A Qualitative Study on the Experiences of Patients with Chronic Low Back Pain in China

doi:10.21203/rs.3.rs-6997515/v1

Objective: Chronic back pain (CBP) affects people physiologically, psychologically，and socially. This study aimed to explore the experience of CBP patients who received massage treatment in China.

Methods: This research used a qualitative content analysis method. 22 CBP outpatients were invited to participate in semi-structured interviews with the purposive sampling. The data were analyzed using qualitative content analysis.

Results: This study identified five main categories, 13 subcategories, and 68 codes. The five categories were: (1) cognition of CBP, (2) impact of CBP, (3) therapeutic perspective, (4) factors hindering access to treatment, and (5) coping with CBP.

Conclusions: The experience of patients with chronic low back pain provides multidimensional intervention targets and humanistic value orientation for manual therapy, systematically demonstrating the integrative value of tuina therapy across biological, psychological, and social dimensions, while proposing a patient-centered CBP management model that offers a broader perspective for outcome assessment.

qualitative research

chronic back pain

life experience

qualitative content analysis

Chronic pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage [1], persisting beyond three months [2]. Epidemiological studies indicate that approximately 20% of the European population and between one-third and one-half of the UK population experience chronic pain [3, 4], with prevalence projected to increase alongside aging demographics. Among chronic pain conditions, chronic back pain (CBP) — characterized by persistent pain in spinal structures, joints, or surrounding tissues lasting ≥ 3 months [5] — is the most prevalent. Pain and pain-related disorders constitute the primary cause of global disability and disease burden [6], among which low back pain represents a particularly significant contributor [7].

Patients with chronic back pain (CBP) prioritize recovery from physical dysfunction, psychological distress, and diminished health-related quality of life (HRQoL) over pain relief alone [8]. Consequently, clinicians and researchers increasingly recognize the importance of patient-reported experiences, developing diverse outcome measures for CBP trials [9]. Core outcome sets—representing outcomes essential to stakeholders (patients, clinicians, and researchers)—should be standardized and reported across all trials for a given condition. However, discrepancies exist between patient and clinician assessments [10–13]: patients often emphasize symptom impact on social role fulfillment [14], while clinicians may focus predominantly on pain presence/severity.

The biopsychosocial model [15], widely advocated as superior to the biomedical model for conceptualizing pain etiology and prognosis, is essential for comprehensive CBP assessment [16, 17]. Evidence indicates that CBP outcomes are influenced by multifactorial determinants [18–20], including anxiety and depression (which amplify pain responses) [21] and physical/psychosocial work environments (which modulate pain persistence pathways) [22]. International multidisciplinary consensus for nonspecific low back pain recommends core outcomes of physical function, pain intensity, and HRQoL [23], yet psychological and environmental factors remain underrepresented in musculoskeletal core outcome sets [14].

Furthermore, standardized patient-reported instruments may inadequately capture post-treatment recovery experiences [24]. Such measurement misalignment risks misleading clinical practice and healthcare policy [25–27]. Thus, integrating patient perspectives into outcome selection for research and clinical care is imperative [28–30].

Limited evidence characterizes the lived experience of CBP among Chinese patients. Understanding this experience could elucidate disease-specific impacts, unmet needs, coping strategies, and treatment expectations. Such insights would enhance clinical decision-making, inform patient-centered outcome measurement, and optimize health outcomes.

Qualitative methodology—exploring human experiences within personal and social contexts—enables deeper understanding of influencing factors and informs practice improvement strategies [31]. Existing qualitative studies reveal CBP’s multifaceted life impacts: perceived stigma and healthcare interactions characterized by "struggling to be seen and understood as a person" [32]; tensions between self-efficacy and dependence [33]; and culturally mediated factors shaping treatment expectations [34]. Cross-cultural studies (e.g., in Spain/Brazil) demonstrate how pain definitions and religious coping mechanisms influence CBP experiences [35]. Nevertheless, scant original research explores the socioculturally distinct experiences of Chinese CBP patients. Given society, environment, and culture critically shape disease perception and management, this study aims to characterize the lived experience of Chinese CBP patients and explore the condition’s impact on daily life.

Design

This research used a qualitative content analysis [36] method, which based on interpretive paradigm and phenomenology methodology to gain more information about patients’ experiences of living with CBP. The results will be reported in full according to the consolidated criteria for reporting qualitative research (COREQ) [37].

