An Integrated Multidisciplinary Rehabilitation Program Experienced by Patients with Chronic Low Back Pain

Abstract

Purpose: To examine how an integrated, multidisciplinary rehabilitation program was experienced by patients with chronic low back pain and to gain insight into how these patients integrated knowledge, skills, and behaviors obtained by the program into their everyday lives.

Materials and Methods: A phenomenological hermeneutic design using Ricoeur’s interpretation theory was used in the analysis. Data were generated through nine semi-structured interviews in patients with chronic low back pain. The study adhered to the Consolidated criteria for reporting qualitative research (COREQ) checklist.

Results: Standardized rehabilitation efforts adapted to individual needs and provided by a highly professional healthcare team in a combination of inpatient stay and home-based activities was experienced as beneficial, because the patients were able to integrate the obtained knowledge, skills, and behaviors into their everyday lives.

Conclusions: The findings revealed that the multidisciplinary holistic approach led to higher bodily awareness, greater mental health, and increased social interaction, which improved happiness and quality of life among the patients. This study emphasizes and highlights a rehabilitation approach that promotes home-based activities to provide a base for co-creation across professions regarding rehabilitation initiatives for patients with chronic low back pain.

Low back pain (LBP) is a common health condition worldwide and is heterogeneous in etiology as well as in severity, duration, and prognosis.¹ Although LBP is a very prevalent health condition, often no clear pathological explanation or cause can be identified.^1-3 An estimated 10%– 15% of individuals with LBP develop chronic low back pain (CLBP), and this group of individuals comprises the greatest burden of disease and disability in the health care system.^4,5 CLBP often causes severe pain and disability, decrease in social ability, mental and psychological disorders, and increased participation restrictions.^1,6 Furthermore, it often generates both high medical and socio-economic costs.^4,6 CLBP is multifactorial, therefore consideration of these factors is important for patient-centered care.^5,7 A rehabilitation approach in a biopsychosocial perspective based on individual needs and disabilities is, therefore, considered relevant and necessary in the treatment of patients with CLBP.^5,8-11 A Cochrane review showed that multidisciplinary rehabilitation programs are more effective than usual-care and physical treatment in decreasing pain and disability in patients with CLBP.⁵ Likewise, the review found that a coordinated multidisciplinary rehabilitation program covering several biopsychosocial domains was more likely to provide long-term benefit to patients with CLBP than usual care.⁵ Furthermore, research shows that to adapt and integrate rehabilitation efforts, these must be designed and adjusted to fit individual preferences, circumstances, and functioning in patients with CLBP.¹²

Even though research has provided a wide range of knowledge on CLBP and multidisciplinary rehabilitation, there is a lack of evidence on the benefits patients with CLBP can obtain by continuously integrating knowledge, skills, and behaviors gained from multidisciplinary rehabilitation into their everyday lives. Therefore, an integrated, multidisciplinary rehabilitation program (integrated program) was developed for patients with CLBP and was compared with an existing rehabilitation program in a highly specialized Danish rheumatic rehabilitation center for patients with joint, back, and muscle disorders.¹³ The integrated program consisted of a combination of inpatient and home-based activities, and a key element was whether patients with CLBP optimize functioning as a result of the obtained knowledge, skills, and behaviors from the program.¹³ We, therefore, examined how this integrated program was experienced by patients with CLBP, and how these patients could integrate the obtained knowledge, skills, and behaviors into their everyday lives.

Methods

Setting and Participants

Data were generated in the form of nine semi-structured interviews conducted in January and February 2019.¹⁴ The participants invited were 12 patients with CLBP, recruited from a highly specialized Danish rheumatic rehabilitation center. Eleven of the invited patients completed the program during 2018, and one patient completed it in 2019 (Figure 1). All 12 former patients were invited by email by the second author to participate in an individual interview, and nine of them agreed to attend. Subsequently, the first author contacted the participants by phone and arranged the interviews. The interviews were either conducted in the participants’ private home, at the rehabilitation center, or at a public café. All interviews had a duration of 45-60 minutes. Characteristics of the participants are presented in Table 1.

Figure 1.

