Living with pain: Experiences, hopes and expectations when going through lumbar spinal fusion - A qualitative study

Abstract

Introduction

Lumbar spinal fusion (LSF) is a common surgical treatment for chronic low back pain (CLBP), yet evidence of its effectiveness compared with conservative care remains inconclusive. While pain is the primary clinical indication, psychosocial factors, including hopes and expectations, may influence outcomes. However, little is known about how individuals experience life with CLBP before surgery or what they hope to regain after LSF.

Objective

To explore patients’ experiences with CLBP prior to LSF and their hopes and expectations for life after surgery.

Methods

A qualitative, exploratory study using semi-structured preoperative interviews and analysed using Clarke and Braun’s thematic analysis.

Results

Fourteen patients (11 women, 3 men) scheduled for LSF participated. Three themes captured how participants experience pain as overwhelming, impacting cognition, emotion, and daily functioning, alongside loss of identity and autonomy, leading to social withdrawal and reduced belonging. Despite these challenges, participants expressed strong hopes, often more prominent than concrete expectations, to regain agency, connection, and meaning in work and family life.

Conclusion

Living with CLBP prior to LSF involves major negative disruptions to identity, agency, and social relationships. Patients’ hopes extend beyond pain relief toward reclaiming life, highlighting the need for holistic, patient-centred rehabilitation.

Introduction

Low back pain (LBP) is the most common cause of disability in the world and can affect people of all ages (Hartvigsen et al., 2018; World Health Organisation, 2023). According to the WHO, approximately 619 million people experienced LBP in 2020, and this number is estimated to reach 843 million people by 2050 (Ferreira et al., 2023). In many cases, LBP can impact a patient’s mobility and function, leading to psychological and social consequences, affecting work capacity and independence (Vlaeyen et al., 2018). Conservative treatment, such as physical exercise, patient education, and activity modification, is the first-line approach for managing LBP; however, if conservative treatment fails and clinical symptoms correspond with radiological findings, surgical intervention may be indicated (Bydon et al., 2014; National Institute for Health & Care Excellence NICE, 2016).

Lumbar spinal fusion (LSF) is a surgical technique stabilising two or more adjacent vertebrae in the lower spine to relieve the patient from pain and thereby increase their functional level (Mobbs et al., 2015). The most common indications for performing LSF are spinal degeneration, including disc degeneration, spondylolisthesis, and spinal stenosis (Foley et al., 2003; Greenwood et al., 2019; Rathbone et al., 2023). Despite its widespread use, current evidence suggests no significant difference in effectiveness between LSF and structured rehabilitation programs incorporating cognitive-behavioural therapy, for managing LBP (Bydon et al., 2014; Mirza & Deyo, 2007). Consequently, increasing attention has been directed towards factors beyond the surgical procedure itself that may influence treatment outcomes.

The efficacy of LSF may not solely depend on the surgery, but also on individual psycho-social factors (Abbott et al., 2010). Psychological factors, particularly fear, have been shown to significantly influence surgical results, as higher levels of fear are linked to increased pain, depression, and greater functional impairment after surgery (Archer et al., 2014). Also, patients’ pre-surgery perception of their general health and level of motivation appears to be associated with surgical outcomes, as patients holding a positive view of their health and maintaining high expectations are more likely to experience satisfying results following surgery (Yee et al., 2008). Finally, it appears that hope may shape the perception of pain and support individuals in managing reduced pain-related physical and mental capacity, as hopeful individuals tend to focus more on their abilities than on their limitations (Or et al., 2021; Snyder & Harvey, 1998). These insights may be applicable in a surgical context, as patients’ psychological orientation may influence how they interpret and cope with pain and limitations both pre- and post-surgery.