Participant recruitment

Outpatients from Tuina and the pain management department, Dongzhimen Hospital, Beijing University of Chinese Medicine were recruited with purposive sampling. People were invited to participate in semi-structured interview if they had been diagnosed with CBP, aged between 18 and 70 years, informed consent and voluntary participation. A wide range of demographics such as age, gender, and occupation of participants were considered in the recruitment. Patients with brain diseases, abnormal judgment ability, back surgery, cancerous pain, headache, psychosis, severe depression, illiteracy, or poor eyesight were excluded. CBP refers to pain and discomfort below the costal margin and above the gluteal fold, with or without going down leg pain, which is characterized by limiting usually daily activities and lasting for > 3 months [38].

Study setting

This study took place in Tuina and the pain management department, Dongzhimen Hospital, Beijing University of Chinese Medicine. Traditional treatments such as massage, acupuncture, hot compress, Chinese ointment and rub are mainly used in the outpatient clinic. Patients are triaged at the triage table after registration. There are several consultation rooms in the ward, each of which has 1–4 treatment beds and can treat 1–4 people simultaneously. Following the wishes of the patients and to save the time of the interviewees, the interview was conducted in the consultation room. During the waiting period of patients or the massage treatment, the researcher introduced herself and the basic information of the subject to the patients and inquired their opinions on whether they were willing to accept the interview. After obtaining the patients’ consent, the interview study was carried out, and the interviewees were numbered according to the order of the interview they received. The researcher promised the interviewees that the collected data would be kept confidential, anonymity would be taken if the data needed to be presented in the research results, and the interviewees were informed that they had the right to withdraw from the research at any time.

The interviewer is a postgraduate student majoring in acupuncture and massage at the Beijing University of Chinese Medicine. She has received qualitative method training and has a specific understanding of the interview process and matters needing attention. In addition, due to her medical background, she can interpret research problems better and understand the experience of patients. This qualitative study provides new ideas for the follow-up clinical work of the interviewer and enables the interviewer to have a deeper understanding of the needs of patients.

Data collection

Qualitative data were obtained through 10-20minute, face-to-face, semi-structured interviews from August to September 2020 by one of the authors. And the interview guide was designed according to the purpose of the study and previous relevant research. We conducted a pilot interview to modify the interview guide and identify problems during the interview and correct them in time. The finalized interview guide can be found in the appendix.

The interview started from collecting demographic data and centered on the interview guide. The order of questions is not fixed. When asked about the life experience of the interviewees with CBP, if the interviewees did not know how to answer, they were asked to start from the beginning of the pain, and then specific questions about the cause of pain, the impact of CBP, treatment of expectations and strategies of coping with CBP. The interviewees' opinions, experiences, and other descriptions were recorded in time and. With the interviewees' consent, the author audio-recorded synchronously to ensure that no critical information was omitted. When no new statements or ideas were generated, the interview was considered to have reached saturation, and we stopped data collection.

Data analysis

Data were analyzed from interview transcripts by two independent researchers(ZY, CH) using qualitative content analysis. And compare and discuss the differences in the analysis process, and then make a revision. Any disagreements that arose between the interviewers had been resolved through discussion with a third researcher(YCH).

The qualitative content analysis included the following basic steps: 1) Researchers read the transcribed text data repeatedly and immersed themselves in the data to have a general sense and determine the meaning unit corresponding to the research goal. The meaning unit refers to the set of words or statements related to the same central meaning; 2) condensation of the meaning unit, that was, reducing the size of the text while preserving its core semantics; 3) annotated the crucial concepts of the condensed unit with words and phrases and carried out open coding. Coding is a process of further analysis that pays emphasizes on description and explanation at a higher logical level; 4) Then, the similar and related codes were classified into subcategories. A category is a group of standard contents, and the categories formed are mutually exclusive. 5) Finally, the possible meaning of the subcategory, the potential content, was expressed as a category.

Participants were 22 individuals with a median course of 7.5 (0.25-41) years, including nine retirees, twelve active employees, and one temporary employee. There were 12 (54.5%) female participants. The age of participants ranged from 26 to 72 (52.91 ± 11.98) years old. Table 1 shows the participants’ demographic information. The data analysis of this study identified the following five main categories,13 subcategories, and 68 codes (Table 2). The five categories: (1)cognition of CBP, (2)impact of CBP, (3)Therapeutic perspective, (4)Factors hindering access to treatment, and (5)coping with CBP.