Illustration of the integrated multidisciplinary rehabilitation program. The integrated rehabilitation program consisted of (1) a pre-admission day, (2) 2 weeks of home-based activities, (3) 2 weeks of inpatient program, (4) 4 weeks of home-based activities, (5) 2 days of inpatient program, (6) 6 weeks of home-based activities, (7) 2 days of inpatient program, and (8) 26-week follow-up.¹³

Table 1.

Characteristics of the study participants

Participant	Gender	Age group (y)	Occupational status	Time from 26-week follow-up to the interview
1	F	50–59	Full time employed	0–30 days
2	F	40–49	Retired	3–4 months
3	F	30–39	Unemployed	4–5 months
4	F	70–79	Retired	0–10 days
5	M	40–49	Part time employed	0–10 days
6	F	70–79	Retired	4–5 months
7	F	60–69	Retired	3–4 months
8	F	50–59	Part time employed	4–5 months
9	M	30–39	Full time employed	3–4 months

Prior to the interviews, a semi-structured interview guide was developed.¹⁴ In addition, the first author did a 3-day participant observational study at the rehabilitation center to obtain insight and knowledge into the context in which the integrated program took place.¹⁵ Clinical observation of the program helped to generate content for the semi-structured interview.¹⁵

We included the patients’ perspectives as an important part of the research process to provide a unique aspect of direct knowledge and experience of the integrated program.¹⁶ Therefore, a former patient who had participated in the integrated program during 2018 was invited to join the study as a research partner and co-author (the third author) to support and improve the quality and transparency of patient and public involvement.¹⁷ The Guidance for Reporting Involvement of Patients and the Public (GRIPP) 2 checklist was used to report the patient and public involvement¹⁷ (Table 2).

Table 2.

Patient and public involvement of the present study¹⁷

	PPI–GRIPP 2 short form
Section and topic	Item
Aim	To include patients’ perspectives throughout the research process in order to provide a unique aspect of direct knowledge about their experience with the integrated programme.
Methods	A former patient was invited to engage as a research partner in order to support and improve the quality and transparency of patient and public involvement.
	This patient has lived experiences with chronic low back pain and had recently participated in the integrated multidisciplinary rehabilitation programme.
	The patient was included from start and throughout the whole study period and participated in three out of four of the study meetings held by the authors and was included in e-mail correspondences.
	Aspects of involvement:
	Aim
	Method
	Analysis
	Discussion
Study results	The recruitment process was enriched and qualified in cooperation with this patient. With her help the invitation and information letters were revised and adjusted from the patient perspective, which helped design and qualify the invitations.
	The patient took part in the study analysis, which nuanced and broadened the perspectives and understandings of the unfolded meaning units and themes.
	Throughout the analysing process all authors discussed and were aware of personal pre-understandings, experiences and opinions regarding the integrated programme.
Reflections / Critical perspective	The public involvement is seen as a strength, because it reflects the diversity of the perspectives among the authors.

Methods

The research design was qualitative and based on Ricoeur’s phenomenological-hermeneutic interpretation theory.¹⁸ A description of these experiences of the phenomena formed the basis for interpretation.^14,18 By applying this methodology, we obtained knowledge of the patients’ subjective experiences of the integrated program, which was solely based on the patients’ life experiences.^14,18 Based on this, it was relevant to capture and explore subjective lived experiences from an open-minded approach, as in phenomenology, by letting the phenomenon manifest itself in the lifeworld in which it unfolds.¹⁹ Hence, to establish an understanding and interpretation of the text through a dialectic movement between explanation and comprehension—between the parts and the whole—the hermeneutic circle.^18,20,21 Thus, through the in-depth analysis and interpretations, the findings moved from a subjective individual level towards a universal level that included how the participants experienced the integrated program and how they managed to integrate the obtained knowledge, skills, and behaviors into their everyday lives.¹⁸