Traditionally, outcomes following LSF have been evaluated using measures such as pain intensity, physical function, and return to work. While these outcomes are important, qualitative research on chronic pain suggests that living with persistent pain affects more than physical functioning alone (Froud et al., 2014). Individuals with chronic pain frequently describe disruptions in identity, social participation, valued life roles, and perceptions of the future (Froud et al., 2014; Rossen et al., 2021). Chronic pain may challenge continuity between past and present selves and contribute to feelings of social disconnection and loss of meaning (Rossen et al., 2021; Snyder & Harvey, 1998). These dimensions are not easily captured through conventional outcome measures but may be central to how patients understand recovery and surgical success. Despite their potential relevance for individuals considering LSF, such experiences remain insufficiently explored in this context.

Although psychological and social factors appear to influence outcomes following LSF, little is known about how patients awaiting surgery experience living with chronic low back pain and the outcomes they hope to achieve. Because experiences such as hope, expectations, identity and social participation are subjective and shaped by personal meaning, qualitative methods are particularly suited to exploring these phenomena in depth and to capturing aspects of recovery that may not be reflected in traditional outcome measures alone (Oranga & Matere, 2023). Therefore, a qualitative study using semi-structured interviews was conducted to explore patients’ experiences with CLBP prior to LSF, as well as their hopes and expectations for life after surgery.

Methods

Design

This study employed a qualitative, exploratory-interpretative design utilising semi-structured interviews. Individual semi-structured interviews were chosen to gain insights into personal expectations and hopes for the future following LSF. Reporting of this study follows the Standards for Reporting Qualitative Research (SRQR) (O’Brien et al., 2014).

Research team

The research team consisted of five healthcare professionals, all authors of this manuscript, with backgrounds in physiotherapy and nursing, with varying levels of qualitative research experience. MA (physiotherapist and first author) conducted all interviews as the primary interviewer, while X2 (research physiotherapist) and X3 (physiotherapist) participated as secondary interviewers/observers. The study was guided by a subtle realist position (Hammersley, 1992). Hence, participants’ experiences were treated as real and meaningful while acknowledging that our own professional and social background influenced our understanding and interpretation of data (Finlay, 2002). All members of the research team had clinical experience working with chronic pain and spinal disorder patients, which may have influenced how we collected and interpretated data.

Study participants and setting

A purposive sampling method (Ayton et al., 2023) was used in the recruitment (regarding age and sex) to ensure a comprehensive view of the participants’ experiences, hopes and expectations. Participants were eligible if they were undergoing surgery at Copenhagen Spine Research Unit, Centre for Rheumatology and Spine Diseases, Rigshospitalet, and fulfilled the following criteria:

• 1)A planned LSF within 2−3 weeks
• 2) ≥18 years of age
• 3)Sufficient proficiency in spoken and written Danish to participate in an individual interview
• 4)LBP and/or leg pain for ≥ three months

Patients were initially screened for eligibility by a spinal surgeon based solely on the predefined inclusion criteria. Subsequently, the surgeon’s secretary contacted eligible patients to enquire whether they were open to being approached regarding participation in the study. If the patients expressed interest, they were contacted by telephone by MA, who provided detailed information about the study. Patients who agreed to participate received written information and a consent form via email. Once informed consent was obtained, an interview was scheduled.

The final sample size was guided by information power, assessed through ongoing evaluation of variation, depth, and relevance of the interview data in relation to the study aim (Malterud et al., 2016). Recruitment continued until the interviews provided sufficient depth and variation to address the study aim and no substantially new perspectives emerged during the analytic discussions.

The local Research Ethics Committee provided written confirmation that, in accordance with Danish legislation, the study did not require ethical approval because of its qualitative design and because it did not involve the collection of biological material or any invasive procedures (Journal No. F-25002949) (The Capital Region, 2026). Handling of data was approved by the Danish Data Protection Agency (p-2023-14925).

Data collection

An interview guide was developed collaboratively by all authors and included semi-structured questions aimed at exploring patients’ experiences, hopes and expectations prior to LSF. While acknowledging that pain often dominates both patients’ narratives and clinical decision-making, the guide was deliberately designed to emphasise deeper insights into patients’ emotional, social, and psychological dimensions of living with pain, including their hopes and expectations for life after surgery. The complete interview guide is available in Appendix A.

