“It's disappointing and it's pretty frustrating, because it feels like it's something that will never go away.” A qualitative study exploring individuals’ beliefs and experiences of Achilles tendinopathy

Jeffrey Turner; Peter Malliaras; Jimmy Goulis; Seán Mc Auliffe

doi:10.1371/journal.pone.0233459

Peer Review History

Original SubmissionDecember 28, 2019
14 Apr 2020 Decision Letter - Denis Martin, Editor PONE-D-19-35845 “It's disappointing and it's pretty frustrating, because it feels like it's something that will never go away.” A qualitative study exploring individuals’ beliefs and experiences of Achilles tendinopathy PLOS ONE Dear Dr. McAuliffe, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== ACADEMIC EDITOR: address each of the comments from the reviewer. clarify the issue around irrational fear of reinjury. ============================== We would appreciate receiving your revised manuscript by May 29 2020 11:59PM. 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Please amend the manuscript submission data (via Edit Submission) to include authors: Jeffrey Turner, Peter Malliaras and Jimmy Goulis Additional Editor Comments (if provided): Thank you for your submission and your patience in awaiting a decision. The paper is well written and the qualitative approach adds useful knowledge to the theory and practice of managing achillies tendon injuries. In addition to the reviewer's comments, which should all be addressed in full, I have added one further point to be addressed. This concerns the finding of fear of movement. Within the context of a biopsychosocial approach to pain, which is where this paper is set, fear of movement or kinesiophobia is usually meant to imply an irrational fear of potential damage. That is well especially well established in low back pain where injury should not be an expected outcome of movement. However, as acknowledged in the introduction, there is a sizeable rate of reinjury in achillies injuries that belies a clear justification for calling fear of fully loading the achilles as irrational. The authors should clarify in 1.4 what exaclty is maladaptive in the beliefs and behaviour they have observed. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for the opportunity to review this manuscript. The authors are to be commended on a well written and very interesting paper that has some useful insights for clinical practice. I have made a number of minor points below - the main issue is the need to provide additional information about key components of methodological rigour. Abstract L30 Need to put in the acronym for AT here the first time you use the full term so that the acronym later in the abstract makes sense. L31 change disorders to disorder L32 There is LITTLE insight? L50 The authors talk about a two cohorts an athletic and non-athletic cohort – I think it would be clearly to say that the sample was a mixture of individuals from an athletic and non-athletic background. Introduction. It would be good to know what the previous study these authors have found (reference 16) and clarify how this current study seeks to extend those findings. Then in the discussion clarify if this work did build on those previous findings and how? Methods L130 Allow health care practitioners TO explore The methods section would benefit from additional detail regarding the demographic and any questionnaire data (the VISA-Q and the VAS) that were collected. The authors state they used convenience sampling. This is fine, but there seems to have been an interest in recruiting both athletes and non athletes what would the authors have done if their convenience sampling only produced athletes (or vice versa). It seems purposive sampling might have been more appropriate. The methods requires additional information about key rigour components in qualitative methods – e.g. credibility, trustworthiness, dependability and reflexivity – defining these and discussing how these were addressed e.g. two different individuals reading the transcripts and using quotes to ensure the themes were rooted in the data. Ensuring all opinions were included including those who were going against the grain, what the authors backgrounds are regarding AT and how this may or not have influenced the work etc… This is probably the key revision that is required. I cannot see if the data has been made available as per PLOS one requirements – apologies if I have missed this. Results Tables 1 and 2 would benefit from a legend covering things like what do the acronyms mean. Figure 1 is excellent – very concise and informative Discussion L478 review by [38] – delete the word BY ****** 6. 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Revision 1
26 Apr 2020 Author Response We thank the reviewers for their thoughtful and thorough review of our manuscript. We have taken every comment into consideration and responded to them individually below. EDITOR: Within the context of a biopsychosocial approach to pain, which is where this paper is set, fear of movement or kinesiophobia is usually meant to imply an irrational fear of potential damage. That is well especially well established in low back pain where injury should not be an expected outcome of movement. However, as acknowledged in the introduction, there is a sizeable rate of reinjury in Achilles injuries that belies a clear justification for calling fear of fully loading the achilles as irrational. The authors should clarify in 1.4 what exactly is maladaptive in the beliefs and behavior they have observed. Author’s Response: Thank you for your comments. We have clarified 1.4 by amending the subtitle to “Fear avoidance behaviors”, to better reflect our results and discussion. L470-488 in our discussion section elaborates on the results found in 1.4 in relation to how our participants’ fear of rupture/damage detrimentally effects their participation in daily activities and recreation. Despite the sizeable reinjury risk that is present in Achilles tendinopathy, the risk of potential rupture is still quite low, prior research by Yasui et al. found 4% of patients with Achilles tendinopathy later developed an Achilles tendon rupture. In addition, exercise-based therapies are considered the front-line intervention for treatment. Furthermore, the terms fear avoidance behaviors/kinesiophobia have been used in previous studies to describe the phenomenon in Achilles tendinopathy (Mallows et al. 2017). Yasui Y, Tonogai I, Rosenbaum AJ, Shimozono Y, Kawano H, Kennedy JG. The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States. Biomed Res Int. 2017; ePub 2017 Apr 30. Mallows A, Debenham J, Walker T, Littlewood C. Association of psychological variables and outcome in tendinopathy: a systematic review. British Journal of Sports Medicine. 