INTRODUCTION

With the rise in the reported cases of low back pain (LBP), an increasing number of patients are opting for surgery, especially those whose pain is not relieved by nonsurgical treatment alone or continues to worsen [1,2]. Surgical treatment reduces pain and improves activities in daily life [3], but the number of patients with persistent or recurring pain after surgery is also increasing despite anatomically successful surgery [1-6]. Pain after surgery has various causes, including psychological problems, and progression of degenerative changes [1,2,7] Patients with pain after back surgery experience a lower health-related quality of life and an even higher severity of pain compared with other forms of chronic pain [6]. Therefore, postoperative pain management is applied, ranging from conservative to invasive treatment [1,2]. In South Korea, traditional Korean medicine, such as acupuncture, electroacupuncture Electroacupuncture (EA), bee venom acupuncture, herbal medicine, Chuna manual therapy, and moxibustion, is used for various pain conditions, including Low Back Pain (LBP) [8-11].

The experience of individual patients needs to be explored in depth to shed light on the influence of pain on patients and their coping behaviors, thoughts, or beliefs about treatment, as well as the meaning of the experience. However, qualitative studies that understand personal experiences of pain and treatment in patients after back surgery are insufficient. One qualitative study nested within a rehabilitation trial described the influential factors for the decision to have surgery, expectations for optimal recovery and satisfaction after surgery in patients who had lum- bar spine surgery [12]. The other qualitative study in patients undergoing spinal surgery described the patients' experiences and perceptions of the health care system [13]. There are several qualitative studies regarding acupuncture for LBP [14-17], but there have been few qualitative studies of EA treatment for LBP or back pain after surgery. Therefore, the aim of this qualitative study is to describe the meaning of personal experiences and perceptions of treatment through a traditional Korean medicine clinical trial in patients with pain after back surgery.

METHODS

1. Study Design

This study is a qualitative study using qualitative content analysis. Qualitative content analysis is the flexible approach for analyzing datas and the ability to extract manifest and latent content meaning. Thus, qualitative content analysis is commonly used to interpret textual data through the systematic process of coding and to identify themes [18].

2. Participants Selection

This qualitative research is nested within a multi-center, randomized, assessor-blinded trial of EA treatment with usual care in patients with non-acute pain after back surgery [19]. Among participants who had LBP that persisted or recurred after back surgery with the current pain episode continuing for 3 weeks or longer in the treatment group, 20 participants were voluntarily enrolled in this qualitative research. Participants received a total of 8 sessions of EA treatment with usual care for 4 weeks. Interviews were conducted after the 4-week treatment period.

3. Researcher Characteristics and Reflexivity

Among three experts in qualitative research method, two were PhDs and one was a doctoral student in nursing. Three researchers constructed research questions and interview questions through related previous qualitative studies [16,17], and discussions with Korean medicine doctors Korean Medicine Doctors (KMDs), to best identify the participants' experiences with the research topics. Researchers shared and discussed their own notes during data collection and analysis to minimize the preconceived notion of the research phenomenon throughout the entire research process.

4. Data Collection

Data were collected from August to November 2016 through one-on-one, in-depth interviews by 3 experts in qualitative research. The interview was carried out with the consideration of the participants' convenience. All twenty participants in the study participated in the interview to the end, and the interview was audio-recorded. For each interview, one qualitative research expert conducted one interview at a time individually, and each expert interviewed six to eight individuals. The main interview question was "Please talk about your experience of pain after back surgery," followed up with additional questions. Additional questions were used as necessary to further clarify the conversation or to facilitate the interview. Examples include, 'What efforts have you made to relieve your pain after surgery?', and 'What do you think was the most effective treatment during the treatment period?'. Interviews were conducted at the hospital conference room where participants felt comfortable and convenient. Each interview lasted for one to two hours. During the interview, the researchers participated as an active listener and made notes on the participants' responses and important clues or meanings to be used for further analysis. If the participants no longer talked about something new, or if the same concept was found repeatedly in analysis, we ended the collection of data, deciding that there was data saturation.

5. Data Analysis

Data were analyzed manually by coding them in accordance with the qualitative content analysis that derives themes inductively from data [18]. All of the three researchers who conducted the interviews had participated in the overall process of data analysis. The researchers immediately transcribed the interview data verbatim. We repeatedly read the data line by line to achieve data immersion and coded meaningful words, phrases, sentences, and paragraphs revealed in the data. After each of the three researchers shared their respective compiled codes, they used a constant comparison analysis to generate concepts, sub-categories, categories and to identify relationships by repeating the discussion until a consensus was reached by the researchers. We grouped similar codes as we compared their similarities and differences, naming sub-categories with increased generalization. Finally, sub-categories were classified into categories with increased abstractness and generalization. Our experiences were shared in the process of collecting and analyzing the data.

