High proportion of industrial accidents
Lamble et al. Cross-sectional Comparing RTW n = 29 Strengths

(2019) study with outcomes between the Burn survivors Included participants from multiple
a qualitative KT intervention group who participated employment fields
component and a control group, in the KT Groups matched for age, sex and TBSA
describing the RTW intervention Both qualitative and quantitative
Canada and the KT intervention study (n = 15) information
experience Clear validation process of questionnaires
Matched controls Limitations
(n = 14) Groups not matched by job task, burn
location or time since injury
Excluded those who had not returned to
work
Interviewed up to two years following
intervention

Methodology and
Author Aims Participants Strengths/limitations
country
Nguyen et al. Qualitative Investigating burn n = 29 Strengths

(2016) descriptive survivors’ and Burns unit MDT Participants had various employment
(thematic clinicians’ perspectives clinicians statuses, diverse workplaces and roles
analysis) on barriers and (n = 9) Perspectives from both patients and
facilitators to work clinicians
Canada reintegration Burns survivors Effective use of quotations to verify results
(n = 20) Limitations
Focus groups had differing combinations of
informants
Small sample size
Recruitment from only one burns unit
Note. KT = knowledge translation; MDT = multidisciplinary team; RTW = return to work; TBSA = total body surface area.
The six qualitative studies reported on 141 participants, with 2 displays all synthesised data, the following results outline
sample sizes ranging from 13 to 39 (Johnson et al., 2016; key information relevant to burn injury support only. Excluded
Lamble et al., 2019; Mansfield et al., 2014; Nguyen et al., data did not describe factors specific to support to RTW, such
2016; Öster et al., 2010; Stergiou-Kita et al., 2014). All studies as barriers to RTW or encompassed information less relevant
included adults between the ages of 20 and 59 years and the to burns support clinicians such as union or financial supports.
majority (80%) of participants were male. Between 24% and Note that the themes described below are analytic themes
100% of burn injuries were work-related. The mean percentage that were developed as the next step on from descriptive
total burn surface area (TBSA) of burn injuries was recorded by themes, in order to specifically address the need for key clinical
Johnson and colleagues (2016), Lamble and colleagues (2019), information. We have comprehensively referenced the original
and Öster and colleagues (2010) and ranged from 14.3% to studies that contributed data to each aspect, but have not
29%. Five studies reported time since injury, which ranged from included specific quotes. The themes are constructed across
two months to over 10 years (Lamble et al., 2019; Mansfield multiple studies, and multiple points of references within those
et al., 2014; Nguyen et al., 2016; Öster et al., 2010; Stergiou- studies, and the nature of analytic themes is that they aim to
Kita et al., 2014). These studies also reported the percentage “go beyond” (Thomas & Harden, 2008, p. 7) the findings of the
of participants who returned to work as ranging from 65% primary studies – key to the original contribution of a synthesis
to 85%. Participants returned to various employment fields in such as this.
differing capacities as outlined in Table 3.
Theme 1: Addressing the complex impact of burn injury
Study quality 1.1. Potential for complex impairments. Burn injuries
All six studies were considered high quality and were included resulted in various physical, cognitive and psychosocial
(Public Health Resource Unit, 2002). In Section A, five studies impairments leading to functional limitations and difficulty
scored ‘Yes’ for five of the six questions corresponding to high performing work tasks (Lamble et al., 2019; Mansfield et al.,
validity of results (Johnson et al., 2016; Lamble et al., 2019; 2014; Nguyen et al., 2016). Recovery timeframes, and therefore
Mansfield et al., 2014; Nguyen et al., 2016; Stergiou-Kita et RTW, varied depending on the nature and degree of the injury
al., 2014). The only weakness was lack of consideration of the and resulting impairments. Some physical impairments may
researcher–participant relationship. The exception was Öster be short-term, such as muscle weakness, while others, like
et al. (2011), who employed a neutral interviewer to minimise muscle contractures, remained long after discharge, significantly
the influence of pre-existing assumptions during interviews, inhibiting RTW for study participants (Mansfield et al., 2014;
therefore scoring ‘Yes’ for all six questions. All six studies Öster et al., 2010; Stergiou-Kita et al., 2014). Recovery from
scored ‘Yes’ to all six questions in Section B, corresponding to less-visible psychological challenges, such as post-traumatic
appropriate reporting of results. In Section C, all included studies stress disorder (PTSD), was reported to take longer than recovery
were determined to be valuable, therefore having high external from physical impairments (Johnson et al., 2016).
validity.
The impact of different types of burn injuries also varied.
Thematic synthesis Electrical burn injuries may cause invisible, severe, persistent
Five analytic themes were identified through thematic impairments with additional cognitive challenges such
synthesis: 1) Addressing the complex impact of burn injury; 2) concentration and memory issues that further complicate
personal connections as vital support; 3) skilled and specialised recovery (Mansfield et al., 2014; Stergiou-Kita et al., 2014).
healthcare as central to RTW; 4) value of knowledge; and 5) Impairments needed to be considered at an individual level,
considering the work environment. Each theme contained which meant that RTW could not be a standardised process or
several sub-themes, which are outlined in Figure 2. While Figure timeframe.

Table 3
Participant Characteristics from Included Studies
Study
Characteristic
Öster et al. (2010) Johnson et al. (2016) Mansfield et al. (2014) Stergiou-Kita et al. (2014) Lamble et al. (2019) Nguyen et al. (2016)
Age (years) Mean, 39.7 Mean, 37.4 Range, 20–59 Range, 20–59 Mean, 42.5 Mean, 44.5
Mean TBSA (%) 29 25 Not reported Not reported 14.3 Not reported
Sex (% male) 74 73 92 92 83 65
Work-related 41 64 100 100 24 25

injuries

Time post injury Mean, 4.6 years Not reported Range, 1–9 years Range, 1–9 years < 1 year, 10% Range, 2 months–
(years) 1–3 years, 52% 5 years
3–5 years, 10% < 1 year, 15%
5–7 years, 21% 1–2 years, 40%
7–10 years, 3% 2–3 years, 25%
> 10 years, 3% > 3 years, 20%
Employment field Not reported Skilled trade, 27% Skilled trade, 62% Skilled trade, 62% Not reported Skilled trade, 25%
Manual labour, 18% Survey technician, 8% Survey technician, 8% Manual labour, 15%
Administration, 9% Information technology, 8% Information technology, 8% Administration, 15%
Disability pension, 18% Laundry, 8% Laundry, 8% Education, 5%
Agriculture, 9% Engineer, 15% Engineer, 15% Service/marketing and
Hospitality, 9% sales, 20%
Truck driver, 9% Mining, 5%
Healthcare and social
services, 15%
Employment Employed, 77% Not reported Employed, 85% Employed, 85% Employed, 99% Employed, 65%
status post injury Student, 3%
Sick leave, 15%
Disability pension, 8%
Note. TBSA = total body surface area.

Figure 2
Themes from Thematic Synthesis
Theme Subtheme Sub-subtheme
Impairments
1. The impact of injury The emotional toll
Ways of coping
Specialised burn services

2. Personal connections
Vocational rehabilitation
Outpatient rehabilitation
Supportive health
professionals
3. Healthcare needs Psychological support
Structured supports
Primary healthcare
Union support
Financial support
Legal supports
Education influences support

4. The value of knowledge
Provision of education
Influences on health
Returning to the workplace and safety practices
Health and safety Employee concerns
Return to work fears Safety recommendations
5. The work environment

Workplace support Attitudes towards RTW
Personal influences on RTW Social and financial resources
Financial influences on RTW Job experience
Note. RTW = return to work.

