Knowledge, Practice and Barriers to Exercise Rehabilitation Among Chinese Patients with Acute Musculoskeletal Injury: A Mixed-Methods Study [Response to Letter]

Dear editor

We sincerely gratitude to Dr. Soner Kocak for his thoughtful and constructive comments on our manuscript titled “Knowledge, Practice and Barriers to Exercise Rehabilitation Among Chinese Patients with Acute Musculoskeletal Injury: A Mixed-Methods Study” (IJGM-573851). His insightful suggestions will undoubtedly contribute to improving the quality of our work. We have carefully considered each of the points raised and would like to respond as follows.

First, Dr. Kocak noted that defining “acute injury” as any injury occurring within the past five years may introduce clinical heterogeneity and recall bias. We fully acknowledge this limitation. However, one of the objectives of our study was to capture the long-term impact of injuries—such as changes in exercise habits and persistent abnormalities at the injury site—which required a broader time window. Moreover, given that injury and treatment are significant life events, we believe most participants were able to recall relevant details with reasonable accuracy. Nevertheless, we agree that future studies should consider narrower recall windows or stratified analyses to enhance precision.

Second, regarding concerns about selection bias due to online recruitment via a single platform, we would like to clarify that WeChat is the most widely used social networking application in China, covering a broad demographic range—from adolescents to the elderly—making it a relatively inclusive tool for survey distribution. Nonetheless, we acknowledge that digital literacy and access may still influence participation, and we appreciate this valuable observation.

Third, we agree with Dr. Kocak that survey validation is important for the quantitative study. However, the main purpose of the quantitative part of this study was to generate interview guide for the qualitative research. It just gave some descriptions. So, the findings should be interpreted within the Chinese cultural context. We recognize the importance of validating measurement tools in future research to enhance the robustness and generalizability of the results.

Fourth, Dr. Kocak pointed out the small number of orthopedic surgeons and physiotherapists in the qualitative part. We agree that a broader and more diverse sample—especially including community-based health providers—would strengthen thematic saturation. However, in the current context of China, exercise rehabilitation is still an emerging field, and professionals with relevant experience are predominantly concentrated in large medical centers. This reflects one of the systemic barriers we aimed to highlight. We appreciate this comment and will strive for more diverse sampling in future studies.

Finally, Dr. Kocak raised an important point regarding the interpretation of “underestimation of injury severity” as a dominant barrier. We concur that the gap between intention and action is multifactorial, involving not only patient beliefs but also systemic issues such as access, cost, and unclear referral pathways. Our findings indeed suggest that both educational and structural improvements are needed.

Once again, we thank Dr. Kocak for his valuable time and insights. His suggestions will be carefully considered for our future research, including the development of pragmatic referral systems, hybrid rehabilitation models, and implementation strategies to bridge the gap between awareness and action.