6. Ethical Consideration

This study was approved by institutional review board Institutional Review Board (IRB) at each hospital (Pusan National University Korean Medicine Hospital (IRB approval no. 2016003), Kyung Hee University Oriental Medicine Hospital at Gangdong (IRB approval no. KHNMC OH 2015-10-002), and Jaseng Hospital of Korean Medicine (IRB approval no. KNJSIRB2016-025)). The researchers did not have any relationship with patients in advance. We explained the research objectives, data collection method, and privacy protection to the participants and then obtained their written informed consent. We clarified that they could withdraw participation voluntarily at any time and guaranteed confidentiality and anonymity of patients. The collected data were managed by identification codes to protect the privacy and anonymity of the patients. Financial compensation was provided to participants as an ethical consideration.

7. Study Trustworthiness

Criteria regarding credibility, fittingness, auditability, and confirmability were applied to ensure validity of this study [20]. To establish the credibility of this study, we interviewed the participants on their experiences until the point of data saturation. The interviews were recorded in their entirety and transcribed with verbatim. We verified the accuracy of transcribed data by listening to the recoded data. After the interviews, the storyline for each participant was described, and the overview and characteristics of their experiences were summarized. Theoretical sensitivity was promoted by using interview questions, taking notes on site, and comparatively analyzing the data. For fittingness, purposive samples were collected as diversely as possible in terms of demographic characteristics and disease. To ensure auditability, the qualitative content analysis procedures were faithfully applied in the process of collecting and analyzing data. One participant was asked to read the results of the study to confirm that the research result described the participants' experiences based on interview data. The research team included three experts who participated in the interview, data coding and analysis. For confirmability, researchers’ prejudice was thus minimized in the entire research process. Each researcher attended to the study neutrally; we discussed emerging issues sufficiently and then interpreted the study results accordingly. The study was conducted according to COREQ [21].

RESULTS

Among Twenty participants (10 male and 10 female), two in their twenties, eight in their thirties, four in their forties, three in their fifties, and three in their sixties. Seven participants were single, twelve were married, and one was divorced. Fifteen participants were college graduates or higher, four were high school graduates, and one was an elementary school graduate. Seventeen participants had a previous experience in traditional Korean medicine, whereas three did not (Table 1).

Participants have had to live with pain after back surgery. The participants experienced both physical and psychological suffering due to the pain. They made efforts to overcome the pain while facing inconveniences in many aspects of their lives. Table 2 shows the generation of 4 categories, 11 sub-categories and 58 concepts.

1. Pain that became a life burden despite surgery

1) Surgery that I wanted to avoid

The participants wanted to avoid undergoing surgery because of its physical and psychological burden but chose to get surgery after facing no alternatives. Most of them were anxious about the negative responses of others toward surgery and the predicted side effects from surgery. Some of them tried to forget their pain by drinking, whereas others held out through non-surgical treatment to avoid surgery. However, as time passed, the pain worsened, compelling them to seek surgery at the end. Some participants chose to undergo surgery thinking that it would be better than experiencing extreme pain. One participant made the decision because she felt pressured by the fact, she was not properly performing her role as a mother and housewife.

I was scared to go to the doctor by myself without my husband. (omitted) When I talk about getting surgery, the first thing out of people’s mouth is, “Don’t get surgery; it will ruin your back.”(Participant 17)

2) Pain that lasts after surgery

The participants suffered from pain that lasted after surgery. Their attention was fully on pain instead of on their life, which changed the importance of the different aspects in their life. They were frustrated and helpless, without a specific alternative for relieving pain. Pain was constantly on their minds, always putting them on edge. The participants perceived pain as "something that must be endured", "a problem that is solved after time", "a problem without a solution", or "something that must be overcome on my own". Some of them blamed themselves for the cause of pain, saying that it was because of their carelessness in daily life after surgery.

The doctor said it would take about a year. But a year has passed and it’s still not getting better, so I’m so frustrated that I’d have to suffer my whole life. (Participant 8)

The participants mostly experienced limited physical motion owing to stiff muscles, as well as increased muscle tension around the pain site. Even as time passed, they could not hold the same posture for a long time because of the pain, especially the standing position. One of them experienced sleeping disturbance due to the difficulty maintaining the same position, waking up multiple times at night. Some were taking medicine to relieve the pain. The pain was sensitive to daily cycles or weather changes; it was severe when patients woke up in the morning, or in the afternoon, or on a cloudy day or before rain.