1.2. Emotional toll. Emotional trauma experienced by some the confidence to request further support if required (Stergiou-
people with burn injury worsened RTW stress (Johnson et al., Kita et al., 2014). This facilitates people to take charge of their
2016; Lamble et al., 2019). Emotional challenges included recovery journey, working towards RTW.
feelings of dejection, fear, frustration and appearance-related
3.2. Structured supports that recognise vocational needs
self-consciousness (Johnson et al., 2016; Lamble et al., 2019).
Questions about the injury or changes in appearance reminded Specialised burn services. Specialised services with expert
people of their accident, causing added discomfort (Lamble et healthcare professionals were seen to provide the most
al., 2019). It was important that others supporting people who appropriate care following burn injury, improving RTW outcomes
had experienced burn injury considered the added emotional (Mansfield et al., 2014; Stergiou-Kita et al., 2014).
impact of injury. Burn injury may cause identity challenges
Deliberate, structured vocational rehabilitation. Structured
as people lose a degree of control over their lives after injury
VR facilitated RTW through job-task analysis, expert work-
(Johnson et al., 2016). Specifically, job changes could elicit
adaptation recommendations and work-readiness assessments
occupational grieving due to the relationship between career
(Lamble et al., 2019; Öster et al., 2010; Stergiou-Kita et al.,
and identity (Nguyen et al., 2016). Identity challenges linked
2014). Establishing work-readiness was considered an essential
to career changes add to the emotional toll of injury, inhibiting
part of VR and the RTW process, indicating that comprehensive,
RTW (Nguyen et al., 2016)
burn-injury-specific resources for assessing and addressing work-
1.3. Supporting coping. Support to facilitate RTW often readiness are needed to enable successful RTW (Öster et al.,
involved more wide-ranging support for people to cope with 2010).
emotional trauma, fears and identity concerns. People with burn
VR that was reported to be successful facilitated effective
injury experiencing emotional trauma appreciated psychological
communication between the person with burn injury, their
assistance and additional time to reflect and process injury
family, workplace and healthcare team (Lamble et al., 2019;
events (Johnson et al., 2016; Lamble et al., 2019; Stergiou-Kita
Mansfield et al., 2014; Nguyen et al., 2016; Öster et al., 2010;
et al., 2014). Practical solutions like involvement in self-care and
Stergiou-Kita et al., 2014). A comprehensive VR MDT was
finding novel ways of completing tasks were experienced to
considered vital, including VR coordinators who can problem-
further enhance recovery through facilitation of independence
solve VR issues from the initial injury to RTW (Öster et al.,
(Johnson et al., 2016; Öster et al., 2010).
2010). Co-ordinated VR can enable a smoother RTW transition.
People with burn injury needed to confront re-injury fears Synthesised, the qualitative evidence indicated that early
as a way of coping with lasting emotional trauma, especially engagement in vocational conversations is beneficial, which can
following workplace accidents (Öster et al., 2010). Returning begin with the acute MDT and carry on into the community
to the injury-site was one way of confronting and overcoming setting.
one’s fears (Nguyen et al., 2016). Effective coping strategies
Participation-focused outpatient rehabilitation. Early
can help people with burn injury to manage emotional stressors
rehabilitation was considered necessary to help people with
throughout the RTW journey.
burn injury regain adequate function required for activities
Theme 2: Personal connections as vital support of both daily living and work tasks. Helpful post-discharge
Relationships with compassionate and understanding family physiotherapy rehabilitation involved task-related strength and
members, friends, employers, colleagues and other people with endurance training (Lamble et al., 2019; Öster et al., 2010).
burn injury were reported to provide crucial informal support Individualised training and goal setting was reported to elicit
(Johnson et al., 2016; Lamble et al., 2019; Mansfield et al., functional improvements, which facilitated RTW (Lamble et al.,
2014; Nguyen et al., 2016; Öster et al., 2010; Stergiou-Kita 2019; Öster et al., 2010). Shifting the focus from impairments
et al., 2014). Informal support networks provided comfort, to activities and participation during rehabilitation optimised
distraction, motivation and practical assistance, which facilitated subjective quality of life in the longer term (Lamble et al., 2019).
RTW (Johnson et al., 2016; Lamble et al., 2019; Mansfield et al.,
Psychological support. Formal psychological support was
2014; Öster et al., 2010).
recommended, with studies indicating it should be offered
Theme 3: Skilled and specialised healthcare as central to all people with burn injury through routine, early initiation
to RTW of psychological screening and referrals (Johnson et al.,
3.1. Supportive, skilled health professionals. Supportive, 2016; Lamble et al., 2019; Öster et al., 2010; Stergiou-Kita
motivating and emotionally invested health professionals et al., 2014). As illustrated in prior themes, people with burn
were experienced as facilitators of RTW (Lamble et al., 2019; injury often experience psychological challenges; therefore,
Mansfield et al., 2014; Öster et al., 2010). There were multiple appropriate psychological support is necessary to facilitate
elements to this experience: healthcare providers needed recovery and RTW.
to recognise each person’s unique injury and refer those
Theme 4: The value of knowledge
experiencing ongoing symptoms for further treatment (Stergiou-
4.1. Education influences support. People with burn injury
Kita et al., 2014). Studies also indicated that health professionals
were reported to feel better supported by those with burn injury
should advocate for their patients while also providing self-
knowledge (Lamble et al., 2019; Nguyen et al., 2016; Öster et
advocacy strategies (Mansfield et al., 2014; Stergiou-Kita et al.,
al., 2010; Stergiou-Kita et al., 2014). People with burn injury
2014). Self-advocacy skills could empower people with burn
could more effectively communicate their needs when others
injury to take greater control of their rehabilitation and have
understood their injury experience (Lamble et al., 2019; Nguyen