Data Analysis

Data analysis was based on nine semi-structured interviews, all of which were transcribed by the first author and uploaded into NVivo^TM22. The transcripts were not returned to the participants for comments, and no repeat interviews were conducted. The text analysis was conducted by following Ricoeur’s phenomenological-hermeneutic text interpretation theory.¹⁸ This methodology included a dialectic process of three analytical levels: an overall naïve understanding, a structural analysis, and a critical analysis and discussion.¹⁸ To validate the analysis, all four authors worked together on one interview. As a result, an overall understanding of the text unfolded, and opinion and meaning units from the text transformed into a concurrent understanding among the four authors. Subsequently, a structural analysis was conducted where a deeper interpretation of opinion and meaning units unfolded through a dialectic movement between explanation and comprehension—from the parts to the whole and the whole to the parts.¹⁸ We thoroughly analyzed and interpreted data with regard to ‘What was being said’ and ‘What was being spoken of’.¹⁸ This led to an overall understanding of the data material and into coding themes and subthemes based on both empirical findings and meaning condensation.^18,23 Moreover, the coding and structural analysis led to a dialectical process involving an in-depth interpretation, which led to main and subthemes.^18,23

The dialectic movement between explanation and comprehension continued in the critical analysis and discussion, where the relevant literature was included in relation to the findings presented.¹⁸ The findings were discussed continuously among all four authors to reach the most valid interpretations. Figure 2 demonstrates the interpretation process.^24,25 In addition, the study adhered to the Consolidated Criteria for Reporting Qualitative research (COREQ) checklist.²⁶

Figure 2.

The hermemeneutical understanding and interpretation of this study, illustrated as a constant movement between understanding and interpretation.²⁵

Ethical Considerations

This study followed the data protection guidelines from the Danish Data Protection Agency.²⁷ According to the Central Denmark Region Committees on Biomedical Research Ethics, the project was not liable to notification in accordance with Comitology Law §14, no. 2.²⁸ Participants in the study were invited by email, and if they were willing to participate, they were informed verbally and in writing. Subsequently, the participants signed an informed consent statement allowing data generation and registry of their personal data. Participants were ensured anonymity and the possibility to withdraw their consent at any time.

Results

The findings represent an understanding of the patients’ experiences of the integrated program and their ability to integrate knowledge, skills, and behaviors obtained by the program into their everyday lives. The naïve reading unfolded in a spontaneous impression of the participants’ experiences, and in light of this, an overall impression was compiled as a narrative (Table 3).

Table 3.

Narrative presentation of key findings based on the naïve reading of all interviews

I am 50-years-old, and last year I participated in an integrated rehabilitation program for people with chronic low back pain. The program consisted of inpatient as well as home-based activities. Overall, it was a nice place to stay, and the staff were absolutely wonderful.

I was assigned to a specific team of healthcare professionals, and this was very meaningful. My physical therapist concentrated on my functioning, and I was given exercises specifically tailored for me. In the sessions with my occupational therapist, I learned things about my body posture and how I should use my body in different positions during daily activities. Further, I learned the importance of taking breaks and relaxing during tasks.

Another aspect was the focus on my mental condition. I had conversations with a nurse, who really made me open up and talk about my inner thoughts and feelings. This was really important and beneficial for me, because I got to know myself much better. These insights have had a positive effect on my life today.

It was nice to be able to go home between the inpatient stays. Even though some of the other patients wanted to stay longer – as in the existing program. But for me this was nice and suited my family situation a lot better. I was even able to come back and get adjustments, ask questions, and experience check-ups.

The fact that the efforts were based on my personal needs made it easier to use most of the knowledge at home, even though I sometimes could not manage to. I felt involved in the process, and I could relate to the different exercises and ways of doing things, and that felt meaningful.

I also built a great relation with my fellow patients, which made my stay more social and interesting. We talked and discussed many things and gained inspiration from one another.

The inpatient program was a bit too loose to my liking, and I would have preferred more physical training and time with my therapist instead of all the time we had on our own. This was also something we patients disagreed on, because others thought the program was way too intensive, so I guess it’s a matter of different opinions and tastes.

Structural Analysis

Based on the structural analysis, three main themes and appertaining subthemes emerged (Table 4). The analysis uncovered experiences of a multidisciplinary approach: the ability to adapt, adjust and integrate efforts into everyday life and a holistic approach.

Table 4.