I couldn’t stand still after the surgery. I would shuffle my feet because my back hurt if I stood still. I would move a few steps to the right and then a few to the left like this [motioning]. (Participant 17)

3) Obstacles in daily life

The severity of pain after surgery was decreased compared with before surgery, but it continued to hinder daily life. The participants said that the things they could do were limited if their back pain occurred. They used the painless body parts to avoid pain, and this tendency led to a muscle imbalance and difficulty in maintaining an upright position. The stiffness and weakening of back muscles resulted in secondary health problems. It was also difficult for the participants to bend their waist forward, making it difficult for them to wash their hair or take a shower. They needed to do some stretching before taking a shower. Indeed, showering became a time-consuming and energy-intensive task given the struggle to be careful. They also reported having a hard time enduring pain whenever they used public transportation or drove a long distance to their places of work or to receive outpatient treatment.

It’s fine when I’m lying down, but I can’t stand up and walk. If I unfold my legs like this [motioning], they feel numb… So, I can’t walk, and I mostly sit or lie around at home… This way it doesn’t hurt. (Participant 10)

Whenever the participants did something repeatedly that would place a load on the back, their symptoms would end up becoming worse. They spared themselves because they could not predict or handle the deterioration of symptoms. Being careful not to put a burden on the back became their preventive measure. They considered the actions or movements that might affect their back, and then they applied ways to work while protecting the back. Others spent as little time as possible shopping, which involved walking around and being in a standing position for a long time; thus, they avoided unnecessary shopping altogether. Some female participants shared housework with their family and took a break after completing a certain amount of housework.

The first thing I think about whenever starting something is how to do it while avoiding back pain. I go on with it if that’s possible, but give up if it’s not, which is why I give up on so many things. (Participant 1)

4) Difficulty in working life

Most participants were office workers or job seekers. They were passive about finding jobs owing to the fear of pain; some reported having to change jobs and others had to give up on a good job offer. Their work efficiency decreased because they could not concentrate, and they felt uncomfortable about having to be careful or awkward around colleagues. Some of them had to ask their colleagues for understanding when they had to do something that causes back pain.

I can’t imagine getting a job. I can’t sit still in meetings at work, and if my bowels don’t behave, it would stink. (Participant 8)

2. Pain that causes depression

1) Lethargy

The participants lacked enthusiasm and lost confidence because of their back pain. They were resentful about the disease and even became so pessimistic about their life. They thought that there was no point in living. One participant experienced helplessness so deeply that she would give anything not to feel pain for even an hour.

I usually don’t get annoyed or irritated, but that day, I was so frustrated. I was really annoyed about why I had to live like this. I studied so hard in the United States, got all my degrees, and now all I have to do is work and get married, and why did this happen to me? I was suddenly hit by these emotions that night (close to tears). (Participant 3)

2) Passive human relations

The participants avoided going out and maintained distant human relations with others to avoid getting hurt from any misunderstanding or discomfort. Whenever they met with friends or attended a party, they could not sit in one position for a long time and thus had to leave early; sometimes they attended only the important part of the gathering, because they thought their condition caused inconvenience to their friends or other people present.

When I meet my friends, after about an hour I start to squirm, and I have to go home. I keep squirming because it hurts even as I drink my coffee. My friends would feel uncomfortable, and so would I. (Participant 1)

The participants mostly stayed at home by themselves. They did not want to be self-conscious and were tired of dealing with people in such uncomfortable situations, so they refused to have friends visit them as well.

When it really hurts, I don’t let people come to my house. I lock myself in my room, which made my depression get worse. (Participant 13)

3. Pain that makes me look for various treatments

1) Finding treatment information

Participants wanted to control the pain for a comfortable daily life like others had. They were enthusiastic about treatment because leaving the pain as is would only make it worse; they were willing to take on a financial burden to relieve the pain. They were engaged in an information search and hospital shopping related to the treatment of back pain through various channels: the internet, the media, and their acquaintances. Any source on any treatment captured the attention of the participants.

Getting better is more important than money right now, so I’m willing to spend more money on treatment. (Participant 4)

The participants wanted to receive any form of treatments consistently. They moved between conventional treatment and traditional Korean medicine for pain treatment or chose hospitals based on size. Some of them trusted the medical staff in university hospitals and preferred to receive treatment there. They felt comforted by the fact that they were not giving up on hope for treatment by receiving treatment. They mostly pursued rehabilitation exercise and traditional Korean medicine, perceiving a difference in the experience of effect even from the same type of treatment.