et al., 2016). Appropriate education enabled people with burn one’s professional reputation, while also triggering symptoms of
injury to RTW with reduced anxiety about workplace interactions PTSD (Lamble et al., 2019; Stergiou-Kita et al., 2014).
(Lamble et al., 2019). Examples of beneficial education included
5.3. Workplace support. RTW was facilitated when people
describing a major burn injury, the pressure garments and
with burn injury returned to supportive work environments
adaptive equipment used to treat scars, and the rehabilitation
with task modifications and assistance from colleagues (Lamble
process (Lamble et al., 2019). Uninformed employers were
et al., 2019; Mansfield et al., 2014; Nguyen et al., 2016;
felt to be more likely to pressure people to prematurely return
Öster et al., 2010). Flexible, progressive RTW enabled people
to previous tasks (Lamble et al., 2019; Nguyen et al., 2016;
with burn injury to engage in rehabilitation while maintaining
Öster et al., 2010; Stergiou-Kita et al., 2014). In particular,
employment, further facilitating work reintegration (Johnson et
electrical injuries are often misunderstood and not legitimised by
al., 2016; Lamble et al., 2019; Mansfield et al., 2014; Nguyen et
employers, work colleagues and insurance providers due to the
al., 2016; Öster et al., 2010).
invisible sequalae of injury (Mansfield et al., 2014; Stergiou-Kita
et al., 2014). Therefore, specific information should be provided
to improve support received. DISCUSSION
4.2. Provision of education. Studies supported the provision Theme one in this review has highlighted the emotional impact
of education to the person with burn injury, their workplace and of burn injury and its effect on RTW. Perceived outcome
family and friends using a flexible, personalised and accessible following burn injury comprises both physical impairments and
information tool (Lamble et al., 2019; Nguyen et al., 2016). the psychosocial impact of injury (Kildal et al., 2005). Fear of
Education about the roles of various health professionals helped re-injury was highlighted in the present review as a catalyst
people with burn injury to better direct their RTW queries for anxiety and the potential to delay RTW. This fear has been
(Lamble et al., 2019). Explaining the healing and rehabilitation reported to be one of the strongest predictors of delayed RTW
process provided people with burn injury with the knowledge (Bunzli et al., 2017). Emotional support has been highlighted
and terminology to discuss their condition (Lamble et al., 2019). within burns literature as an effective coping strategy (Kildal et
Provision of additional social interaction strategies assists with al., 2005). Furthermore, the psychosocial benefits of RTW in
workplace reintegration (Nguyen et al., 2016). itself are well described in VR literature (Bunzli et al., 2017). The
present review supports informal support from family, friends,
Workplace education about possible physical impairments
employers, colleagues and other people with burn injury who
should include solutions to overcome these barriers (Mansfield
likely provide this crucial emotional support. The therapeutic
et al., 2014; Nguyen et al., 2016). Inclusion of testimonies of
benefits of returning to work were also highlighted in the
previous burn injury RTW successes may be useful (Mansfield
present review.
et al., 2014; Nguyen et al., 2016). Informative workplace
conversations facilitate increased understanding of the Theme three identified a need for formal psychological
worker’s journey and their needs, and help to justify required intervention following burn injury due to the psychological and
accommodations (Mansfield et al., 2014; Nguyen et al., 2016). emotional impact of injury. Literature has shown the benefits
of psychological treatment on symptoms, clinical outcomes
Theme 5: Considering the work environment
and quality of life (Waddell et al., 2008). Finnes and colleagues
5.1. Benefits of returning to the workplace. As well as
(2019) evaluated the effect of psychological treatment on
practical issues such as financial needs, is important to consider
sickness absence among individuals with common mental or
the therapeutic benefits of returning to work (Johnson et al.,
musculoskeletal disorders. The authors identified a reduction
2016; Lamble et al., 2019; Nguyen et al., 2016). Working was
in sickness absence; however, specific effective treatment
reported to elicit improvements in both function and self-esteem
modalities were not identified (Finnes et al., 2019). As stress
while providing structure and routine (Lamble et al., 2019;
disorders and depression are prevalent following burn injury,
Nguyen et al., 2016; Öster et al., 2010).
formal psychological support for people with burn injury could
5.2. RTW Fears. The RTW process may create fear and be equally successful in reducing RTW time (Dalal et al., 2010).
anxiety among people with burn injury, where they experience
This review outlined the importance of specialised, structured VR
an enduring sense of vulnerability due to re-injury or
that includes work environment and/or job accommodation and
unemployment fears (Johnson et al., 2016; Lamble et al., 2019;
effective communication between the workplace, the injured
Mansfield et al., 2014; Stergiou-Kita et al., 2014). This could
person and healthcare providers. Research with musculoskeletal
further impede RTW. Work-related injuries have been correlated
and chronic condition populations supports structured VR
with increased RTW stress; therefore, people returning to work
programmes, improved communication and work adaptations
after burn injury may require increased emotional support
(Franche et al., 2005; Waddell et al., 2008; Welsh Assembly
(Johnson et al., 2016; Stergiou-Kita et al., 2014). Furthermore,
Government, 2006). Temporary work accommodations facilitate
while initiating VR was considered appropriate quite early in
early return to appropriate tasks, allowing for a gradual
the rehabilitation process, the timing of RTW was discussed as
transition to previous work demands (Waddell et al., 2008).
an important issue to be carefully considered. Sometimes the
Additionally, as no single service can deliver effective VR alone,
timing of RTW could create added stress, as people with burn
increased communication between RTW parties provides
injury experienced pressure to RTW before they were ready
workers with more successful, coordinated care (Waddell et al.,
(Lamble et al., 2019; Stergiou-Kita et al., 2014). Premature RTW
2008).
can cause added job-performance anxiety and fear of losing

VR components are discussed extensively in literature, The review was limited by lack of available research within the
particularly within chronic condition populations (de Buck et burn injury population. Authors were unable to address the
al., 2002; Waddell et al., 2008; Welsh Assembly Government, return to meaningful activity aspect of the research question,
2006). Effective components include physical training, skills due to absence of literature. The findings could also be limited
training, employment placement, personalised education by the search parameters. A limited number of databases were
and action plans, counselling, guidance and group meetings searched, and it is possible some key studies were not indexed
involving education, exercise and peer support (de Buck et in the selected databases. Finally, because we elected to resolve
al., 2002; Waddell et al., 2008; Welsh Assembly Government, differences in reviewer decisions by discussion processes and all
2006). Outpatient follow-up was highlighted in this review as an differences were quickly resolved in this way, we do not have
appropriate setting to deliver these key components. In the New data on initial inter-rater agreement.
Zealand setting, specialist VR providers may also be involved.
A major limitation in application of the review findings to the
RTW support for people with burn injury should consider
local context was that no New Zealand burn injury studies
inclusion of these elements, and clear communication between
were identified for inclusion. Furthermore, most participants
the various rehabilitation providers even when there is specialist
were Caucasian, with very few Indigenous participants. As
VR provision, as research has highlighted the importance of
Mäori are overrepresented in New Zealand burn statistics, it is
coordinated care.
important to examine the specific considerations required when
The value of knowledge and therefore the importance of supporting this population to RTW following burn injury (Tracy
appropriate education was another prevalent finding identified et al., 2019). Lack of Indigenous participants and methodologies
in theme four. Lamble and colleagues (2019) offered a possible makes it even more important to have further development
method of delivering education. In this study, participants viewed in partnership with Mäori as part of implementation of the
six videos addressing various aspects of burn injuries, the recovery recommendations from overseas research within an Aotearoa
process and RTW. The participants then had the opportunity to New Zealand context.
show these videos to family, friends, employers and colleagues.
Clinical implications
An occupational therapist was also available to answer questions
Physiotherapists involved with burn injury rehabilitation
and discuss appropriate work tasks and potential adaptations
should consider all aspects of this review to better understand
(Lamble et al., 2019). While Lamble and colleagues’ (2019)
the experiences and specialised needs of people who have
quantitative results were not significant, participants in this
experienced burn injury. Key clinical implications include
study identified the need for workplace education to enable
referrals from the acute hospital setting to ensure early
progressive, safe RTW. Education remains a key component of
outpatient follow-up and provision of specialised VR and
successful VR among a variety of non-burn injury populations
comprehensive education. Physiotherapists should consider
(Waddell et al., 2008). As public knowledge of burn injury
referrals to ACC VR programmes alongside providing outpatient
rehabilitation is limited, workplaces are often not prepared for
follow-up. Additionally, physiotherapists need to be aware
workers’ specific needs in regard to job-task modifications,
of the importance of psychology input, ensuring appropriate
rehabilitation engagement and progressive RTW. Our review
referrals are made and psychology input is provided. Outpatient
findings confirm that educated workplaces are experienced as
rehabilitation should include personalised, task-specific training.
more supportive during RTW. Additionally, people with burn
As part of the VR MDT, specialist physiotherapists must provide
injury who are educated are more likely to self-advocate (Lamble
work adaptation recommendations and contribute to work-
et al., 2019; Mansfield et al., 2014). Therefore, comprehensive
readiness training and assessment. Physiotherapists should
education should be provided to all stakeholders.
provide detailed burn injury and RTW education to patients as
This review identified that people with burn injury require a well as workplace education as a part of VR. Physiotherapists as
wealth of formal and informal support that facilitate RTW, part of the VR MDT need to provide co-ordinated VR including
outlined in themes two and four. Similarities can be seen in effective communication between VR clinicians and the
RTW literature in other injury populations. For example, Murphy workplace.
and O’Hare (2011) found workplace-based social support as
Recommendations for future research
key in facilitating RTW after spinal cord injury. Workplace social
This review highlighted the lack of research addressing RTW
support provides a welcoming environment, enhancing comfort
support within the burn injury population. The importance of
and motivation (Murphy & O’Hare, 2011). Health professionals
education was evident; however, an effective, standardised
should ensure people with burn injury receive adequate social
delivery tool still requires development. Building upon the
support, either within or outside the workplace, and consider
findings of Lamble and colleagues (2019), future research
facilitating peer-support groups as part of VR (Grieve et al.,
should look to develop this tool with appropriate burn injury
2020).
and RTW content discussed in the present review, considering
Review strengths and limitations video as an effective modality. Future research could assess
A key strength of this review was the rigour of the process, current support provided by New Zealand burns units by gaining
including independent screening and critique of all articles. the perspectives of specialised health professionals and ACC
Other strengths included following a pre-established process representatives. This research should address considerations for
that outlined inclusion and exclusion criteria and analysis Mäori with burn injury.
approach, and that we included recently published studies,
ensuring relevance to the current system and climate.