Main themes and subthemes^*

Main themes	Subthemes
A multidisciplinary approach	Professional expertise
	Combined efforts
To adapt, adjust and integrate	Ensuring transition
	Everyday life
A holistic approach	Bodily awareness
	Mental insights
	Social interaction

^*Based on the structural analysis related to how the patients experienced the integrated rehabilitation program and how they managed to integrate the obtained knowledge, skills, and behaviours into their everyday lives.

A Multidisciplinary Approach

Professional expertise

The integrated program implied that each patient was assigned a multidisciplinary team of healthcare professionals (HCP). All patients expressed satisfaction with their teams and experienced a high level of professionalism among the HCPs. All patients attended therapy with a physiotherapist. This approach ensured specially adapted exercises that were tailored to improve the patients’ functioning and well-being and organized to fit individual needs to integrate the exercises into their everyday lives. During the integrated program, the physiotherapist continuously adjusted the individual exercises in cooperation with each patient. Most of the patients described how this contributed to a higher level of functioning and mobility and only one patient did not experience any improvement in pain or improved functioning.

Patient no. 2: After the first week, I walked down the stairs with my suitcase in my hand… It was a change from 0 to 100… I could climb the stairs without problems.’

The sessions with the occupational therapist involved knowledge on activity and participation level and ensured focus on individual limitations within the patients’ everyday lives. Furthermore, factors such as household aids, body posture advice, and the importance of breaks were discussed and recommended.

Patient no. 6: ‘Well I realized that I actually could do more if I used my body in a different way.’

Furthermore, each patient had continuous sessions with either a psychologist or nurse with coaching expertise. These conversations were of personal character, and several patients experienced a convivial rapport and an empathic approach. This ensured openness regarding mental and emotional health issues and enabled remarkable personal insights, awareness, and recognition.

Patient no. 5: ‘I was able to look into myself and figure out who I was before and who am I now, despite all the things I have been through, and that has given me a lot.’

Overall, the patients found the multidisciplinary HCPs to be very welcoming, helpful, qualified, and easy to talk to, and they got the impression of being seen, heard, and understood. Thus, most patients experienced an improved functioning based on the range of multidisciplinary efforts.

However, there were various opinions on the content and structure of the integrated program regarding whether it was experienced as too compressed or too loose. Some patients would have preferred more physical activity, whereas others described the program as being too intense, which contributed to their inability to maintain attention, and therefore, they were not able to benefit from or appreciate the efforts.

Combined efforts

The combination of the multidisciplinary HCPs and their different expertise was considered of great value.

Patient no. 5: It was the combination of everything that was great and that you were associated with all groups of HCPs and it was just lovely and super.’

The patients felt comfortable because they always met the same HCPs and experienced transparency throughout the integrated program.

Patient no. 8: I thought it was nice. It was the same people you talked to. I did not have to constantly repeat myself and they knew exactly what you were talking about and they remembered it from time to time.’

Based on the multidisciplinary approach, the patients’ experienced coherent and meaningful efforts, and further, the patients described how this led to higher functioning and increased activity and participation skills. However, some patients did not find it meaningful with some of the elements in the program, like mindfulness. Likewise, the fact that the hot water pool was not working was a disappointment for several patients.

To Adapt, Adjust, and Integrate

Ensuring transition

The patients experienced a relevant transition from the inpatient efforts to their everyday lives, which was aided by ongoing check-ups with their multidisciplinary HCPs. That the integrated program was a combination of both inpatient and home-based activities enabled the patients to receive feedback and adjustments throughout the program.

Patient no. 3: ‘They were good at evaluating along the way, and they were good at talking to me about what to improve and how to work towards the goals I had.’

However, a few patients had the experience that the number of inpatient days in the integrated program were too few. Furthermore, they found the existing rehabilitation program of 4 inpatient weeks would have been more effective and rewarding for them.

Patient no. 4: ‘I was sad that I only got 3 weeks because I am absolutely sure I could have obtained much more out of 4 weeks. I might have been able to reach a completely different level and obtained better habits and therefore reached better results.’

Some patients had a different opinion and found it very meaningful to combine the inpatient and home-based activities, partly because it was convenient and useful in their personal situation. Further, they found it motivating to be responsible for efforts conducted in their own environment.