2017;51(9): 743-748. REVIEWER: Abstract: L30 Need to put in the acronym for AT here the first time you use the full term so that the acronym later in the abstract makes sense. Author’s Response: We’ve added the acronym AT after “Achilles tendinopathy.” L31 Change disorders to disorder Author’s Response: Thank you, we’ve updated this. L32 There is LITTLE insight? Author’s Response: Thank you, we’ve updated this to “little insight”. L50 The authors talk about two cohorts, an athletic and non-athletic cohort – I think it would be clearer to say that the sample was a mixture of individuals from an athletic and non-athletic background. Author’s Response: Good point on modifying language here to improve clarity, see update below. Original: “This study offers a unique insight into the profound impact and consequences of Achilles tendinopathy in a cohort of both athletic and non-athletic individuals.” Updated: “This study offers a unique insight into the profound impact and consequences of Achilles tendinopathy in a mixed sample of both athletic and non-athletic individuals.” Introduction: It would be good to know what the previous study these authors have found (reference 16) and clarify how this current study seeks to extend those findings. Then in the discussion clarify if this work did build on those previous findings and how? Author’s Response: Excellent feedback. Themes from Mc Auliffe et al. were similar to those we found in our present study. Our sample was larger and included a mixed cohort of both athletic and non-athletic participants with AT, whereas Mc Auliffe et al. only had athletic participants. We’ve amended the intro, discussion, and limitations to include this which can been seen in the marked manuscript version. Mc Auliffe S, Synott A, Casey H, Mc Creesh K, Purtill H, O'Sullivan K. Beyond the tendon: Experiences and perceptions of people with persistent Achilles tendinopathy. Musculoskeletal Science and Practice. 2017;29: 108-114. Methods: L130 Allow health care practitioners TO explore Author’s Response: Thank you, we’ve now updated this. The methods section would benefit from additional detail regarding the demographic and any questionnaire data (the VISA-Q and the VAS) that were collected. Author’s Response: Thank you for the feedback. Participant data is presented in the first part of the results section, we have amended the manuscript to include additional details regarding demographic and objective data collected. See below. Participants Section Updated: Fifteen participants (8 male and 7 female) with AT were invited to participate in the telephone interviews. Table 1 details the specific demographics, objective, and subjective data of the included participants. Table 2 details the mean characteristics across the participants. Subjective and objective data collected included: Victorian Institute of Sport-Achilles questionnaire, AT pain at rest, AT pain during activity, duration of symptoms, running experience, and average weekly running distance. Elements of the audit trail are detailed in S2 Appendix. The authors state they used convenience sampling. This is fine, but there seems to have been an interest in recruiting both athletes and non-athletes what would the authors have done if their convenience sampling only produced athletes (or vice versa). It seems purposive sampling might have been more appropriate. Author’s Response: Thank you for the feedback. The sampling was convenient in nature - we didn’t intentionally select a specific number of athletic and non-athletic participants, they conveniently presented in this manner as part of a routine private practice setting. We felt that this method of recruitment best represented the sample seen in clinical practice. We are happy to change if the reviewers are not happy with this justification in sampling method terminology? The methods requires additional information about key rigour components in qualitative methods – e.g. credibility, trustworthiness, dependability and reflexivity – defining these and discussing how these were addressed e.g. two different individuals reading the transcripts and using quotes to ensure the themes were rooted in the data. Ensuring all opinions were included including those who were going against the grain, what the authors backgrounds are regarding AT and how this may or not have influenced the work etc… This is probably the key revision that is required. Author’s Response: Thank you for your comments, we have updated the “Data Analysis” section to include the below paragraph. Please also see the “Trustworthiness techniques” section of our S2 Appendix: Audit Trail for further information. Data Analysis Updated: To ensure the rigor of our data collection and analysis, widely accepted strategies of trustworthiness in qualitative research were adopted, including credibility, transferability, confirmability, and reflexivity [23]. Credibility was established by having two separate researchers reading, coding, and analysing the transcripts and by using quotes throughout the results to ensure the themes were rooted in the data. The current study’s transferability was addressed through thick description of our participants’ demographic, subjective, and objective data (Table 1 and Table 2). Audit trails describe the research steps taken from start to finish and are a foundational approach to establishing the dependability and confirmability of qualitative research findings. This study’s audit trail is attached as a supplementary appendix (S1 Appendix and S2 Appendix) [23, 24]. Lastly, reflexivity was established by maintaining a constant, open, and reflective dialogue between the authors during the coding and thematic analysis from each interview to the final stages of the study [23]. I cannot see if the data has been made available as per PLOS one requirements – apologies if I have missed this. Author’s Response: Thank you for bringing this to our attention. We submitted the files as part of the overall submission but apologise if you were unable to access these documents. We have attached the data, supplemental appendix 1 and 2, with this re submission for your consideration. Results: Tables 1 and 2 would benefit from a legend covering things like what do the acronyms mean. Author’s Response: Thank you for bringing this to our attention. Legends have been updated to reflect all acronyms within their corresponding tables. Discussion: L478 review by [38] – delete the word BY Author’s Response: Thank you, this has been removed. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0233459.r002
6 May 2020 Decision Letter - Denis Martin, Editor “It's disappointing and it's pretty frustrating, because it feels like it's something that will never go away.” A qualitative study exploring individuals’ beliefs and experiences of Achilles tendinopathy PONE-D-19-35845R1 Dear Dr. McAuliffe, We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements. Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication. Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. With kind regards, Denis Martin, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Thank you for your response to the comments. Reviewers' comments: https://doi.org/10.1371/journal.pone.0233459.r003
Formally Accepted
14 May 2020 Acceptance Letter - Denis Martin, Editor PONE-D-19-35845R1 “It's disappointing and it's pretty frustrating, because it feels like it's something that will never go away.” A qualitative study exploring individuals’ beliefs and experiences of Achilles tendinopathy Dear Dr. Mc Auliffe: I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. For any other questions or concerns, please email plosone@plos.org. Thank you for submitting your work to PLOS ONE. With kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Denis Martin Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0233459.r004

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