CONCLUSION de Buck, P. D., Schoones, J. W., Allaire, S. H., & Vliet Vlieland, T. P. (2002).
Vocational rehabilitation in patients with chronic rheumatic diseases: A
The present review has highlighted the complex nature of burn systematic literature review. Seminars in Arthritis and Rheumatism, 32(3),
injury recovery with impairments that are not only physical 196–203. https://doi.org/10.1053/sarh.2002.34609
but also psychological and emotional. Despite common RTW Escorpizo, R., Reneman, M. F., Ekholm, J., Fritz, J., Krupa, T., Marnetoft, S.-U.,
fears, RTW should be encouraged due to clear therapeutic Maroun, C. E., Guzman J. R., Suzuki, Y., Stucki, G., & Chan, C. C. (2011).
A conceptual definition of vocational rehabilitation based on the ICF:
benefits. Successful RTW should involve support from Building a shared global model. Journal of Occupational Rehabilitation,
specialised, supportive health professionals through facilitation 21(2), 126–133. https://doi.org/10.1007/s10926-011-9292-6
of structured VR, communication and collaboration between all
Espinoza, L. F., Simko, L. C., Goldstein, R., McMullen, K. A., Slocum, C.,
involved parties, outpatient rehabilitation, workplace support, Silver, J. K., Herndon, D. N., Suman, O. E., Meyer, W. J., Gibran, N. S.,
psychological support, comprehensive education and informal Kowalske, K., Zafonte, R., Ryan, C. M. & Schneider, J. C. (2019). Postacute
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Physical Medicine and Rehabilitation, 100(11), 2015–2021. https://doi.
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KEY POINTS Esselman, P. C. (2011). Community integration outcome after burn injury.
Physical Medicine and Rehabilitation Clinics, 22(2), 351–356. https://doi.
1. Both physical impairment and emotional trauma affect org/10.1016/j.pmr.2011.01.001
work-ability and return to work (RTW) after burn injury.
Finnes, A., Enebrink, P., Ghaderi, A., Dahl, J., Nager, A., & Öst, L. G. (2019).
2. Knowledge of common experiences regarding impact Psychological treatments for return to work in individuals on sickness
absence due to common mental disorders or musculoskeletal disorders:
of injury can assist clinicians, employers and people A systematic review and meta-analysis of randomized-controlled trials.
experiencing injury to facilitate a successful RTW. International Archives of Occupational and Environmental Health, 92(3),
273–293. https://doi.org/10.1007/s00420-018-1380-x
3. Vocational rehabilitation after burn injury needs to
be specialised to the burn injury experience while Flemming, K., Booth, A., Garside, R., Tunçalp, Ö., & Noyes, J. (2019).
Qualitative evidence synthesis for complex interventions and guideline
acknowledging core principles of vocational rehabilitation development: Clarification of the purpose, designs and relevant methods.
more generally. BMJ Global Health, 4(Suppl. 1), e000882. https://doi.org/10.1136/
bmjgh-2018-000882
4. Vocational rehabilitation intervention should span burn care
Franche, R.-L., Cullen, K., Clarke, J., Irvin, E., Sinclair, S., & Frank, J.; Institute
settings from acute to community, making physiotherapists for Work & Health (IWH) Workplace-Based RTW Intervention Literature
vital personnel when it comes to both support and Review Research Team. (2005). Workplace-based return-to-work
education. interventions: A systematic review of the quantitative literature. Journal
of Occupational Rehabilitation, 15(4), 607–631. https://doi.org/10.1007/
DISCLOSURES s10926-005-8038-8
No funding was received for the research. There are no conflicts Gobelet, C., Luthi, F., Al-Khodairy, A. T., & Chamberlain, M. A.
(2007). Vocational rehabilitation: A multidisciplinary intervention.
of interest that may be perceived to interfere with or bias this Disability & Rehabilitation, 29(17), 1405–1410. https://doi.
study. org/10.1080/09638280701315060
PERMISSIONS Grieve, B., Shapiro, G. D., Wibbenmeyer, L., Acton, A., Lee, A., Marino, M.,
Jette, A., Schneider, J. C., Kazis, L. E., & Ryan, C. M.; The LIBRE Advisory
No permissions were required. Board. (2020). Long-term social reintegration outcomes for burn survivors
with and without peer support attendance: A Life Impact Burn Recovery
ADDRESS FOR CORRESPONDENCE Evaluation (LIBRE) study. Archives of Physical Medicine and Rehabilitation,
101(1), S92–S98. https://doi.org/10.1016/j.apmr.2017.10.007
Dr. Joanna Fadyl, Centre for Person Centred Research, Auckland
Higgins, J. P. T., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page,
University of Technology, Auckland, New Zealand.
M., & Welch, V. (Eds.). (2019). Cochrane handbook for systematic
Email: [email protected] reviews of interventions version 6.0 (updated July 2019). The Cochrane
Collaboration. Available from handbook.cochrane.org.
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burns.2009.10.001

RESEARCH REPORT
Experiences and Perceived Effectiveness of Carbon-fibre

Triplanar Orthotics for People Affected by Polio: A Qualitative
Descriptive Study
Rachelle A. Martin DipPhys, MHealSc, PhD
Lecturer, Rehabilitation Teaching and Research Unit, Department of Medicine, University of Otago Wellington, Wellington, New
Zealand; Research Lead, Burwood Academy of Independent Living, Christchurch, New Zealand
Anne C. Fitzpatrick BA(Hons), GradDipSc, MBA

Executive Leadership Coach and Consultant, Lead to Success, Wellington, New Zealand
William M. M. Levack BPhty, MHealSc, PhD

Professor, Rehabilitation Teaching and Research Unit, Department of Medicine and Dean and Head of Campus, University of Otago
Wellington, Wellington, New Zealand
ABSTRACT
A new type of carbon-fibre triplanar orthotic (CTO) was recently introduced to New Zealanders affected by polio. This study aimed
to assess CTO recipients’ experiences and perceptions of these orthotics. A qualitative descriptive study based on semi-structured
interviews was conducted to explore experiences of people who have had polio regarding the impact of CTOs on health and
wellbeing, the process of training and adjustment, and how benefits from the CTOs were or were not achieved. Participants
described substantial investments of time, energy and money needed to acquire and adapt to CTOs (Theme 1). They expected the
CTOs to improve their posture, mobility, relieve pain and prevent deterioration in functioning. However, frequently there was a
mismatch between reality and expectations (Theme 2). Ongoing orthotic and rehabilitation support plus sustained commitment and
effort by CTO recipients contributed to benefits gained from these orthotics (Theme 3). When considering purchase of a CTO, people
who have had polio should be aware of the time, energy, effort and personal cost required to fully benefit from the new orthotic.
They should also be aware that individual responses to orthotics, including subjective reports of success, can be highly variable.
Martin, R. A., Fitzpatrick, A. C. & Levack, W. M. M. (2021). Experiences and perceived effectiveness of carbon-fibre
triplanar orthotics for people affected by polio: A qualitative descriptive study. New Zealand Journal of Physiotherapy,
49(3), 147–155. https://doi.org/10.15619/NZJP/49.3.05
Key Words: Orthotics, Poliomyelitis, Post-polio syndrome, Qualitative Research, Rehabilitation
INTRODUCTION It is difficult to establish the exact number of polio survivors