Cognition of CBP

This category refers to patients' understanding of chronic back pain (CBP), derived from two subcategories: (1) predisposing factors and (2) perceptions of disease etiology and progression, based on the original coding framework.

Predisposing Factors of CBP

Patients reported various triggering factors for CBP onset. Symptoms often occurred unexpectedly and included pain, immobility, or movement hesitancy. Identified triggers included heavy weight-bearing, accidental sprains, falls, improper postures (such as bending or slouching), prolonged maintenance of positions (like extended sitting), physical inactivity, prolonged walking, fatigue, pregnancy, and even vigorous actions like coughing or sneezing.

Participant P1 stated: "When I was doing heavy work and lifting heavy objects, my lower back became immobile. This was my first experience of low back pain. I didn't seek hospital treatment, and the pain resolved spontaneously."

P5 reported: "While lifting an object from a low seat, I extended my back and couldn't move."

P19 described: "Sometimes I suddenly experience considerable discomfort. My lower back becomes acutely uncomfortable, likely due to prolonged sitting. One episode occurred while lying sideways on a soft sofa watching television."

Perceptions of CBP

Some patients attributed CBP to aging, viewing it as musculoskeletal deterioration accompanying physiological decline. Others associated it with occupational factors like prolonged sitting, or self-perceived bodily neglect and overexertion. Patients characterized CBP as having multiple potential diagnoses, uncertain etiology, recurrent nature, chronic duration, and poor curability.

P3 stated: "I've received outpatient therapy for years with recurring episodes."

P7 explained: "I don't attribute it to anything specific - it's simply age-related."

P9 noted: "It may relate to work-related sitting, or possibly age-related tendon degeneration."

P11 recounted: "Initially, diagnoses varied from bone fracture to disc herniation. After physical examination here, the doctor diagnosed lumbar muscle strain."

Impact of CBP

CBP affects patients multidimensionally, primarily impairing physical functioning, social functioning, and emotional functioning, with consequent reduction in quality of life.

Physical Functioning

CBP significantly compromises activities of daily living including self-care, weight-bearing, standing, walking, flexibility, bending, turning, squatting, sitting, lying down, rising from positions, maintaining postures, movement, exercise, excretion, and sleeping.

P7 described: "My back seems less flexible than before; I've started protecting it and avoid bending forward." This activity avoidance reflects long-term physical restriction. Physical limitations also affect health management behaviors; P16, who has diabetes, discontinued his walking-based glycemic control regimen due to back pain: "I stopped walking, my blood sugar rose. When I resumed walking along the river, my sugar decreased but my back started aching."

During acute episodes, basic self-care abilities (dressing, brushing teeth, washing, eating, turning, toileting) become severely compromised. P10 reported: "All activities were restricted for two weeks to a month. After two weeks, I could finally put on socks."

Sleep disruption was also common. P8 stated: "Back pain prevents sleep, forcing me to walk for relief."

Social Functioning

Physical limitations restrict social behaviors, reduce leisure activities, hinder childcare and housework, affect family roles, and impair work capacity.

P4 noted: "All activities decreased because I needed bed rest." CBP impedes desired activities and social participation, creating challenges in relational integration. P16, who enjoyed ball sports, reported when asked about continued participation: "Absolutely not. I'm an elderly man with back impairment - young players exclude me."

Physical constraints prevent childcare and domestic tasks, affecting family functioning. P15 said: "I don't dare hold children," while P8 added: "I can't bend to help my children retrieve dropped items, but we maintain relationships through communication."

Work impacts were particularly salient. Some patients continued working despite pain, others changed jobs, while some experienced unemployment or early retirement. P20 described productivity loss: "My efficiency decreased significantly. I feel uncomfortable and depressed - how can I work when unwell?" P10, a massage therapist, noted: "I avoid certain techniques, apprehensive they'll trigger back pain."

Emotional Functioning

Patients compared their current and pre-illness selves, experiencing worry and fear about their future. Limited self-efficacy and perceived loss of control generated anxiety, depression, irritability, and fear.