Patient no. 9: ‘I was 100 percent motivated, the fact that I felt responsible for the agreements I had made with my HCPs. When I came back for the next stay, I was just like: ‘Bring it on’, because I had done everything we discussed and agreed on. I almost felt that I was able to fly. I had a feeling – both physically and mentally – it was a redemption and it was really nice.’

Everyday life

A key element to integrating the obtained knowledge was that each patient received individual exercises, appropriate body posture, and learned the importance of breaks based solely on individual functioning and needs.

Patient no. 9: ‘Well, they looked at my individual needs and what I thought was best, of course, in consultation with them.’

However, a few patients did not experience the ability to integrate the obtained efforts within their everyday lives. This was mainly because the efforts did not contribute to pain relief or increased functioning and were, therefore, not prioritized.

Interviewer: ‘Would you feel a difference if you performed the recommended daily exercises?’ Patient no. 4: ‘No, I really don’t think so, I really don’t.’

From a different perspective, the integrated program ensured active participation and involvement among the patients, which also had a major influence on how the patients managed to integrate the obtained knowledge, skills and behaviors into their everyday lives.

Patient no. 7: ‘I think it is important that you are involved, otherwise it is more difficult to integrate the efforts, because you probably won’t get it done.’

A Holistic Approach

Bodily awareness

The patients experienced an intense focus and professionalism regarding their individual health-related functioning. The provided individual physical exercises affected their mobility, activity, and participation level, and one patient stopped taking pain medicine. The understanding and importance of listening and acknowledging body signals and managing to act appropriately was important knowledge for the patients.

Patient no. 7: ‘I learned that I should listen more to my body, to myself. It was not the easiest task when your mind wants more than your body is capable of. But being able to listen to my body and knowing when I overused it, and then take a break and lie on the couch. Now, I’m able to do that with a much better conscience.’

The ability to listen to their bodies and the awareness of their functioning resulted in less pain, increased mobility, and released more energy. Some patients expressed it could be difficult to comply with breaks, and therefore, they did not always make use of breaks, despite their pain. Hence, taking breaks, dividing tasks, and prioritizing energy were described by the patients to ensure body relaxation and a higher functioning.

Patient no. 3: ‘I make use of breaks and it’s much easier for me to clean now. It actually allows me to do more, without being completely exhausted afterwards.’

Mental insights

Several patients found great value and relevance regarding the focus on their mental and emotional health issues. This focus gave the patients personal insights and higher self-awareness and was considered a very important aspect of their overall experience of the integrated program.

Patient no. 9: That was almost the best– the holistic part of it. It proved to be extremely important, too, to talk about difficult mental things, which can be difficult to express… it was definitely as important as the physical dimension.’

Thus, the mental and emotional part of the program made it possible to look inwardly and achieve higher awareness of inner thoughts, feelings, and their own mental health condition. In the process of learning and getting to know oneself better, an important aspect was acceptance. Several patients had learned to accept their situation and disability. The acceptance led to a feeling of relief, strength, and inner peace.

Patient no. 5: ‘After I learned to accept my situation, I was relieved, and I dared to know more about myself and show the outside world how I was really feeling.’

On the flipside, however, one patient did not experience the mental and emotional part of the program as being useful.

Patient no 4: “Listening to the other patients’ mental problems was boring… and mindfulness was not me… I didn’t enjoy it and I couldn’t follow the instructions.”

For other patients, the mental awareness enabled self-confidence, and one patient was no longer ashamed of her condition but felt more confident to stand up for herself instead. Moreover, the influence and responsibility one has on one’s own thoughts and how this affects the quality of life became obvious for the patients.

Patient no. 9: Why did you end up here, where do you go from here? Yes, you feel adversity, eh, you can help yourself and that was also an eye-opener for me, I actually do have influence on how I express my own story.’

Social interaction

The awareness of listening to your body and the mental insights gained thereby allowed patients to interact socially. Moreover, the social interactions among co-patients revealed an opportunity to share experiences and meet people in the same situation, which embraced openness and social participation on a higher level.

Patient no. 1: ‘It made a difference that we interacted so well together in the group… It gives you a feeling that there are people who want to listen to you, also you are not alone in coping with your situation and the changes in your life.’