in New Zealand because there is no formal record for this.
There is currently an estimated 9,750 people in New Zealand
Many people who survived polio just returned to their prior
living with the effects of polio (Jones et al., 2016; Jones et al.,
lives after recovering from the initial infection, managing their
2017). Polio (also called poliomyelitis) is a highly infectious viral
muscle impairments, joint problems and breathing difficulties
disease that devastated communities worldwide in the first half
independently, and “rarely spoke again of those polio years”
of the 1900s (Smallman-Raynor & Cliff, 2006). New Zealand
(Morris, 2013, p. 1). Polio survivors became increasingly
was no exception to this pandemic, with polio resulting in
forgotten by the New Zealand health system after the successful
hundreds of deaths and long-term neuromuscular disabilities in
introduction of a vaccine in the 1950s (Stewart, 2015).
the many thousands of people who survived the initial infection
(Butterworth & Ross, 1994; Ross, 1993; Wilson & Baker, 2012). One of the key needs in New Zealand’s polio community
In addition, approximately 40% of those initially infected with today is for specialist orthotic services (Jackman, 2016, 2017).
polio went on to develop post-polio syndrome (Lin & Lim, People who have had polio may have idiosyncratic muscle
2005). Post-polio syndrome is characterised by the onset of impairments in their lower limbs, contributing to a variety of
new or worsening muscle weakness 30–40 years after the problems with mobility-related activities such as walking short
original polio attack, resulting in new or exacerbated disabilities. and long distances, climbing stairs and performing various
Currently, many thousands of New Zealanders experience activities of daily living (Farbu, 2010). Musculoskeletal changes
mobility restrictions, joint contracture, shortness of breath and following polio and post-polio syndrome are different than
problems with sleep, fatigue and pain due to both the original those experienced by people with other types of neurological
impairments sustained during polio in their youth and/or as a conditions, such as stroke or multiple sclerosis, so require
consequence of post-polio syndrome, or as a result of living with different solutions to optimise physical functioning (Genêt et al.,
a long-term disability (Chetwynd et al., 1993; McNalley et al., 2010; Portnoy & Schwartz, 2013).
2015).

The standard type of orthotic for people who have had polio in grounded theory methods (Charmaz, 2014), to gather data
New Zealand is made of metal or solid plastic, can be ill-fitting from people affected by polio who had been recently fitted
and uncomfortable, and is limited in the assistance it provides with a CTO. Ethical approval for this study was granted by
during walking (Jackman, 2016). These types of orthotics are the University of Otago Human Ethics Committee (Health)
primarily designed to help prevent hyper-extension during the (reference number H19/021). The research team comprised one
stance phase of gait and foot drop during the swing phase. person with lived experience of paralytic polio and post-polio
However, they do not correct the many other problems with syndrome in New Zealand (AF, female, Päkehä) and two research
joint alignment experienced by people who have had polio physiotherapists with extensive experience of qualitative
– particularly issues of inversion and eversion at the ankle or methods (WL, male, Päkehä and RM, female, Päkehä).
internal rotation at the knee – and can be uncomfortable for
Participant recruitment
some to wear. In 2018, in response to these challenges, people
To be included in this study, participants needed to be adults
who have had polio in New Zealand began exploring options
diagnosed with polio, who had been fitted with a CTO within
for accessing a new type of carbon-fibre triplanar orthotic (CTO)
the past two years. The Duncan Foundation contacted recipients
provided by orthotists outside of New Zealand. These new
of the CTOs to elicit their willingness to participate in the study.
orthotics used carbon-fibre materials to provide lightweight,
At the time of the study (May 2019 to January 2020) only 10
dynamic support in three dimensions of movement (flexion/
people who have had polio in New Zealand had received a CTO.
extension; inversion/eversion; internal/external rotation) and
This study collected data from people who had already received
were promoted as having the potential to dramatically improve
their CTO and did not influence the way that CTOs were
a person’s functional abilities, reduce falls, reduce pain and
assessed or provided or how ongoing follow-up was delivered.
discomfort, and reduce energy consumption during movement.
The Duncan Foundation (a New Zealand registered charity for Data collection
people living with neuromuscular conditions) began supporting Semi-structured interviews were conducted by one researcher
individuals with polio to consider use of these new types of (AF) via videoconference. The initial interview questions were
orthotics. They also began providing funding to support the developed by two researchers (AF and WL) based on issues
physiotherapy required after people were fitted with a CTO. raised in a prior survey on orthotic experiences of Polio NZ
However, these CTOs still required a significant financial members (Jackman, 2016) and on the lived experience of one of
investment for people who have had polio, since funding for the researchers (AF) (see Appendix A). We sent questions to the
the orthotics was not (and still is not) available through New participants in advance so they could prepare for the interview.
Zealand’s health system, nor could they be funded by private Interviews lasted between 60 and 90 min, with one participant
insurance companies. Therefore, there was a need to gather electing to provide written answers only. All interviews were
information on the effectiveness of these new orthotics to digitally recorded and transcribed verbatim. We also collected
inform decisions about whether to invest in them. demographic data including gender, age, ethnicity, age of onset
of polio, limbs affected by polio, and orthotic and mobility aids
There are several challenges with undertaking research in this
used prior to the new CTO. We sought quantitative data on
area of clinical practice. First, the population of people who
mobility before and after fitting of the orthotics (e.g., walking
might benefit from these CTOs is relatively small, with a high
speed, endurance, balance) but this had not been routinely
degree of heterogeneity in their presenting impairments, making
collected for all participants using standardised measurement
it difficult to standardise interventions for research purposes
methods so was not available for reporting.
and making randomised controlled trial methods unsuitable.
Second, because little research has previously been conducted Data analysis
in this area of clinical practice, there is very little information We used NVivo 12 (QSR International) software to facilitate
about what types of standardised outcomes measures would analysis and management of qualitative data. We used constant
best detect improvements that might be meaningful to the comparative methods to analyse the data (Charmaz, 2014).
people receiving the orthotics. Third, there is little information We read and reread each transcript, incorporating findings
beyond anecdotal reports on optimal preparatory and follow- from additional data as the study progressed. We conducted
up physiotherapy that is required for people to benefit fully initial data coding (open coding) on a line-by-line basis with
from these CTOs. As such, we conducted an initial qualitative subsequent analysis exploring relationships between codes
study to explore the experiences and perceptions of people to develop higher-order concepts. We did not have enough
affected by polio and who had received CTOs, regarding: 1) the eligible participants to permit theoretical sampling or to test
impact of CTOs on their health and wellbeing; 2) the process assumptions about reaching data saturation, so a full grounded
of adjustment when learning to live with CTOs, including theory study was not possible.
reflections on both the formal (e.g., provided by health
One researcher (AF) undertook initial analysis of all data,
professionals) and informal (e.g., learning from experience)
discussing and peer reviewing the data with a second
aspects of the adjustment process; and 3) the possible
researcher (WL) as the study progressed. A third researcher (RM)
mechanisms of effect regarding how CTOs achieved or did not
independently read and coded all data to further enrich the
achieve positive health effects.
range of interpretations of the dataset. The whole research team
METHODS was involved in the development of the final analysis, which was
reached by consensus. To further strengthen the credibility and
Research design
trustworthiness of this analysis, we provided participants with
We conducted a qualitative descriptive study, influenced by