P9 expressed irritability: "Constant unrelieved pain inevitably causes irritability - illness frustrates anyone." Worry was prevalent, particularly among long-term sufferers. P4 feared progression: "I worry it will worsen and disrupt my normal life. What will happen when I'm older?" P10 reported occupational concerns: "I worried about my career prospects while still young."

Movement-related fear was prominent. P17 stated: "I feel nervous, anxious, afraid - what if I couldn't walk?" P9 avoided exercise: "I didn't dare cycle," and P16, formerly active, said: *"I previously walked 20,000–30,000 steps daily but now hesitate."*

Unpredictable onset and uncontrollable pain create frustration about present limitations and future uncertainty, collectively diminishing quality of life and fueling desires for normalcy.

Therapeutic Perspectives

Patients demonstrated medication hesitancy, surgical concerns, and preference for conservative treatments like massage. Four subcategories emerged: views on pharmacotherapy, surgery, massage, and treatment expectations.

Views on Pharmacotherapy

Most patients avoided analgesics, perceiving limited efficacy and tolerable pain levels. P6 stated: "I won't take painkillers. My cartilage issue isn't severe enough." Some acknowledged acute-phase utility. P11 noted: "During severe episodes, bed rest and analgesics are essential."

Views on Surgery

No respondents underwent surgery, emphasizing concerns about efficacy and safety. Most declined surgical intervention due to fear and outcome uncertainty. P3 explained: "I avoided surgery because it seemed frightening and unsafe - what if I worsened?" P21 felt unqualified: "Surgery isn't warranted yet; long-term conservative treatment should suffice." P6 viewed it as last-resort: "Surgery should only be considered when alternatives fail."

Views on Massage

All participants received massage therapy. They perceived it as conservative treatment that unblocks acupoints, relaxes muscles, promotes circulation, and improves lumbar curvature. Patients reported relief from pain, discomfort, stiffness, muscle relaxation, and sleep improvement, with additional comfort and relaxation benefits.

P3 described: "It's quite relaxing. I feel comfortable after each session."

P7 stated: "Massage relaxes superficial muscles and dredges acupoints."

P10 commented: "It provides prompt pain relief. I believe static lesion repair might be effective."

Treatment Expectations

Some patients accepted incurability, seeking only symptom relief, prolonged remission, shortened episodes, and reduced treatment frequency. Others hoped for cure. Additional expectations included restored physical function, unrestricted movement, walking ability, unimpaired work capacity, and improved quality of life.

P1 stated: "It can't be cured, but hopefully pain can be reduced."

P3 expressed: "I just want unrestricted movement. At my age, I don't expect to regain youthfulness."

P10 wanted: "Prolonged remission since pain recurred regularly initially. During recurrences, I hope for shorter duration, reduced intensity, improved quality of life, and extended work capacity without daily life disruption."

P20 emphasized appearance preservation: "Body image shouldn't be affected."

Factors Hindering Access to Treatment

Barriers included temporal constraints and disease characteristics.

Temporal Factors

Patients reported significant time commitments for treatment, waiting, travel, and frequent appointments, particularly conflicting with work obligations. P21 explained: "During severe periods, I visited twice weekly, but frequent leave-taking is problematic with my busy work schedule."

Disease Characteristics

Diagnostic uncertainty created initial specialty selection difficulties. P13 stated: "Initially, I didn't know which specialty addressed back pain." Mobility limitations prevented hospital access. P10 noted: "I couldn't travel to hospital due to restricted movement." Elderly patients faced technological barriers. P3 reported: "I struggle with mobile technology. Hospital digital payment systems requiring code scanning are inconvenient."

Coping with CBP

Coping encompassed attitudes and strategies toward disease management.

Coping Attitudes

Some patients maintained hope despite temporary relief. P16 stated: "I'll persist with treatment for two years if it brings eventual improvement." Others accepted chronicity through normalization. P11 said: "I no longer distress over it - prolonged duration has led to acceptance."

Coping Strategies

Patients employed medical consultation, self-management, and tolerance. Professional guidance was prioritized. Self-management included body awareness, activity modification, self-applied patches, firm bedding, stretching, and movement. During public pain episodes, patients often tolerated discomfort.

P2 described: "I use firm bedding with padding and apply topical rubbing."

P4 reported: "When back pain strikes at work, I endure it and rest," adding: "I seek immediate medical care when symptoms appear."