The semi-structured interviews were conducted from November 2023 to May 2024, after pre-consultation with the participants’ treating surgeon and before their planned LSF. Interviews were conducted according to participants’ preferences, by telephone, online, or in person, to ensure comfort and facilitate open dialogue. Participants were informed that the interviewers were not involved in their clinical treatment. The interviews varied in duration, ranging from 18 to 120 minutes (mean 37 min.).

MA served as the primary interviewer, while either HT or MHK acted as the secondary interviewer and observer, ensuring the presence of two researchers at each interview. During phone or online interviews, the interviewers participated from the same meeting room using speakerphone. This setup facilitated immediate post-interview reflexive discussions concerning interpretations and initial analysis of data.

One pilot interview was conducted to test the interview guide. As only minor adjustments were required and the interview generated data of sufficient relevance and depth to address the study aim, it was included in the final analysis. All interviews were recorded on a digital voice recorder.

Data analysis

All interviews were initially transcribed using AI Transcription software (Viceron ApS, XX), followed by manual refinement and anonymisation. All participants were assigned pseudonyms. The transcripts were then reviewed, coded, and organised using NVivo qualitative data analysis software (QSR NVivo v20.6.1.1137).

Braun and Clarke’s six-phase Thematic Analysis was selected for data analysis due to its flexibility and applicability across various epistemological positions, including respect for the participants’ voice, and the researchers’ role as interpreters (Braun & Clarke, 2006). We identified themes and codes at a descriptive, semantic level to maintain the clarity and authenticity of the participants’ voices. Themes and codes were discussed within the author group to reflect on potential influences of preunderstandings and interpretations on the analysis. Selected quotations were translated from Danish into English with initial assistance from Microsoft Copilot. The translations were subsequently reviewed and refined by the research team to ensure that the original meaning, context, and emotional nuances were preserved. To emphasise the trustworthiness and confirmability of our process, a timeline of research activities was maintained (See Appendix B and Table 1).

Table 1.

Each phase of the thematic analysis related to the analysis.

Phase 1	The authors, X1, X2, and X3, read and edited the transcription from Viceron to ensure complete alignment with the audio recordings.
Phase 2:	X1 coded all datasets using NVivo. As the coding of the interviews progressed, an increasing number of codes were developed. A thorough review of the previous interviews was conducted to determine whether further data could be included in the new codes.
Phase 3:	X1 and X3 reviewed the data and codes and subsequently developed the initial themes. The initial themes were discussed in the entire research group.
Phase 4:	X1 reviewed the initial themes of the entire dataset to ensure they accurately reflected the data and aligned with the aim of the study. This process led to the development of new themes.
Phase 5:	The reviewed themes were refined and defined by X1 and X3, resulting in the identification of three main themes and six subthemes. A thematic map (Figure 1) illustrates each theme and subtheme.
Phase 6:	Descriptive and interpretive narrative texts of each theme were formulated, discussed, and refined after discussions with the entire research group. Findings from the analysis were contextualised to existing theory and former research.

Results

A total of 24 patients were invited to participate in this qualitative study, and 14 participants were interviewed, and their interviews analysed (See flowchart, Appendix C). Three interviews were conducted at the hospital, one at the participant’s home, and 10 over the phone. The final study population consisted of a mixed group regarding age, sex and occupation (Table 2).

Table 2.

Participant characteristics (N = 14).

	N (%)
Sex
Female	11 (79)
Prior spine surgery
Yes	8 (57)
Time with pain
≤1 year	3 (21)
2−5 years	6 (43)
≥6 years	5 (36)
Occupation
Working or student	2 (14)
Sick leave	2 (14)
Early retirement/Incapacity benefit	2 (14)
Retirement	6 (43)
Part-time employed	2 (14)
Age group
40−60	6 (43)
61−80	8 (57)

By following the procedural phases from Clarke and Braun’s thematic analysis (Braun & Clarke, 2006), we identified three themes through the analysis: 1) When pain takes over, 2) The social cost of disconnection from everyday life, and 3) Hopes for the future. The 3 themes and 6 subthemes are illustrated in Figure 1.