a summary of findings and presented preliminary (anonymised) CTOs were worth the investment, with several saying it was too
findings as a presentation at a national polio conference in New early to tell.
Zealand on 18 October 2019. Feedback during and following
Three key themes have been identified from participants’
this conference supported the direction of the analysis and the
experiences and perceptions of CTO use. The first theme
conclusions we had reached.
(Substantial investments) relates to the investment of time,
RESULTS energy, money and support that was needed to acquire and
adapt to the new orthotics. The second theme (Expectations
Participants
and reality) examines the range of expectations that participants
Eight out of 10 people (six men, two women; age range 55 to
had of the difference CTOs would make to their lives and how
77 years) who had received CTOs agreed to be interviewed.
closely the reality matched their expectations. The third theme
One declined because he was unable to use the CTO for health
(Contributors to success) explores factors that appeared to
reasons unrelated to the orthotic. The other person declining
contribute to recipients perceiving that the CTO optimised their
did not provide a reason. Five participants had single CTOs
health and wellbeing and therefore that their investment had
and three participants had bilateral CTOs. We interviewed the
been worthwhile.
participants 2 to 20 months following their CTO being fitted.
Seven participants used orthotics (callipers or standard-issue Theme 1: Substantial investments
ankle-foot orthosis) prior to CTO provision. Three participants Overall, participants talked about the significant investment
lived in a city, three lived in a provincial town and two of time, energy and money required to purchase and train
participants lived rurally (Table 1). to use the CTOs, with no guarantee of success. Financially,
CTOs were a significant investment with the cost of CTOs
Table 1
varying between NZ$10,000 to NZD$54,000 per person (mean
Participant Characteristics (N = 8) NZD$19,250). Participants funded their CTOs from a variety of
sources, including loans from Polio NZ and other philanthropic
Age Mean: 67.9 (range 55–77) years organisations, via crowdfunding or at personal cost.
Gender Male: n = 6
My total investment … [is] in the vicinity of $20,000 is
Female: n = 2
expensive but I look at it from the point of view that if I want
Ethnicity New Zealand European: n = 6
to retain my freedom, that’s the price. That’s what I am going
Mäori: n = 2
to have to do. (P7)
Type of CTO Single ankle-foot orthosis: n = 4
Bilateral ankle-foot orthoses: n = 2 Additional, usually unforeseen, costs were also incurred. These
Single knee-ankle-foot orthosis: n = 1 included costs associated with travel and accommodation for
Bilateral knee-ankle-foot orthoses: n = 1 CTO assessments and follow-up appointments, treatment
Time since CTO Mean: 13 (range 2–20) months costs to attend physiotherapy sessions, vehicle modifications
fitted in response to altered posture or movement patterns, and
purchase costs of parallel bars and other mobility equipment
Note. CTO = carbon-fibre triplanar orthotic. such as walking poles to allow the participant to practise using
their CTOs. Participants often needed to purchase different
Overview of findings footwear because the CTO would not fit in their existing shoes.
The impact of CTOs on participants’ health and wellbeing Different size shoes were often required for each foot.
varied greatly, with some participants describing the impact as
We had to buy shoes about five sizes too big because to
being positively “life changing” (Participant [P]3), while others
get the width you have to go up in shoe size … and it’s
described the CTOs as being “ill advised, [a] waste of time and
compounded because you only need it on one leg and not
an expensive nonsense” (P2). For those participants who had
on the other. (P8)
experienced improvements in their functioning, the CTO allowed
them to participate more fully in valued activities and life roles If the CTO was worn underneath participants’ clothing, trousers
and had a positive impact on their wellbeing: “The period of also needed to be replaced to accommodate the CTO.
time I can stand for in the brace is pretty much limitless … it
Physically preparing to get the CTOs and then learning to use
gives you a level of comfort and confidence that I never used to
them required a considerable investment of time and effort.
have” (P7).
Participants needed to undertake a daily stretching regime to
However, of the eight participants, only one was using his CTO improve their range of movement. They also needed to learn
for most of his daily functioning, five were using their CTOs to stand and walk with new postures and movement patterns
for part of their daily functioning and two were not using their before they could use the CTOs functionally: “You’ve got to
CTOs at all. All participants described the process of adjustment basically change your whole way of walking which you’ve been
as being both lengthy and energy intensive. At the time of the doing all your life, and you’ve got to change that, and it’s a
interview, none of the participants felt they had completed their pretty difficult task” (P8).
journey to full use of their new orthotic. Some felt they had
Many began by putting their new orthotics on for just an hour
made no progress; others that they were about halfway to full
every second day, increasing their duration and frequency of
adjustment to the orthotic; while most indicated that they were
practice over time. Some participants ended up training several
less than halfway. There were a variety of views as to whether

times each day: “When I got home, about four times a day I postural alignment and with greater stability. This allowed
would get into my braces and just stand there between the participants to stand and converse with people more easily,
parallel bars, initially just standing there and then starting to which many participants reported was a significant benefit:
move my hips” (P3). “Before when I was talking with people I was looking around
after about 5 minutes for someone to hang on to, but now I can
Donning and doffing the CTOs also took more time than
just stand there for like half an hour and it’s perfect” (P4).
previous orthotics, although participants reported that this
became quicker with practice. Some participants reported that Partners and other family members commented on how
regular daily practice with the orthotic was not possible due to much straighter and/or taller the participant was standing.
the time required to put on the CTO. This ability to stand for more extended periods with less effort
allowed participants to participate in activities and roles that
I should be spending more time but when I put them on I
were meaningful for them and had a positive impact on their
usually have them on for about an hour and I have tried to
wellbeing.
put them on the weekend because that’s the only time when
I’ve really got time to focus on them. (P1) Mobility
Improved walking was a fundamental expectation held by
A particularly vexing issue for participants was the need to
many participants. One participant (P4) reported that he could
slowly adapt to using the CTO while also needing to continue
now walk double the distance that he had been able to before
to use their previous orthotics to participate in daily tasks. When
transitioning to the CTO. Another recipient described the
they reverted to using their old orthotics, it was challenging
positive difference in his walking and that moving had become
to return to the movement patterns they used to function at
“amazingly different and wonderful” (P3). However, many of
previous levels.
the participants reported that while they had mastered walking
The extensive practice and associated concentration required to on the flat or uphill without too much difficulty, they struggled
learn to use the CTO also involved a considerable investment of with downhill, cambers and uneven ground.
mental and emotional energy. Many participants reported that
It’s fine going up a rise but going down a rise is dreadful. So,
the demands of adjusting to the new orthotics could lead them
when I go to town, I’ve [still] got a crutch in the car and if I’m
to feeling exhausted, discouraged and even despairing: “Coping
going to town to shop, I take the crutch with me. (P6)
with that feeling of despair is the thing I would say everyone is
going through and I certainly had to deal with” (P3). Pain
Relieving pain was another key expectation that participants
Theme 2: Expectations and reality
had of transitioning to using a CTO. Again, there were mixed
In this second theme, we explore the impact of CTOs on
responses as to whether CTO use impacted on participants’
participants’ ability to undertake a range of functions and how
experience of pain. For some CTO wearers, their pain levels were
closely reality matched their expectations. Participants had a
reduced when wearing the CTO. For one participant (P3), the
variety of expectations of the difference CTOs would make
CTO had provided relief from the pain he had suffered for most
to their lives. Reasons given for wanting to change to CTOs
of his life. Another (P1) commented that the pain in his knee
included factors related to improved postural alignment (i.e.,
and ankle joints had reduced because his ankles were held in
standing straighter, preventing further deformation), improved
fixed positions by the orthotics. However, for some participants,
mobility (i.e., improved walking, reduced falling), improved
the changed movement patterns required to function while
functioning (i.e., looking after self, having the opportunity
using the CTOs had contributed to the development of new
to do things not previously able to do), relieving pain (i.e., by
pains in other joints. The participant who had reduced pain in
reducing the load on specific joints or surfaces) and preventing
his knees and ankle joints (P1) experienced new discomfort in
deterioration in functioning (i.e., being able to stay out of a
his hips, for instance. Another reported having problems with
wheelchair, retaining ability to mobilise independently and
his back as a result of wearing the CTO. He explained: “You
keeping active in the community for longer). Other reasons for
can’t limp with it; you have to walk properly and if I try and walk
transitioning to CTOs included getting an orthotic that was
properly that’s when it really hurts” (P2). As such, an increase in
stronger and less likely to break.
pain was an unanticipated reality for some participants, contrary
It was all about keeping me active and able to look after to their expectations.
myself as I get older and also of course if I could walk better,
Functional activities
you know that was the biggie. I mean you know if I could
Another unanticipated reality for some participants was the
improve my walking and which of course I was limping more
negative impact that CTO use had on their ability to function
and more heavily as my legs deteriorated. (P6)
within some of their daily activities. While one recipient found
Postural alignment and standing that performing activities such as “lifting, reaching up to
While not identified as being a key reason for wanting to heights, playing music, painting [were] just a million times
transition to CTO use, improved postural alignment and better” (P3), many other participants found that the CTOs
endurance while standing emerged as one area in which constrained their ability to undertake activities. While they were
participants noticed improvements. The CTOs appeared to able to walk, they felt that the CTO was limiting their ability
contribute to the participants feeling they were able to stand to undertake activities they had been previously able to do
with less effort for more extended periods, with improved with their old orthotics, such as driving and gardening: “I quite