1. Core Characteristics of Illness Experience in Chinese CBP Patients

1). Cultural Specificity of Illness Cognition

This study aims to deeply describe Chinese patients’ experiences with chronic back pain (CBP) through qualitative content analysis, revealing unique illness cognition patterns. Chinese CBP patients focus on functional recovery but neglect etiology: Although clearly understanding clinical diagnoses (e.g., lumbar muscle strain, disc herniation), they prioritize functional restoration over etiological investigation (e.g., P10 focuses on pain management). Older patients generally accept "degeneration as a natural aging process" (P7: "This comes with old age"); younger patients pay more attention to occupational protection and pain control (P10: "Hope it won’t affect work"). International literature indicates that diagnosis is crucial for patients as proof for social welfare, where physiological and pathological changes of diseases, along with visible signs and symptoms such as observable disability and persistent symptoms, are core elements proving legitimate existence. For patients with nonspecific low back pain, they desire a diagnosis to legitimize their illness because when X-rays, CT scans, and other clinical diagnostic tests show no significant abnormalities, the cause of pain may be explained psychologically and socially [39]. Acceptance of medical care indirectly confirms the illness [40]. Interviewed Chinese patients care more about whether their needs are met.

2). Specificity of Multidimensional Impact

The impact of CBP on patients is the research focus, involving physical, psychological, and social dimensions. For CBP patients, pain correlates with physical function, social roles, and emotional changes.

Biological dimension: Centered on pain and dysfunction, severely limiting basic life abilities (bending/walking/sitting-lying, P7/P10). Unbearable pain causes nocturnal awakening (P8: "Pain prevents sleep; I must get up and walk").
Psychological dimension: Marked by kinesiophobia, with significant avoidance behaviors: Fear of aggravating symptoms leads to activity avoidance (P9 dares not cycle; P16 dares not walk). Studies note that kinesiophobia affects all aspects of daily life, including loss of occupational roles, altered interpersonal relationships, reduced leisure activities, and barriers to returning to work. Kinesiophobia is a psychological and emotional change—an avoidance mentality arising from pain limitations and fear that movement will worsen symptoms. It reflects complex interactions among pain, physical function, social roles, and psychology, increasing challenges in managing CBP. Additionally, age-specific anxiety exists: Younger patients fear progressive deterioration (P4); older patients dread paralysis/disability (P9).
Social dimension: Impacts are broad but relatively mild, mainly manifested in occupational function (reduced work efficiency (P20), forced job change or unemployment) and family roles (limited childcare capacity (P15: "Dare not hold children")). Work is one cause of CBP, and CBP also affects work status. Deepening understanding of the correlation between CBP and occupational factors is a necessary prerequisite for treating and preventing CBP. Literature mentions that patients’ work status affected by CBP may increase colleagues’ workload. Male patients unable to earn livelihoods exhibit psychological states of guilt and remorse due to forced reliance on family support. Their illness imposes additional pressure on friends, colleagues, and family, affecting normal social and family relationships. Despite social withdrawal (P16) and reduced leisure activities, family relationships remain intact, and social isolation is milder than in Western studies.

2. Integrative Value of Tuina Therapy in CBP Management

1). High Alignment with Patient Needs

Although no single treatment is universally effective for CBP, efficacy remains patients’ primary concern. CBP has extensive evidence-based interventions, including medication, surgery, complementary and alternative medicine (CAM), and exercise. Patients express concerns about surgical efficacy and safety, believing surgery carries high risks and cannot guarantee restored normal function. Some patients repeatedly undergoing surgery confirms reasonable suspicion about surgical outcomes. Simultaneously, differing opinions among doctors regarding surgical intervention make patients skeptical of surgical efficacy and safety, leading them to seek alternative treatments. Surgery is usually not the preferred option for CBP. Due to persistent CBP symptoms, oral NSAIDs or opioid injections are used for symptom relief, with varying responses and effects. Patients worry about medication side effects; some discontinue use after observing side effects impacting work (e.g., P6 rejects analgesics). Medication is part of life for some patients. Some fear long-term analgesic use may cause dependency and addiction; others suggest additional medications may be needed to treat analgesic side effects. Chinese patients rarely choose analgesics, possibly related to their condition severity or perceptions. Chinese patients report trying or accepting CAM, which alleviates symptoms while avoiding concerns about side effects and potential addiction (P3: "Surgery is terrifying"). Targeting core issues like "muscle stiffness" (P7) and "limited mobility" (P10), tissue-regulation manipulation directly improves joint mobility, and gunfa technique releases deep muscle groups (immediate comfort reported by P3). Additionally, the therapy features mind-body integration: Tactile stimulation regulates autonomic function (reducing anxiety in P9; improving sleep in P8), embodying TCM’s theory of "harmony of body and spirit" (simultaneous physical relaxation and emotional improvement).

