There were no differences in sociodemographic and clinical data between participants with and without missing values. In total, 171 participants agreed to participate in the study. Nineteen participants were excluded as they did not fulfil the selection criteria or had missing values for question 17 (Figure 1). A total of 152 responses were included for data analysis. Seventy-three percent (73%) of the study population was female, 98.7% were Chinese nationals and most came from South Central China (51.3%), which is also the second most populated region (39) . Fifteen percent indicated that they experienced LBP every day and the mean (SD) pain intensity was 3.9 (1.5) on a 10-point numeric rating scale. Additional participant characteristics are presented in Table 1.
Table 1. Participant characteristics (n=152)
Age (years)
Median (IQR)
Sex (% female)
Nationality (%)
Chinese
Dutch
Region
South Central China (28.4% of total population)
East China (29.5% of total population)
North China (12.5% of total population)
Southwest China (14.5% of total population)
Northeast China (7.7% of total population)
Northwest China (7.4 % of total population)
Other
|
29.0 (24.0 - 40.8)
73.0%
98.7%
1.3%
51.3%
21.1%
15.1%
7.9%
3.9%
0.0%
0.7%
|
Years since the first episode of LBP*
Median (IQR)
LBP everyday (% yes)
LBP present now (% yes)
Pain intensity* (if LBP present now)
Mean (SD) on 10-point numeric rating scale
Pain medication use in history (% yes)
Comorbidities (e.g., cardiovascular diseases, arthritis)
% yes
|
3.0 (0.2 - 6.0)
15.1%
44.1%
3.9 (1.5)
5.9%
17.1%
|
Work/school absenteeism due to LBP (% yes)
Duration of absenteeism* (Days)
Median (IQR)
LBP impacts daily life (% yes)
|
17.1%
14.0 (7.0 - 32.5)
36.8%
|
Years since the first episode of LBP* (11 missing values); Pain intensity* (1 missing value); Duration of the absenteeism* (5 missing values).
What is your perception of why your low back pain is persistent or recurrent?
Five discourses were identified. Most participants answered this question with one or two sentences, and their responses were assigned into one or more of the identified discourses. The initial agreement between YJL and WSP was 90%, and all discrepancies were resolved through discussion. An overview of the five discourses is presented in Table 2 and below.
Table 2. Discourses identified from the answers to the question “What causes your persistent or recurrent LBP”.
Discourses (Thinking Patterns) and n (%)
|
Explanation
|
Examples
|
LBP as biomedical problem.
N = 101 (66.4%)
|
LBP is explained by incorrect postures, damage, degeneration or weakness of neuromusculoskeletal structures. Pain is produced or provoked because something is biomedically wrong in the body.
|
Participant 20: “Pelvic tilt anteriorly, lacking strength in abdominal muscles with hypertonic erector spinae muscles, thorax vertebrae kyphosis, slight scoliosis, flat foot problem and gait problem”
|
LBP as unbalanced lifestyle.
N = 74 (48.7%)
|
LBP as a warning sign, or consequence, of an unbalanced lifestyle. A metaphorical individualised “balance scale” about the amount of exercise, sitting, standing, walking time or load.
|
Participant 21: “… Doing too much or too little exercise? ...”
Participant 58: “Unregular daily routine …”
|
LBP is about menstruation and ‘kidney’ status.
N = 14 (9.2%)
|
In Chinese culture, menstruation is important to women’s overall health while ‘kidney function’ is vital to men’s. Women during menstruation are generally believed vulnerable and emotionally unstable while men who have poor kidney function, are believed to have low sexual performance.
|
Participant 21: “ShenKui (kidney deficiency) ...”
Participant 37: “Because of menstruation”
|
LBP is about the ‘Five Elements’ imbalance.
N = 12 (7.9%)
|
There are ‘Five Elements’ in Chinese medicine: Water, Fire, Wood, Metal and Earth. It is considered important to keep the balance between these elements to maintain good health. Climate conditions such as wind, heat, dampness, dryness and cold are represented separately by wood, fire, earth, metal and water. It is thought that climate conditions can ‘invade’ the body and cause an imbalance in the Five Elements.
|
Participant 38: “… after staying in cold water for several hours, my back pain suddenly occurred”
Participant 61: “Accumulation of Wind, Damp”
Participant 114: “… and drinking too little water will cause my recurrent low back pain”
|
LBP is about energy status.