quickly realised that even if I got walking properly on it, it was provider. Participants required a qualified person such as a
going to be a way big step down from what I had in terms of physiotherapist with neurological rehabilitation expertise to train
function” (P2). them both before and after the CTO had been provided. Those
who did access rehabilitative support before the provision of the
Some mentioned finding it hard to bend down or kneel with
CTO frequently reported improvements in postural alignment
the CTO on. Another observed that “as for twisting and turning
and strength separate to that provided by the orthotic, with one
and climbing ladders and walking on uneven ground, it was
participant speculating that “now I have strengthened the leg,
impossible” (P2). For other participants, substantial effort and
maybe we could have done away with these dynamic braces”
time were needed to get to the point where the CTO did not
(P4).
constrain them. One participant (P6) reported that it had taken
nine months of regular practice to get to the point where they Participants also felt that, after the CTO had been provided,
could drive with their CTOs and walk around the supermarket regular reviews over time were needed for a successful transition
without holding on to the trolley. to CTO use. As one participant observed: “there should be
someone [who] assesses you every three months to make sure
Theme 3: Contributors to success
[you’re] doing it right” (P1). A small number of recipients were
Two key factors appeared critical to a successful transition to
able to access physiotherapy services in their local publicly
CTO use for participants: 1) access to ongoing orthotic support
funded health services. The Duncan Foundation provided limited
to adjust or modify the CTO and 2) access to rehabilitation
physiotherapy support to participants who were able to travel to
support to facilitate and receive feedback on their movement
the physiotherapist before and after fitting of the CTO. Others,
retraining. The chances of success were also improved by
however, did not have this opportunity and either had to pay
sustained effort on the part of the recipient – to complete the
for private physiotherapy or manage without any rehabilitative
required stretching exercises and to practise using the CTOs
support: “They sort of gave you some suggestions and gave you
during mobilisation tasks and functional activities.
a bit of assistance … it’s very much relying on the individual to
Ongoing orthotic and rehabilitation support actually do the work” (P8).
The importance of being able to access appropriate orthotic and
Participants who did not receive this support were often unsure
rehabilitation support before and after the provision of the CTO
whether their gait technique was correct and were fearful that
was evident across all respondents, especially when this support
they would have to start over again if they made mistakes in
was offered collaboratively and the clinicians worked together
their retraining: “What bugs me the most is that there is so
to solve problems.
much uncertainty. I don’t know if I am doing things right” (P5).
[The local orthotist] has been with [CTO provider], he’s been
One participant (P3) reported having to start again with learning
making them over here for [the CTO provider]; we’ve seen
correct movement patterns when the CTO provider gave him
him a couple of times. [The physiotherapist] would bring [the
feedback that his new walking technique was suboptimal.
local orthotist] across to assess me to see if she was doing [it]
right you know. The whole thing’s a big learning curve even Sustained commitment and effort
for the hospital as well. (P4) All participants stressed the need for sustained attention to
motor relearning over an extended period.
Equity of access was related to the physical location of the
recipient in relation to services, access to orthotic expertise The first six months of it is just all about retraining your
and access to a physiotherapist with neurological rehabilitation mind, retraining how you stand, retraining the basic
expertise on an ongoing basis. movements and once you’ve got those down, then I think
the development after that comes a lot quicker. (P8)
For participants in this study, the CTOs were provided by a
supplier who was based outside of New Zealand. Therefore, Participants described that a great deal of self-discipline,
CTO recipients required support from a New Zealand-based perseverance and tenacity was required, stating that “you’ve
orthotic provider for adjusting the CTOs in response to emerging really just got to drive yourself to stick with it and do the
issues related to fit, comfort, amount of movement and exercises” (P6). Participants talked about the importance of
evolving postural changes over time. Publicly funded orthotic being “of a mindset to put in that work” (P6) to ensure a
services in New Zealand varied in their willingness to assist CTO successful transition to CTO use. One participant noted that he
recipients. This meant there was considerable variation between had underestimated the need to do preparation exercises: “If
participants in their ability to access this required ongoing you do a lot of work training yourself to stand properly before
support. One recipient felt that her foot was rolling within her you get this thing, it would be a lot more effective and a lot
new CTO and her local orthotic service identified a possible easier, I think, to adapt to it” (P8).
cause so could make adjustments. A small number of recipients
For some participants, other daily responsibilities and activities
were able to adjust their own orthotics. Some participants had
made this sustained commitment difficult and, in some cases,
follow-up video conversations with the US-based CTO provider
unachievable. Some were unable to do the training needed
and, in a few cases, videos of standing and walking were sent
because of their other health conditions. Participants who were
for gait retraining feedback.
in full-time paid employment reported that it was challenging to
However, participants felt that more support was required than find the time and energy to practise wearing the new CTO, with
could be provided via online videoconferencing with the CTO one participant (P6) taking a month off work to concentrate on