Figure 1.

Themes and subthemes identified through thematic analysis.

When pain takes over

The pervasive and consuming nature of pain

Pain was a dominant experience across all participants, which caused limitations and was manifested in diverse and individual ways. The participants described the pervasive and consuming nature of pain, which over time appeared to undermine not only their physical functioning but also their sense of self and continuity in daily life, gradually becoming an essential organising factor in their everyday experience.

“When you have severe pain and this and that, it destroys and consumes all the good in your existence. (…) When you’re battling pain 24/7, it’s all-consuming. It overwhelms your thoughts and occupies every aspect of your life.” (Jacob, 40−60 yrs)

Rather than representing a symptom alone, chronic pain appeared to shape how participants engaged with everyday life. Participants described continuously evaluating activities, social events, and daily tasks in relation to their potential to aggravate pain, resulting in heightened vigilance, avoidance, and withdrawal from previously valued aspects of life.

Loss of identity and inner disorientation

Several participants expressed how pain had become the main focus of conversation, often being the first topic raised, and thereby an unwanted part of their identity, making it difficult for the participants to be recognised for who they were beyond their condition.

“Sometimes it can be challenging because people often ask, ‘How’s your back?’ and things like that. But I make a real effort not to let that be the main focus when I’m out. I just want to be myself.” (Laura, 40−60 yrs)

The challenges participants faced in their everyday lives gradually led them to withdraw from activities that once brought meaning and joy, causing a fading connection to valued aspects of their personality, like being social, energetic, or active. The emotional impact of this shift was considerable, often accompanied by feelings of sadness, frustration, and inner disorientation, which negatively affected their mood.

“I am normally, before all this started, a very social person, outgoing, active musician. Yes, (sigh) and everything that I used to enjoy has, in a way, been ruined because of these problems I’m struggling with.” (Jacob, 40−60 yrs)

These accounts describe a growing discrepancy between who the participants perceived themselves to be before the onset of pain and who they felt able to be in their current circumstances. Leaving them in an identity crisis, where the characteristics previously defining who they were, no longer fits.

The social cost of disconnection from everyday life

A feeling of loneliness and isolation

Chronic pain gradually restricted the participant's ability to engage in social and everyday activities, resulting in a growing sense of loneliness and isolation. Limitations in mobility and energy reduced opportunities to maintain relationships and participate in activities that had previously provided enjoyment, routine, and connection.

“I have friends, I typically take for long walks, but now I can’t do that either. So, in that sense, it feels quite lonely.” (Margaret, 40−60 yrs)

However, participants’ accounts suggested that the consequences extended beyond missing specific activities. One participant expressed the struggle of seeing how much had happened in her absence, creating a painful awareness of her increasing distance from everyday life.

“I find it really challenging, this sense of ‘wow, so much has happened while I’ve been away.’” (Mona, 40−60 yrs)

These experiences indicate that chronic pain affected not only social participation but also participants’ connection to valued social roles and communities. The loss of everyday interactions seemed to challenge their sense of place within family and social networks. From this perspective, loneliness was not merely a consequence of reduced activity but reflected a broader process of biographical disruption, in which chronic pain undermined previously taken-for-granted assumptions about participation, belonging, and the future.

Maintaining identity through work

For those participants of working age, the ability to return to work was highly important, not primarily due to financial necessity, but because of the significant role employment played in sustaining identity, meaning, and social relations. The workplace represented more than a site of employment; it was a space for social belonging and meaningful contribution.