Openness towards one’s situation and being able to take rests during activities and participation helped the patients to be more social and active in their everyday lives. The patients described how this caused happiness and positive thoughts and made it possible for them to take part in social interactions rather than be withdrawn and introverted.

Patient no. 2: ‘It means that I can be much more active… I can easily go on trips with my friends, even if we must walk a lot. So, it gives me freedom, which means I can participate on an equal level with others.’

In general, the holistic approach led to higher bodily awareness, greater mental profit and understanding, and increased social interaction, which created and embraced happiness and quality of life among the patients.

Discussion

Critical Interpretation and Discussion

Our findings suggest that the patients found the multidisciplinary approach to be of great value and very beneficial. This is consistent with previous research, which indicates that when HCPs work together and complement each other in a multidisciplinary rehabilitation setting, short- and long-term benefits of the rehabilitation process are supported, and the patients experience the efforts as more beneficial than usual care.^5,9,29 This relates well to our findings, primarily that the integrated program contained within a suitable and defined setting where the HCPs performed appropriate and targeted healthcare tasks was beneficial. In addition, research has illustrated that a high quality of patient–professional interaction supports the effects of a rehabilitation program in patients with CLBP.³⁰ This was also consistent with our findings where the patients expressed that the patient–professional relation was important, and it enabled a comfortable and confident communication platform.

Whether the integrated program ensured a greater ability to integrate knowledge, skills, and behaviors into the patients’ everyday lives could be questioned. Previous research has shown that both inpatient and outpatient rehabilitation programs may induce persistent improvements in pain, mobility, functioning, and quality of life in patients with CLBP.^31,32 Rehabilitation efforts that take individual needs and preferences into account, like the present integrated program, are more effective in patients with CLBP.^7,33 The possibility to integrate knowledge, skills, and behaviors into their everyday lives, combined with subsequent inpatient sessions, was considered relevant, rewarding, and effective by most patients. This experience is supported in that activities are influenced by the context, and consequently, efforts aiming at optimizing functioning should take place in the environment in which the activity unfolds.⁸ However, some patients did not appreciate the integrated program, partly because they found the inpatient period too short, and their ability to integrate the efforts into their everyday lives did not turn out as they expected. This diversity may be a question of individual preferences or a matter of the lack of improvement in disability and pain among the patients. Despite this diversity, the integrated program supports the recommendations within the Danish Healthcare System, where recommendations rely on rehabilitation programs to be a part of long-term treatment based on individual needs in patients with CLBP.¹⁰ Likewise, such programs must consist of specific strategies and relevant efforts suited to each patient’s future course based on environmental and personal preferences and must contain measures to prevent relapse and disability in patients with CLBP.¹⁰ This is in line with the efforts of the integrated program, which is to continue the learning and integrating process so the patients experience the ability to continue learning and integrating knowledge, skills, and behaviors into their everyday lives.

Our findings further revealed valuable insight into the importance of a holistic rehabilitation approach, and thus, the integrated program supports the values and components included in the biopsychosocial model.³⁴ The patients explained they were overwhelmingly grateful for the psychological focus in the integrated program. Research supports the value of the psychological focus in patients with CLBP, because it enables a change in pain beliefs and promotes independence, which helps to improve disability and health conditions.³⁵ Patients with CLBP who had experienced a biopsychosocial intervention in which HCPs offered personal and realistic strategies, suggestions, and focus on psychological factors believed the intervention supported a positive change in how they coped with their life situation.^36,37 Thus, previous research supports the findings of the present study by indicating that focus on psychological and social factors greatly supports the positive effects of multidisciplinary rehabilitation in patients with CLBP.³² In addition, research in patients with CLBP has shown that rehabilitation programs are more beneficial when they contain individual components dealing with health conditions, activity, and participation in a meaningful contextual matter.^5,8 This was consistent with the findings in the present study, that a combination of efforts supporting physical, personal, and environmental factors increased the experienced function and quality of life among the patients. Finally, the findings support the intention of the integrated program, which was to achieve a high degree of learning, improve rehabilitation efforts, and optimize long-term benefits in patients with CLBP.¹³