adjusting to the orthotic and another stating that “I put them illustrates several reasons why establishing a strong evidence
on [at] the weekend because it is the only time when I really base in this area is difficult. The population of people who might
have time to focus on them” (P1). benefit from CTOs is relatively small for research purposes.
Recruitment in clinical trials is notoriously difficult. For instance,
DISCUSSION
almost half of all publicly funded clinical trials in the UK fail to
The accounts of participants in this study demonstrate the meet their target sample size due to problems with participant
variability in outcomes that can occur when people who have recruitment (Walters et al., 2017). Recruitment rates are not just
had polio receive new CTOs. Participants were more likely based on the number of people with a condition in a population
to find the experience of receiving a CTO worthwhile when but also on the eligibility of people to participate when
they were able to access ongoing orthotic support to adjust considering exclusion criteria, the willingness of people to enrol
or modify the CTO, when they received rehabilitation support in a randomised controlled trial – considering for instance that
to facilitate gait retraining and when they had the time and they may not receive the treatment they are hoping for – the
resources required to access and then learn to use their new ability of people to get to a clinical centre where a study is being
orthotics. The chances of success were also improved by conducted, the timing of the trial for when a person is ready for
sustained effort on the part of CTO recipients. a particular intervention and so forth. Participant recruitment
also must account for dropout rates. For comparison, only one
One prior qualitative study of orthotic use by people with
third of stroke survivors who are screened to join clinical trials
neuromuscular conditions (including some people with
of stroke rehabilitation are actually recruited, with a median
experiences of polio) has also highlighted the variability in
dropout rate of 6% (interquartile range 13%) of the people
outcome experiences from new orthotics – ranging from very
randomised to treatment groups (McGill et al., 2020). People
positive to very negative (McCaughan et al., 2019). This prior
who have had polio in New Zealand are highly diverse from a
study identified that any transition from an old to new orthotic
clinical perspective, relatively few in number in comparison to
could be challenging, making people reluctant to move to a
other conditions and geographically dispersed, making fully
new orthotic. The new information that our study adds is the
powered clinical trials very difficult to conduct.
extent of structured therapeutic exercise that might be required
before any new orthotic is useable – particularly when the As suggested by our study there is a high degree of variability in
new orthotic requires people to relearn movement patterns. presentation, both biomedically (e.g., the nature and range of
For some participants in our study, this additional therapeutic impairments) and psychosocially (e.g., social support, economic
exercise amounted to several hours of self-directed training each wealth, competing priorities, personal goals, attitude and
week over a period of many months. resilience), which impact on an individual’s response to CTOs.
The orthotic itself is highly unlikely to influence changes in
These findings highlight the importance of comprehensive
health and wellbeing without extensive additional therapy. The
assessment and establishing clear expectations when prescribing
comprehensive additional therapy could itself have a large effect
costly interventions such as CTOs. Assessments before fitting of
on the health and wellbeing of people who have had polio so
an orthotic need to focus on more than just the biomechanical
would also need to be studied separately. This makes it difficult
aspect of movement but also should consider when and how
for the polio community to conduct the kinds of studies that are
people will be able to complete all of the movement retraining
typically required for a strong economic argument to support
required to fully benefit from their new orthotics – within the
new health funding from the public health sector or insurance
context of their individual supports, resources and daily lives.
providers. There is, therefore, a need to embrace ‘practice-based
Exploring people’s goals, priorities and anticipated outcomes,
evidence pathways’ rather than solely ‘evidence-based practice
while also providing information about potential challenges,
pathways’ to gather meaningful evidence to support personal
is likely to facilitate a more successful transition to CTO use.
decision making and public health policy in this area of clinical
Potential recipients may benefit from talking to peers who have
practice, as recently advocated by Ogilvie et al. (2020).
already had a CTO fitted, as discussion with experienced peers is
known to aid informed decision making (Hammell, 2007; O’Neill Alternative research designs are needed to provide quantitative
et al., 2007). evidence supporting clinical and policy decision making around
the funding of orthotics for people who have had polio.
The experiences of participants in this study also indicated how
For example, single-case experimental designs (SCEDs) can
challenging it is for people with long-term health conditions to
rigorously demonstrate whether a treatment effect is evident
find and access the health services they need over their lifespan.
for individual participants, while also exploring the range of
Some participants in this study reported that the intensive
responses to interventions (Kratochwill et al., 2013). Synthesised
physical training they completed resolved some of the problems
findings from a number of SCEDs can support the development
with pain and functioning they had been experiencing before
of evidence-based practice by contributing knowledge not only
even being fitted with the CTO. However, the participants in this
about whether an intervention works in controlled and ideal
study reported that this type of rehabilitation support to meet
circumstances but also on how it may work, for the range of
their ongoing and changing health needs was often not easy for
people who access it (Shadish et al., 2014). This study suggests
them to access in their usual healthcare services.
that future SCEDs on the topic of new orthotics for people with
We initially started this study as a result of a call from the polio experience of polio could usefully focus on outcomes related to
community in New Zealand for more research to be conducted individually meaningful occupational performance, duration of
on the cost-effectiveness of orthotics. This study however time in standing per day and health-related quality of life.

Although we invited all potential participants in New Zealand ACKNOWLEDGEMENTS
to participate in this study (with only two declining), this
We would like to thank all the participants who gave their time
study was limited by its small sample size, which reduced the
for the study and the Duncan Foundation and Polio NZ who
range of experiences and opinions that we could draw on to
supported this research. In particular, we thank Gordon Jackman
develop these results. Furthermore, we did not have access to
for his endless enthusiasm and support.
quantitative clinical data on the participants’ impairments and
functioning before and after receiving their orthotics, making it ADDRESS FOR CORRESPONDENCE:
more difficult to consider the transferability of these findings to
Professor William Levack, Rehabilitation Teaching and Research
other people in other settings.
Unit, University of Otago Wellington, Wellington, New Zealand.
When considering the data from this study, it is important to
be aware of the context in which they were collected. The
participants in this study were the first people in New Zealand REFERENCES
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KEY POINTS Jones, K. M., Balalla, S., Theadom, A., Jackman, G., & Feigin, V. L.
(2016). Prevalence of polio: An international systematic review (2016)
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Appendix A
INTERVIEW QUESTIONS
1. Could you please briefly tell me about your experiences What has that involved?
of polio to date?
What support have you had in learning to adjust to the
Prompts
braces?
When did you get polio; where were you; what
Do you have any comments on the cost of the dynamic
happened?
braces and funding them?
What parts of your body were affected and in what
What resources were you supplied to guide your
way?
training?
How did having polio influence your life?
How well did you understand the information you were
2. Could you please tell me about your past experience of given?
orthotic services?
How well do you understand gait functions?
Prompts
What problems have you experienced since fitting (e.g.
What’s it been like?
range of motion, muscular control, pain, body image
What kind of orthotics have you worn? For how long? etc.)?
How did that make you feel? What do you think about 5. What has been the impact on you of having the braces
that? on your health and wellbeing?
Prompts
What operations, if any, have you had to assist you with
your mobility? Physically
What other health services have you used to assist you Socially
with your mobility?
Emotionally
What relationship did you have with your orthotist?
Psychologically
3. What has been your experience of getting dynamic
Financially
braces?
Prompts Pain levels
What led you to decide to get dynamic braces? Fatigue levels
What did you expect it might be like to get dynamic Clothing and footwear
braces?
How the orthotic looks and how it affects how you look
What were your expectations for the braces?
How you function day to day
What problems were you having that you hoped the
Your work
dynamic braces would address?
On your family
What was it like to be assessed for the dynamic braces?
6. Overall, how worthwhile have the orthotics been for
What was it like to be cast for the dynamic braces?
you?
What was it like to be fitted for the dynamic braces? Other prompts
What preparation did you do prior to receiving the Consider mechanism of effect:
braces? Any exercises?
How did the braces lead to that effect?
4. What has been your experience of adjusting to the
What other factors were involved in leading to that
braces?
effect?
Prompts
Why or how did that happen?
What have you had to do to adjust to wearing the
braces? What did you do in order to gain/alleviate this effect?
What have you had to do to learn to use the braces
effectively?

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2021 | VOLUME 49 | ISSUE 3: 113–156

ISSN 0303-7193 (PRINT)

• Physiotherapists’ and GPs’

www.pnz.org.nz/journal MOVEMENT FOR LIFE

117 127 147

New Zealand Journal of Physiotherapy Physiotherapy New Zealand

NEW ZEALAND JOURNAL

Why does Aotearoa New Zealand need an Osteoarthritis

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 117

New Zealand Physiotherapists’ and General Practitioners’

Richard J. Siegert PhD

Sandra Bassett PhD*

Jennifer N. Baldwin PhD

Valerie Wright-St Clair PhD*

INTRODUCTION should be multi-faceted and reflect the different ways the

118 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 119

All GPs Physiotherapists

Participants 295 100 87 30 208 70

120 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

All GPs Physiotherapists

Frequency of treating patients with hip and/or knee

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 121

All participants GPs Physiotherapists

122 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 123

124 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 125

126 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

Daniel W. O’Brien PhD

Gareth Terry PhD

Jennifer N. Baldwin PhD

Tom Ruakere DHSc

Toni Mekkelholt BHSc

Peter J. Larmer DHSc

INTRODUCTION greater preoperative comorbidities and have more postoperative

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 127

128 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 129

130 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 131

132 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 133

Supporting People Experiencing a Burn Injury to Return to

Julia Nicholson BHSc (Physiotherapy)

Natasha Bale PGCert (Health Science), BHSc (Physiotherapy)

Joanna K. Fadyl PhD, MSc, BSc (Psychology)

134 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 135

136 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

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