“If I had to reduce my working hours that would be okay. But having colleagues is also incredibly important. And, I mean, it also provides some meaning.” (Sandra, 40−60 yrs)

Across the interviews, work represented a setting where they could express their skills, education, and former selves without being solely defined by their limitations. For some, continuing in their professional role supported a fragile but vital sense of equality and normalcy.

“To feel like I’m on the same level as everyone else, at least in some way. Even though I know that’s not entirely the case, I’m aware of that. But just being myself, with my education and professionalism, when I’m at work.” (Julia, 40−60 yrs)

In addition to identity preservation, work enabled participants to preserve a sense of relational balance, particularly within close relationships. One participant noted how returning to work would allow her to bring experiences into her life, thereby maintaining a more equal dynamic with her partner:

“That I have something to share when I get home, and that I've had a few experiences throughout my day.” (Molly, 40−60 yrs)

Despite exacerbating their symptoms, participants expressed a strong desire to remain connected to the labour market. Their accounts suggest that work functioned as a means of maintaining continuity between their former and current selves, preserving valued social roles and affirming a sense of competence, belonging, and personal worth. In this way, work appeared to serve not only an economic function but also an important role in sustaining identity and social inclusion.

Hope as a way to reclaim everyday life

To live with a tolerable amount of pain

Participants’ accounts revealed a shared hope that surgical intervention would reduce their pain to a more manageable level. Rather than expecting complete pain elimination, most participants framed success in terms of gaining relief sufficient to resume aspects of their everyday life. However, for some, particularly those who had lived with long-term and intense pain, the operation carried deeper existential significance, as a final chance to restore an acceptable life.

“Well, I guess I have pretty high expectations if you can put it that way. Because (...) for me, this is kind of the last shot I’ve got, to have a more bearable life.” (Julia, 40−60 yrs)

Many hoped for a relief from this exhausting mental vigilance that pain dictated, such as the ability to engage in activities, social events, or certain ways to move. And thereby hoping to let go of the ongoing caution and worrying.

“It’s about not always having to be cautious and just being carefree. I want to be able to stop thinking, ‘Now I have to be careful.’ That would be wonderful.” (Sara, 61−80 yrs)

Hope for pain reduction appeared to extend beyond the physical domain and was closely tied to emotional change and the regaining of agency and liveability. Thereby, participants rarely described pain relief as a goal itself; rather, it represented a way to resume life and to be more mentally and physically available to themselves and those around them.

To fully engage in life post-surgery

For most participants, family relationships represented an important source of meaning, belonging, and continuity in everyday life. However, they had not been able to fully engage in their family’s life, often because of long travel times, physical demands, or lack of energy. This inability to participate deeply in family moments caused feelings of sadness and frustration. Several participants expressed a strong desire to fully engage and take an active part in the lives of their loved ones and hoped for the surgery to give them this opportunity.

“To be able to do everything with them [the grandchildren], when they come and ask ‘Grandma, can you do this?’ and I can say, ‘Yes, NOW I can’, you know. ” (Edith, 61−80 yrs)

Participants’ narratives suggest that the impact extended beyond missed activities. Inability to engage fully in family life challenged valued roles such as grandparent, partner, or parent, contributing to disconnection and loss of purpose. Chronic pain thus appeared not only to restrict participation but also to disrupt key sources of identity and belonging. For many, hopes for surgery were linked to restoring relationships and re-engaging in everyday life rather than pain relief alone. Although the specific roles varied, the desire to regain participation in valued relationships was consistent across participants.

Discussion

This qualitative study aimed to explore patients’ experiences of pain prior to LSF, their hopes and expectations for life after surgery. The findings showed that pain was experienced as overwhelming, impacting function, cognition and emotion. Participants described a profound loss of identity and autonomy, accompanied by social withdrawal that led to isolation and diminished belonging. Despite these challenges, they expressed a strong hope, often more prominent than concrete expectations, to regain sense of agency and reestablishing belonging and meaning in their work and family lives.