I think it’s about mindset. The disease is in my mind, so now that I received treatment, wouldn’t it get better? You know, it’s hope. It’s better than just staying at home. (Participant 2)

2) Receipt of rehabilitation exercise

The discharge education after surgery that the participants received merely provided guidelines to relax and perform some exercises. The participants did not have any idea what exercise they needed to do. They performed just a few exercises, referring to the exercise manual they had received at the hospital. However, it was not helpful.

I think it would be better if the specialized medical personnel teach us what to do at first and then guides us through individualized exercises. (Participant 4)

The participants wanted guidance from the experts so that out of many exercises they could determine which ones suit them, and with the adequate time, intensity, and number of repetitions. A few participants performed exercises with the help of personal trainers at a fitness center and carried out hospital shopping for rehabilitation exercise. However, these exercises could not last long because of the financial burden on the participants and showed low satisfaction owing to a difference in effects depending on intensity or duration.

I keep using the same muscles over and over; so, I should check regularly with the experts and do the exercises as they say so that I can keep my physical balance. (Participant 15)

3) Participation in a clinical trial of traditional Korean medicine

The participants joined a clinical trial of traditional Korean medicine, as if they were clutching at straws in a situation in which their pain management method was not satisfactory. There were those who had had a positive experience of traditional Korean medicine, whereas others were receiving such treatment for the first time. The ones who received EA treatment for the first time through the clinical trial had an initial mistrust of the treatment effects but later provided positive feedback after experiencing the effects of EA treatment. Most considered traditional Korean medicine to have limited side effects and thought that the effects would appear after long-term treatment.

At first, I was a little scared. I had a fear of getting acupuncture on the parts where my back hurt and was even more scared of electrical stimulation. Would EA treatment really control pain? Well, I was amazed that it did. (Participant 6)

Most participants felt their bodies became lighter and refreshed, and they found the pain was reduced with EA treatment. The participants who experienced the effects of EA treatment wanted to keep receiving treatment even after the clinical trial. They were so positive about the effect that they felt it was worth recommending to others as well. Even as they received the traditional Korean medicine, they emphasized the importance of receiving appropriate treatment for them. However, others regarded EA treatment as an adjuvant therapy. In addition, other participants hoped to be free from pain as soon as possible by receiving both conventional treatment and traditional Korean medicine, as each of them has distinct benefits.

I came here to get EA treatment when the pain was about 60 [as measured by visual analog scale Visual Analog Scale (VAS) pain intensity score], but, now, it’s much better. (Participant 10)

The clinical trial provided an integrated treatment of EA treatment, physical therapy, and a standardized educational program on LBP. However, most participants were disappointed the educational program because they expected to receive individualized exercise through the program. Participants said that repeated exercise was important for them so they could perform it on their own without forgetting what they learned. Several the participants had extensive knowledge on exercises because of their hospital shopping before surgery.

They gave us a brochure, but it was more like just leaving us to do whatever we can on our own. I came here thinking that rehabilitation exercise is led by specialized medical personnel who actually shows what to do at the hospital. I looked at the educational program on the brochure, and all the exercises in there are the ones I already knew from visiting countless hospitals for over 10 years. I know all that because I spent tens of millions of won on exercise and all. (Participant 9)

The participants felt that the KMDs whom they met in the clinical trial related to and comforted them. When the participants asked questions, the KMDs provided explanations that were easy to understand; the KMDs also treated the patients kindly, making them feel relaxed as they underwent treatment. Thus, the participants had more trust in the KMDs.

I’m talking about my pain, right? And the KMDs would even exaggerate on some of the things that can be empathized with me that even my parents won’t. It wasn’t too much or anything; I actually liked that. The sincere response was relaxing and pleasant. (Participant 5)

4. Pain that makes me try

1) Daily care of the body

The participants consciously practiced the exercises and corrected their posture in daily life. They mostly performed stretching, walking, swimming, and exercises that strengthened their back muscles, and as well as movements to straighten their backs when sitting down on a chair. However, they started to become lazy once the symptoms were alleviated and then returned to trying hard again when the symptoms were reoccurred; this pattern was difficult for them to overcome.

I helped at a friend’s store for about four hours. I did some exercises then, holding my legs up like this as I stand, and during the 3~40 minutes going back and forth. I searched online for exercises that I actually tried in real life, which improved my symptoms a lot. (Participant 17)

They also showed good sense by using assistive devices that helped them through the day and alleviated the need to bend their waist forward. They mostly made the devices themselves or based on the ideas of their families.