Methodological Considerations

A phenomenological-hermeneutical Ricoeur analysis approach enabled us to explore how the patients’ experienced and described the phenomena that emanated from their lived experiences.¹⁸ By using this methodological approach, we were able to embrace and interpret the patients’ lived experiences of the integrated program, which increased the validity of this study.¹⁸ This was applied by using a stringent and transparent analysis approach in which we interpreted the meaning of the parts and the whole, and through this dialectic movement between explanation and comprehension, we obtained a deeper understanding of: ‘what was being said’ and ‘what the text spoke about’.¹⁸

When conducting the interviews, it was important to achieve a respectful and empathic atmosphere characterized by safety to facilitate experiences and feelings in an open and honest way.¹⁴ The interviewer has a solid knowledge and experience with individual therapy, which promoted a safe atmosphere and supported a convivial rapport throughout the interviews and is considered a resource that contributed to increase the validity in this study.³⁸ However, it can be considered a limitation, as the interviewer could be described as a novice in a research-related interview situation.

The validity of the study was strengthened by conducting most of the interviews in the participants’ homes, which reduced a possible power imbalance between the participant and the researcher.¹⁴ This may have supported a deeper understanding of the participants’ subjective experiences, and thereby, expanded the descriptions of the phenomena.¹⁴ A higher number of participants might have contributed to a broader and more nuanced understanding of the examined phenomena. However, when analyzing the interviews, the research group was of the opinion that expansive descriptions of the phenomena emerged and were sufficiently covered in relation to the interview guide.¹⁴ The length of time from completion of the rehabilitation program to the individual interview might have constituted a limitation. This aspect addresses the uncertainty of whether the patients were equally able to recall their experiences, which may have created an imbalance in the results. However, we are of the impression that the patients were able to recall their experiences, and we, therefore, consider it a strength, as the experiences are illuminated in different time perspectives. Throughout the interview, the interviewer sought to unfold a nuanced description of the integrated program, but the findings showed that most of the patients’ statements predominated described positive experiences. These positive descriptions might be related to that these patients with CLBP were relieved to finally get help and support regarding their CLBP, and therefore, mainly were pleased with the program.

To strengthen the reliability of the study, the authors worked together on the analysis.^38,39 A separate naïve reading was conducted, after which notes were compared. Disagreements were addressed and discussed until a common consensus was reached. This triangulation made it possible to capture different dimensions of the described phenomena and, thereby, expanded and enriched the analysis, which enhanced transparency and increased the credibility and the validity of the results.³⁹ Additionally, the methodological triangulation of the observational study and individual interviews aligned multiple perspectives and led to a more comprehensive understanding of the phenomena.¹⁵ This uncovered a deeper meaning in the data and increased the validity of this study.³⁹

That this study involved a former patient (the third author) in the research process qualified and enhanced the study process. This was especially the case in relation to preparing invitations to the participants, insights regarding the integrated program, the ongoing patient perspective, and co-authorship.¹⁷ The former patient has lived experiences with CLBP and an experienced pre-understanding of the integrated program, which created an extra awareness throughout the analysis and ensured an open minded and phenomenological understanding of the experienced phenomena from the patients’ perspective.³⁹

The participants in the present study represent a heterogeneous group because of differences in age, type and severity of CLBP, and employment; however, with regard to gender, more women were represented. The patients in this study were recruited from one highly specialized rheumatic rehabilitation center in Denmark, which may affect the generalizability of the results. In spite of this, we believe the findings can apply to similar patient groups in similar healthcare settings in the Western world.

Conclusion

This study explores how an integrated rehabilitation program was experienced by patients with CLBP. The findings revealed that the multidisciplinary holistic approach was of high quality and supported how well the patients adjusted and integrated the obtained knowledge, skills, and behaviors into their everyday lives. The patients believed the knowledge obtained from the program to be very beneficial and meaningful, because they were based on individual needs and preferences and gave them the opportunity to combine an inpatient stay with home-based activities. Thus, this holistic approach led to higher bodily awareness, greater mental profit and understanding, and increased social interaction, which extended and embraced happiness and improved quality of life among the patients.