The findings of this study illustrate a broader perspective of living with pain, which is consistent with the theoretical biopsychosocial model, as it considers the subjective experience of pain from both a biological, psychological and social aspect (Engel, 1977). Besides the physical aspects of pain, the participants in our study described a deepening sense of disconnection and detachment from social contexts, accompanied by a shifting perception of self. These observations resonate with earlier research, including the longitudinal study by Rossen et al. (2021) and the qualitative meta-synthesis by Froud et al. (2014). Theses study shows, similarly to our study, that people with CLBP tend to disengage from valued activities, leading to diminished social interaction and reduced opportunities for participation. However, across several qualitative studies and evidence syntheses, researchers have shown that some people with chronic musculoskeletal pain are able to sustain or reconstruct a valued sense of self despite ongoing symptoms (Grant et al., 2019; Liedberg et al., 2021; Zelčāne & Pipere, 2024). Highlighting the importance of psychological resources such as resilience, adaptive coping and acceptance, as well as social and structural factors like supportive relationships and flexible workplace arrangements, in facilitating ongoing engagement in work and daily life (Grant et al., 2019; Liedberg et al., 2021; Zelčāne & Pipere, 2024).

In this study, the psychosocial aspect was also present for participants of working age. Work emerged as a particularly salient source of identity, valued less for its financial function and more for its role in providing meaning, normalcy, and social connection. Among non-employed participants, similar functions were described in relation to other meaningful roles and everyday activities, particularly family responsibilities and participation in daily routines.

This perspective differs from findings in a previous study, where the focus lies more heavily on fear of job loss, financial instability, and stigma (Froud et al., 2014; Rossen et al., 2021). In this study, chronic pain was often associated with anxiety around disclosure, workplace disbelief, and the risk of marginalisation. The discrepancy between our findings and those of Rossen et al. (2021) and Froud et al. (2014), may be explained by differences in the study populations, including greater individual resources among our participants or the influence of Denmark’s comprehensive welfare system. Taken together, our findings suggest that, for individuals living with chronic pain and undergoing LSF, participation in work and similar activities should be recognised not only as a means of economic survival but also as a fundamental component of identity formation and social inclusion. Thereby, rehabilitation should prioritise engagement in valued social roles while supporting a timely and appropriate return to work that takes individual capacities and the risk of symptom exacerbation into account. As healthcare professionals, we need to address psychosocial aspects when supporting patients going through spine surgery, maintaining a sense of purpose, and navigating towards new or redefined identities. These findings highlight that the impact of chronic pain on identity is dynamic and shaped by both personal and contextual conditions.

As part of exploring how participants oriented themselves toward the future, we were particularly interested in how they articulated hope and expectations regarding life after surgery. According to Leung et al. (2009), expectations are grounded in perceived likelihood and prior experience, whereas hope reflects emotionally and existentially meaningful desires that may persist despite uncertainty.

Participants in this study rarely expressed expectations of complete recovery. Instead, they described hopes of regaining valued aspects of themselves related to work, family life, social participation, and identity. In this context, hope appeared to function not merely as optimism regarding pain relief, but as a way of maintaining the possibility of a meaningful future despite ongoing uncertainty about surgical outcomes. This may be particularly relevant in LSF, where participants had been informed that surgical outcomes could not be guaranteed. In line with previous research, hope may therefore be understood as an important psychological resource that supports the participants' future orientation, coping, and adaptation in the context of chronic pain (Shanahan et al., 2021). However, hope may also contribute to distress or disappointment if surgery does not restore the hoped-for level of participation or identity. As hope is associated to better physical function, lower pain intensity and less psychological distress, it may influence how rehabilitation success is interpreted (Shanahan et al., 2021).

Aligning with previous research (Corbett et al., 2007), our findings support that rehabilitation following LSF should extend beyond the restoration of physical function to encompass the emotional and psychosocial dimensions of living with CLBP. A biopsychosocial, person-centred approach that incorporates patients’ hopes and concerns regarding work, family, and social participation may therefore support both recovery and the restoration of identity and valued life roles.