2). Multistage Intervention Pathway

Disease Stage	Patient Needs	Tuina Protocol	Scientific Basis
Acute phase	Rapid pain relief (P10)	Ashi point pressure + lumbar oblique-pulling	Pain signal inhibition
Chronic phase	Functional recovery (P3)	Tuina + Taiji Push Hands	Neuromuscular control enhancement
Elderly patients	Safety and mildness (P7)	Viscera-regulating Tuina	Autonomic nerve rhythm modulation

3). Diagnostic and Therapeutic Advantages with Chinese Characteristics

Cultural adherence enhances compliance: Patients explain conditions using TCM terminology ("meridian dredging" P7; "qi-blood stagnation" P9), confirming Tuina theory’s cultural embeddedness. Techniques integrate the "unity of heaven and humanity" concept (e.g., temporal acupoint selection based on Zi Wu Liu Zhu ), enhancing treatment acceptance.
Evidence-based refinement of characteristic techniques:

Patient Feedback	Corresponding Technique	Scientific Mechanism
"Lumbar stiffness" (P10)	Lumbar micro-adjustment	Restores facet joint sliding
"Cold-induced soreness" (P19)	Medicated rubbing (e.g., Ilex ointment)	Promotes transdermal absorption
"Recurrent episodes" (P3)	Solar-term-based Tuina care	Modulates autonomic rhythm

Research direction

Culturally adaptive clinical trials are needed (e.g., comparing Tuina acceptance between Chinese/Western patients) to establish a China-specific Tuina evaluation system.

3. Constructing a Patient-Centered Tuina Treatment Model: From Demand to Practice

Patient experiences reveal limitations of conventional medical models, necessitating demand-driven treatment pathways. Studies show patients are dissatisfied with doctors’ and nurses’ standardized guidance and routines because patients’ precise expectations are overlooked. Providing precise treatment plans based on patient-doctor agreement about the problem’s nature can improve patients’ conditions. Integrating patient expectations into treatment plans, focusing more clearly on patient experiences, and promoting a person-centered approach to CBP management are meaningful. CBP patients’ expectations are multifaceted. Controversy exists about whether current measurement tools cover all expectation domains and truly reflect patient changes. Qualitative findings can inform the development and validation of quantitative measures. Exploring patients’ treatment expectations can provide appropriate perspectives for treatment planning and prognosis assessment. Future research could develop localized PRO scales incorporating daily-life indicators such as dressing ease (P10) and sleep quality (P8), or composite bio-psycho-social indicators like lumbar mobility + Tampa Scale for Kinesiophobia + work absenteeism rate.

In healthcare, literature indicates patients value not only treatment accessibility and appropriateness but also clinicians’ understanding, trust, respect, and effective communication. For chronic nonspecific low back pain, stigma from medical systems, families, and society—due to lacking obvious physical and clinical manifestations—harms mental health, creating a vicious cycle of bio-psycho-social impacts. Full trust in doctors may relate to the characteristics of Tuina intervention received by Chinese patients. Tuina is a tactile therapy; touch is a fundamental element of human interaction that regulates social bonds. In therapeutic settings, touch is a useful strategy for alleviating musculoskeletal pain. Respondents generally reported symptom relief, physical and mental relaxation after Tuina, leading to high satisfaction with the medical process and absence of medical system stigma.

CBP changes patients’ attitudes toward life. Its negative impacts fuel expectations for symptom relief and cure. Patients desire a return to normal life and actively take measures to reduce pain. Patients want to cure the disease but then realize the pain will not disappear and must accept it [41]. Coping with CBP is prolonged and complex. Determination, dreams, family support, and spiritual strength sustain them [42]. Studies found patients’ self-management strategies include listening to the body, active social participation, dynamic lifestyles, adapting management strategies to different environments, and choosing more self-compassionate coping styles [42]. Those with shared experiences understand each other better; teamwork promotes sharing, encouragement, and mutual learning, offering broad directions for managing illness [43]. Understanding patients’ CBP experiences helps doctors focus on patient needs, listen to their feelings, and comprehend their health perspectives. In CBP management, prioritizing person-centered care and shared decision-making may yield unexpected therapeutic benefits. Maintaining empathy in medical practice is vital—"To comfort always, to relieve often, to cure occasionally”.