At home, there are many objects that enable me to do things, [such as] standing up. There’s a long object made of hangers, which I just whip like this [motioning]. When I take out the laundry, for example, you must bend down or stoop, right? But I have a long stick with a hook at the front, which I use to pull out the laundry. (Participant 9)

2) Perception of the importance of prevention

The participants realized the importance of prevention and mentioned the need to educate the proper postures for adolescents or adults. One participant personally promoted stretching and upright positions to others based on experience but stated that the role of specialized medical personnel is important, as they can maximize the public relations effect. Moreover, the participants said there was a need for attention and for the policy support of public medical institutions, such as nearby public health centers.

Children are often in stiff or improper postures, which can’t be fixed after childhood. If public health centers in each neighborhood make it obligatory in a system to teach these simple things like stretching, … (Participant 9)

DISCUSSION

The experience of pain is extremely personal and subjective; thus, for effective pain management, it is important to understand deeply and describe the meaning of personal experiences and perceptions of treatment in patients with pain after back surgery. Pain was a burden in life and a major source of depression for these patients. Nonetheless, they searched for and applied various treatments to control the pain and realized the importance of its management in their daily life.

Some patients experience persistent or recurrent pain and disability after back surgery or show no change in the severity of pain before and after surgery [1,2]. Pain after back surgery may be caused by various postoperative factors such as degenerative changes in the areas of the spine and increased tension from adjacent muscles [7]. According to a systematic review, a higher level of pre-operative pain affected outcomes after lumbar disc surgery [22]. Therefore, the approach to these patients should be considered before surgery and applied from before to after surgery.

The participants in this study chose surgery as a last resort; however, unlike their expectations regarding surgery that pain would disappear after surgery, the pain continued and hindered their daily and working life. Some participants were passive about finding jobs or had to give up on a good job offer. In addition, because patients cannot predict the extent of the deterioration of their symptoms after surgery, they begin to display depressive symptoms. One study has shown that LBP patients with the experience of surgery had worse pain and depression than did patients with non-specific chronic back pain [23]. Therefore, medical personnel must focus on depression in these patients, which can include lethargy and diminished interpersonal relations, as well as the pain itself.

Spinal surgeons tend to think that the problems of their patients are solved through surgery [24]; however, some patients still undergo persistent or recurrent pain after back surgery. The gap in the perception of pain between doctors and patients motivated the latter to seek other treatment options by themselves. This also indicates that patients with pain after back surgery failed to reach the trajectory of patients with chronic diseases, thereby repeating the process of finding and applying treatment themselves. Patients with pain after back surgery were in a blind spot within medical care and needed constant attention and support of medical personnel. According to qualitative studies of patients undergoing lumbar spine surgery, providing the patients with appropriate information in a timely manner [13] and increasing patient engagement in postoperative management [12] is important.

In this study, the patients preferred non-surgical treatments such as exercise, physical therapy, and traditional Korean medicine, in consideration of the safety of the treatments. The participants in this study evaluated the empathetic attitudes of the medical personnel positively. A previous qualitative study on chronic LBP in older adults emphasized the importance of empathy and patient-centered care [25]. The patients also demanded customized selfmanagement so that they could control pain themselves in daily life. However, standardized exercise provided by this clinical trial did not satisfy the patients’ needs. One qualitative study of patients undergoing spinal surgery emphasized the need to provide care in consideration of the individual needs and preferences of each patient rather than the 'one size fits all' approach [13]. In addition, the participants realized the importance of prevention and the need for adolescents or adults to correct their postures for this reason. Therefore, the attention and policy support of public medical institutions, such as nearby public health centers, are needed for the prevention and management of LBP.

The findings of this study indicate that an integrative management program needs to be developed to consider the physical or psychological problems and treatment experiences of patients who undergo back surgery. In addition, such a program needs to be developed using a multidisciplinary approach that includes psychological counseling, pain management, individualized exercise, and education for proper posture to prevent and manage pain after back surgery. A limitation of this study is that it was conducted with only a part of the treatment group of patients participating in the multi-center randomized clinical trial; this may limit the external validity of our findings.

CONCLUSION

In conclusion, an integrative management, including physical and psychosocial interventions, is needed to relieve pain in patients with pain after back surgery. Specifically, it is necessary to have a customized program for pain management, counseling and education, and exercise through a multidisciplinary approach based on the experience of patients who undergo the surgical procedure. Also, future studies should be conducted to evaluate the effectiveness of integrated interventions through a multidisciplinary approach.