Finally, our findings raise questions about whether traditional measures of LSF outcomes fully reflect the important dimensions of recovery experienced by the participants. While traditional outcomes emphasise pain reduction, function, and return to work, participants in this study described broader concerns, including regaining self-worth, restoring disrupted identities, and reconnecting with life roles and relationships. This aligns with the systematic review by Mescouto et al. (2022), who argue that despite endorsement of the biopsychosocial model, psychosocial dimensions are often reduced to individual psychological factors, neglecting broader social and existential aspects of recovery. The differences between the traditional measures and our findings emphasise the need to reconceptualise improvements post LSF by moving beyond a predominantly biomedical or narrowly psychological orientation. A holistic approach may therefore involve discussing with patients which activities, relationships, and roles they consider central to meaningful recovery, and incorporating these perspectives into goal setting and rehabilitation planning alongside traditional outcomes such as pain and physical function. Pre- and postsurgical consultations may therefore benefit from addressing not only expected functional outcomes, but also patients’ hopes, valued life roles, and concerns regarding participation after surgery, to insure a coherent and meaningful rehabilitation.

Strength and limitations

An important strength of this study was the use of investigator triangulation, by including all authors in the analysis, which helped reduce personal bias. Furthermore, a timeline of research activities was maintained to enhance the trustworthiness of the study. The trustworthiness could have been further strengthened through participant validation (Shenton, 2004), or the inclusion of a patient research partner, which might have enhanced the credibility of the findings and their alignment with participants’ experiences.

Several limitations should also be acknowledged. Some eligible patients declined participation, suggesting that those who agreed to participate may represent a more resourceful or motivated subgroup. In addition, recruitment was facilitated through spinal surgeons, which may have introduced selection bias if surgeons recruited patients who were more engaged with treatment or more positive towards surgery. The sample was characterised by a predominance of women, which may have influenced the experiences represented in the data and limits transferability to men undergoing LSF.

Furthermore, the interviews were conducted prior to surgery while patients were still experiencing pain. Some may also have felt compelled to justify their decision to undergo surgery. We tried to address this by designing the interview guide to explore the broader emotional, social, and psychological aspects of living with pain. Most interviews were conducted by telephone, limiting opportunities to observe non-verbal communication and contextual cues. However, the presence of two researchers during all interviews allowed for ongoing discussion of tone, pauses, and verbal expressions, which partly mitigated this limitation. Finally, as the study was conducted within the Danish publicly funded healthcare system, transferability to healthcare settings with different organisational structures and access to care should be considered with caution.

Conclusion

Our study demonstrates that patients experience pain as overwhelming and identity-disrupting, often leading to social isolation and loss of meaning in life. At the same time, the participants expressed strong hopes, rather than concrete expectations, of regaining identity, connection, and agency. To best support recovery after LSF, rehabilitation should therefore extend beyond physical restoration to address the psychological and social dimensions of living with chronic pain. Success should be measured holistically, encompassing restored self-understanding, meaningful relationships, and participation in everyday life.

Appendies.

Appendix A

Interview guide

Lower Back Issues Can you tell me about the problems you are experiencing with your back?	• How long have these issues been present? • What is it like living with these symptoms? (Please provide examples if possible) • What limitations do you experience as a result of your symptoms?
The Future After Back Surgery What thoughts have you had about the surgery?	• What considerations have you made about the time after your back surgery? • What do you hope to achieve with the back surgery? • When would you consider the surgery to have been successful? • What will be important for you to be able to do after the surgery—both immediately after and, for example, 3 weeks or 3 months later?
Values What is important for you to be able to do in life?	• What is important for you in relation to your back problems? • Has your back problem ever prevented you from living according to these values? (Can you elaborate?) • Do your values and your hopes for the future after surgery align? • Which valuable activities has your back problem stopped you from doing? • In relation to your values, how can progress regarding your back problem be measured? • How do you envision your life in a year? What do you dream about, and what do you fear?