4). Research Strengths and Limitations

Strengths:

This study first adopted qualitative content analysis to deeply deconstruct illness cognition patterns in Chinese CBP patients, revealing the "prioritizing function over etiology" treatment demand and filling a cognitive gap in East Asian patient experiences within international research. By capturing patients’ native discourse (e.g., P7’s "meridian obstruction"), it constructed a localized integration path for TCM theory and the modern biopsychosocial pain model. It meticulously parsed CBP’s multidimensional impacts, broke through traditional biomedical frameworks, systematically quantified CBP’s triple-dimensional outcomes (physical/psychological/social), and provided evidence-based targets for Tuina’s "body-spirit harmony" approach. It pioneered a "demand-technology-evaluation" translational pathway: demand-stratified response, evidence-based technology refinement, and innovative evaluation systems. Through culturally specific insights, closed-loop clinical translation, and research paradigm breakthroughs, this study not only established Tuina’s core role in CBP multidisciplinary management but also constructed a methodological paradigm for traditional medicine modernization, offering a "Chinese exemplar" for global complementary medicine research.

Limitations:

One limitation is that the study originated in a specific treatment context—Tuina departments of TCM hospitals—which may limit the applicability of findings to other settings. For example, CAM utilization in Western versus TCM hospitals may differ significantly. Additionally, results are based on interviews with volunteers visiting TCM hospital Tuina departments who received conservative TCM treatments without other interventions (e.g., surgery). This may lead to insufficient population diversity, and the sample may not reflect the experiences of large national populations. The qualitative nature of the study does not exclude researcher interpretation subjectivity, and the impact of chronic low back pain on patients may be underestimated. Healthcare professionals should fully understand the special nature of CBP, focus on patient needs in management, prevent CBP occurrence, and implement multidisciplinary treatment to avoid further impact expansion.

CBP patients’ illness experiences provide multidimensional intervention targets and humanistic value guidance for Tuina therapy. The study systematically demonstrates Tuina’s integrative value across biological, psychological, and social dimensions: improving dysfunction through tissue-regulation techniques, regulating anxiety via tactile stimulation, and accelerating social role reconstruction. It offers a broader perspective for outcome assessment when standardized back pain and dysfunction evaluations are unavailable. Therapeutic effect evaluation in CBP clinical trials should extend beyond pain and dysfunction to include social participation, roles, emotions, economics, and adverse effects. Changing physical, psychological, and social work environments may be fundamental interventions for improving persistent pain. Beyond biomedical education, healthcare workers need enhanced social and psychological training to effectively address psychosocial barriers and innovate treatment/management approaches. Tuina shortens the distance between doctors and patients. The Tuina therapy environment helps patients relax and partially aligns with their expectations, inspiring patient-centered CBP management.

CBP	chronic back pain
HRQoL	health-related quality of life
CAM	complementary and alternative medicine
TCM	traditional Chinese medicine

Ethics approval and consent to participate

This study adhered to the principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics Review Committee of Dongzhimen Hospital of Beijing University of Chinese Medicine (Ethics Review Batch No. : DZMEC-KY-2020-60). Informed consent was obtained from all participants.

Consent for publication
Consent was obtained from all participants for the publication of their data or information.

Availability of data and materials
The data that support the findings of this study are available from the corresponding author upon reasonable request.

Competing Interests
No conflicts of interest exist.

Funding
This study was funded by the National Natural Science Foundation of China for Young Scientists (81803956), and the Capital Health Development Scientific Research Special Project (2020-4-4195).

Authors' contributions
YCH was primarily responsible for the study design, CH mainly participated in data collection and analysis, and ZY drafted the manuscript.