N = 9 (5.9%)
|
Thinking low or disturbed energy status is a cause of LBP. In traditional Chinese medicine a low (disturbed) mental energy status can be caused by, or causes a possible ‘Qi’ stagnation, resulting in muscle pain. ‘Qi’ understood as a ‘matter-energy’ or ‘vital force’, connects physical and mental energies in individuals.
|
Participant 10: “JingShen status is not optimal”
‘Jing’ means essence while ‘Shen’ means ‘Mind’. ‘JingShen’ status can be understood as mental energy status.
Participant 70: “… also because of life stress and fatigue caused by work”
|
Participant’s response can be coded into one or more of the five discourses.
Discourse 1: LBP as a biomedical problem
‘LBP as a biomedical problem’ was the most prevalent discourse. Two-thirds of the responses were underpinned by this discourse. Participants explained their persistent or recurrent LBP by physical damages, incorrect posture, muscle imbalance and congenital issues. Their responses indicated that they considered their body in an anatomical, biomechanical and/or physiological way. Their underlying belief seemed to be that if there was something wrong biomedically in their back (body) that this would produce or provoke pain. For instance, some discussed physical damages as the cause of their ongoing LBP, such as Participant 16, who wrote: “I had an injury during long jump in secondary school and I didn't pay attention to it. So, I probably got LaoSun (muscle strain) for a prolonged period”. ‘LaoSun’ is a common Chinese term which means overuse of muscles that can lead to muscle strain and injury (40). Participant 72 wrote:
Probably because of continuous stimuli, and I didn't get the right diagnosis and treatment for my low back injury. In the beginning, I had an injury in another part of the body which caused poor posture during running. Later on, this led to unequal left and right muscle strength which compressed and pushed out my vertebra.
Like a number of other participants, Participant 106 also discussed posture, attributing their LBP persistence or recurrence to “Lower-crossed syndrome, anterior tilt of my pelvic causes incorrect posture during standing”. And participant 157 wrote: “…Working posture is not correct”.
Also underpinned by biomedical discourses, one participant indicated congenital issues as the source of their LBP. Participant 98 wrote: “I had an X-ray, the doctor said there is a deformation in my bone, my family members also have hereditary low back problems”.
Discourse 2: LBP as unbalanced lifestyle
‘LBP as unbalanced lifestyle’ was the second most commonly reported discourse. Around half of participants’ answers were identified to fit within this discourse. LBP was described as a warning symptom or the result of an unbalanced lifestyle. A figurative individualised ‘balance scale’ that considers exercise, sitting, standing, walking time or load, could be identified from the responses. For instance, Participant 5 wrote: “I don’t perform enough exercise and physical activities, I sit for a long time” and Participant 21 thought the cause could be “Doing too much or too little exercise?”.
Often, ‘LBP as unbalanced lifestyle’ seemed to be related to the first discourse ‘LBP as a biomedical problem’. For example, a quote selected from the response of Participant 59:
I think it’s because I’m not exercising regularly. When I do go to gym, I will definitely train my lower back muscles with the back-extension equipment. The problem is, I should have gone more frequently than I usually do.
First, this participant pointed out the importance of balanced lifestyle (exercising regularly). They then related the lack of exercise to the idea that back muscles should be trained specifically (indicating a biomechanical view of LBP). The participant then reinforced the importance of a balanced lifestyle by adding “I should have gone more frequently (to the gym) than I usually do”. One response related to unbalanced lifestyle based on traditional Chinese beliefs regarding pregnancy: “I didn't take care of my low back during ZuoYueZi (postpartum care)” (Participant 143). This answer related to traditional Chinese health beliefs. ZuoYueZi is a part of Chinese custom that intends to improve health after pregnancy (41). After delivery, it is strongly recommended that the mother takes particular actions such limiting movement, eating special food and not washing her hair (41). Also, family members are an important part of ZouYueZi, providing social support to the mother, such as doing housework and taking care of the baby (41).
Discourse 3: LBP is about menstruation and ‘kidney’ status
‘LBP is about menstruation and kidney status’ was the third identified discourse. Approximately, 9% of the responses appeared from this discourse. In Chinese culture, menstruation is important to women while ‘kidney function’ is vital to men. To a certain extent, menstrual function and ‘kidney function’ reflect reproductive health. The understanding of ‘kidney function’ in Chinese medicine is fundamentally different to Western medicine (42). In traditional Chinese medicine, the kidney is not be considered as a real organ but as a symbol that controls reproductive health (34) and causes LBP when the kidney is deficient (34).
As is evident in this quote from Participant 50, “Because of menstruation, I have LBP 2 days before menstruation, but I don’t know the reasons behind it”, several participants considered menstruation to be the cause (or one of the causes) of their LBP. Further, Participant 28 wrote, “LBP appears before menstruation” and Participant 37 responded, “Because of menstruation”. One male participant indicated “ShenKui” was a reason for his LBP. ‘Shen’ means Kidney while ‘Kui’ means deficiency (43). In China, women are generally believed vulnerable and emotionally unstable during menstruation (44), whereas men who have ShenKui are believed to have low sexual performance (43). Psychosocial stresses in this discourse may be relevant to the LBP reported by participants.