Appendix B

Timeline of Activities

This article documents the systematic progression and key milestones achieved in the development of a bachelor’s project that transitioned into a research project. Key activities, including interviews, theoretical discussions, and analysis phases, are highlighted to showcase the organised and methodical approach adopted by the project team.

October 2023

• 24 ^th October: MA, HT, and MHK started a protocol, and a project plan was conducted. Further, the qualitative research stance was discussed.

November 2023

• 10 ^th November: Discussion of the content in the interview guide in the research group

• 14 ^th November: Pilot interview/interview 1 conducted by MA and MHK.

• 16 ^th November: MA and MHK conducted Interview 2.

• 17 ^th November: MA and MHK completed Interview 3.

• 18 ^th November - 11 ^th December: Transcription and coding of interviews by MA and MHK

December 2023

• 12 ^th December: MA, HT, and MHK reviewed codes and developed themes derived from Interviews 1–3.

January 2024

• 11 ^th January: Presentation of codes and themes in the research group, including MA, HT, MHK, and JC.

March 2024

• 22 ^nd March: MA, HT, and MHK planned and delegated tasks for the next phase.

• 23 ^rd March—15 ^th April: Initial contact with further participants was made and interviews were scheduled.

April to May 2024

• 16 ^th April–8 ^th May: MA, HT, and MHK conducted Interviews 4–14, and the interviews were transcribed.

May 2024

• 23 ^rd May: MA and HT created a comprehensive timeline for the project.

June 2024

• 13 ^th June: Familiarisation with data from Interviews 4–8. Codes and themes were revisited and refined.

• 20 ^th June: Familiarisation with Interviews 10–14 was completed. Plans for NVIVO analysis were draughted, and responsibilities for the first analysis were allocated

July 2024

• 16 ^th July: Familiarisation with Interview 9 by MA and HT.

• 17 ^th July: Introduction to NVIVO software for data analysis.

• 22 ^nd July: Preparation of a presentation for the research group’s status meeting.

August 2024

• 5 ^th August: A status meeting involving MA, HT, MHK, JC, and BAE was held. Preliminary results, methods, and interview processes were presented. Theoretical and analytical approaches were discussed, and the next steps were planned.

• 12 ^th August: MA continued Phase 2 of the analysis, focusing on generating coding.

• 28 ^th August: MA and HT reviewed and discussed preliminary codes in Phase 3 of the analysis and discussed themes.

September 2024

• 9 ^th September: MA began Phase 4, focusing on reviewing themes from the data.

October 2024

• 7 ^th October: MA and HT planned the draughting and structure of the research article.

• 25 ^th October: Symposium presentation draft was prepared by MA and HT.

November 2024

• 11 ^th November: In Phase 5, MA and HT evaluated themes and quotations. The background and methodology sections were revised.

• 13 ^th November - 11 ^th April (2025): Revisions to the results section were completed, including a re-evaluation of supporting quotations.

May 2025

• 12 ^th May—2 ^nd August: MA and HT manuscript writing

July 2025

• 3 ^rd July: MA and HT met to review and evaluate the results section and discussed which elements might be relevant to include in the discussion.

August 2025

• 5 ^th August: MA began collecting theoretical perspectives to support the findings and draughting the discussion section.

• 29 ^th August: A status meeting was held between MA and HT, during which the discussion section was reviewed and evaluated.

September 2025

• 16 ^th September: MA and HT reviewed the discussion section.

October 2025

• 10 ^th October: MA review the whole article before sending it to be reviewed by HT, MHK, JC, and BAE.

November 2025

• 16^th November - 19^th December: MA review the article and included the relevant comments from the other authors, before sending it to a final review within the author group

Appendix C

Flowchart of participation

Funding Statement

This work was supported by the Lundbeck Foundation, The Capital Regions Research Fund, The Danish Rheumatism Association (A82279), and The Research Foundation of the Danish Physiotherapists.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

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