Acknowledgements

not applicable

Clinical Trial Number

Clinical Trial Number: not applicable

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Table 1

participant	gender	sick time (year)	diagnosis	occupation
P(1)	female	30	Lumbar intervertebral disc herniation, bulging	retired
P(2)	male	6	Lumbar intervertebral disc herniation	retired
P(3)	female	30	Lumbar intervertebral disc herniation	retired
P(4)	male	20	Lumbar intervertebral disc herniation	the driver
P(5)	female	8	Lumbar intervertebral disc herniation	temporary workers
P(6)	male	3	Lumbar intervertebral disc herniation	retired
P(7)	female	0.25	Lumbar intervertebral disc herniation, bulging; Spinal canal stenosis	retired
P(8)	female	10	Chronic lumbar muscle strain	algorithm engineer
P(9)	male	2	Spinal canal stenosis	foreign enterprise staff
P(10)	male	25	Spinal sequence instability; Lumbar intervertebral disc prolapse	doctor
P(11)	male	7	Chronic lumbar muscle strain	salesperson
P(12)	female	10	Lumbar curvature straightens	office worker
P(13)	female	20	Chronic lumbar muscle strain; Spinal sequence instability	office worker
P(14)	female	0.5	Chronic lumbar muscle strain; Spinal sequence instability	graphic designer
P(15)	female	41	Lumbar intervertebral disc herniation	retired
P(16)	male	4	Lumbar olisthe	researcher
P(17)	female	0.42	Spinal canal stenosis	retired
P(18)	female	8	Scoliosis; Lumbar intervertebral disc bulging	retired
P(19)	female	20	Lumbar intervertebral disc herniation	civil servant
P(20)	male	3	Lumbar intervertebral disc herniation; Chronic lumbar muscle strain	state-owned enterprise employee
P(21)	male	3	mild lumbar intervertebral disc herniation; Lumbar disc bulging	civil servant
P(22)	male	2	Chronic lumbar muscle strain	public institution employee

Table.2 Extracted category and sub-category from content analysis of the date
Category	Sub-category	Codes
Cognition of CBP	Predisposing factors of CBP	Weight bearing
		Accidental sprain
		Improper posture or position
		Fatigue
		Lack of exercise
		Pregnancy
		Coughing or sneezing
	The perception on CBP	Related to aging
		Related to work
		Lack of care for their bodies
		Recurrent
		Protracted
		Unlikely to be cured
Impact of CBP	Physical functioning	Self-care ability
		Weight-bearing
		Upright
		Walking
		Flexibility
		Bending
		Turning over
		Squatting
		Sitting
		Lying
		Standing up
		Keeping a single body position
		Movement
		Exercise
		Defecation
		Sleeping
	Social functioning	Social,recreational,and leisure activities
		Family roles
		Work status
	Emotional functioning	Low self-efficacy
		Worried
		Anxious
		Depressed
		Irritable
		Fearful
		Affects how you feel about your image
Therapeutic perspective	Views on drug therapy	Not to the point of taking painkillers
		The drug effects limited
		Don't want to take painkillers
	Surgical views	Unwilling to receive surgical treatment
		Not to the point of surgery
		Surgery is a last resort
	Massage views	A conservative therapy
		Dredging acupoints
		Relaxing muscles and promoting blood circulation
		Improving lumbar curvature
		Relieve pain,discomfort and stiffness
		Relax muscles
		Improve sleep
		Certain therapeutic effect
		Brings a comfortable and relaxed experience
	Treatment expectations	Relieve pain and discomfort
		Prolong the onset cycle
		Shorten the course of the disease
		Reduce the frequency of treatment
		Cure
		Recovery of physical functioning
		The ability to walk
		Do not interfere with work
		Improve the quality of life
Factors hindering access to treatment	Time factor	Treatment and waiting time
		Long distance to hospital
		High treatment frequency
	Disease characteristics	Do not know which department to visit
	Disease characteristics	Limited movement
Coping with CBP	Coping attitude	Actively receive treatment
	Coping attitude	Neglect and accept it
	Coping strategy	Seeking medical help
		Self-management
		Tolerance

No competing interests reported.

Appendix.docx

A Qualitative Study on the Experiences of Patients with Chronic Low Back Pain in China

Status:

Version 1

Abstract

Introduction

Methods

Data analysis

Results

Discussion

1. Core Characteristics of Illness Experience in Chinese CBP Patients

2). Specificity of Multidimensional Impact

2. Integrative Value of Tuina Therapy in CBP Management

2). Multistage Intervention Pathway

3. Constructing a Patient-Centered Tuina Treatment Model: From Demand to Practice

4). Research Strengths and Limitations

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1