Discourse 4: LBP is about the ‘Five Elements’ imbalance
The discourse ‘LBP is about Five Elements imbalance’ was only occasionally mentioned (7.9%) but was identifiable from the responses. Related to the balance of Yin and Yang, there are ‘Five Elements’ in Chinese medicine: Water, Fire, Wood, Metal and Earth (34). There is a self-regulating balance within the five elements. For example, Water balances Fire, but Fire produces Earth that balances Water in return. In traditional Chinese medicine it is considered important to encourage this self-regulating balance to maintain good health. Water is considered to be the foundation of the other Elements (34). This appears to be the discourse underpinning Participant 114’s response “Drinking too little water will cause it (LBP) to recur”.
The Five Elements can represent different seasons, directions, colours, tastes and climates (34). For example, spring, summer, autumn and winter are represented by wood, fire, metal and water, respectively (34). Climates such as wind, heat, dampness, dryness and cold are represented separately by wood, fire, earth, metal and water, respectively. The self-regulating balance can be disturbed by exterior invasion of cold, wind and dampness which is believed to cause LBP (34). Also, external cold can affect ‘kidney function’ when it invades the low back region, which often happens to modern women due to exposure of lower abdominals and loins in modern fashion (34). Thus, participant’s answers related to climates (e.g., “Probably suffer from cold” - Participant 9), and seasonal change (e.g., “…Pain will certainly occur during autumn-winter seasonal rotation and spring-autumn seasonal rotation, mainly because of climates…” - Participant 41) were considered to be underpinned by this ‘Five Elements’ discourse.
Discourse 5: LBP is about energy status
The least common discourse (5.9%) was based on ‘LBP is about energy status’. In traditional Chinese medicine, ‘Qi’, understood as a ‘matter-energy’ or ‘vital force’, connects physical and mental energies in individuals (34). Qi should circulate freely inside the body and also flow in and out the body in a healthy situation (34). A low (disturbed) energy status can be caused by, or causes, ‘Qi’ stagnation, resulting in muscle pain (34). Answers related to low energy status were considered to draw from this discourse. For example, Participant 10 responded, “…JingShen status is not optimal”. ‘Jing’ means ‘essence’ while ‘Shen’ means ‘mind’. ‘JingShen’ status can be understood as energy status. Also, answers indicating a disturbed energy status, caused by stress or mental fatigue, were underpinned by this discourse. For example, Participant 70 wrote, “…also because of life stress and fatigue caused by work”.
Where does the perception come from?
Most participants selected only one of the five options and did not provide additional sources as ‘other’ options. Almost two thirds indicated that their perception of what causes their LBP to become persistent or recurrent came from healthcare professionals (n=90, 59.2%). The options ‘internet’ (n=37; 24.3%), ‘family’ (n=35; 23.0%) and ‘friends’ (n=25; 16.4%)) were also frequently listed. ‘Religion’ 0 (0%) was not indicated as an information source. Originally, the option ‘other’ was selected by 30 participants. However, two answers overlapped with the option ‘healthcare professionals’, and were moved from the option ‘other’ and into the option ‘healthcare professionals’. In total, twenty-eight participants (18.4%) selected the option ‘other’. One of these reported two information sources and another reported three. Under the option ‘other’, most reported some sort of self-reflection (n=24, 15.8%) as information source. Others indicated previous medical related education (n=2, 13.2%), scientific literature (n=1, 0.7%), and TV programmes (n=1, 0.7%) as information sources. Three participants (2.0%) provided unclear answers. For example, Participant 19 answered “my personal experience” and Participant 37 wrote “daily observation”. An overview of responses for this question are provided in Table 3.
Table 3. Information sources identified from the answers to the question “Where does your perception come from?”.
Source of beliefs
|
n (%)
|
Healthcare professionals
|
90 (59.2%)
|
Internet
|
37 (24.3%)
|
Family
|
35 (23.0%)
|
Friends
|
25 (16.4%)
|
Religion
|
0 (0%)
|
Other
- Self-reflection
- Education
- Scientific literature
- TV programme
- Unclear answers
|
Total*: 28 (18.4%)
24 (15.8%)
2 (1.3%)
1 (0.7%)
1 (0.7%)
3 (2.0%)
|
* Under the option ‘Other’, one participant reported two information sources and another one reported three.