A complex problem such as chronic pain cannot be solved by a simple technique and/or passive treatment. The development of multicomponent programs adapted to the specific needs of each patient is necessary. Treatments may not be effective even if they follow the recommendations of clinical practice guidelines when based on "one size fits all".55 After functional categorization, patients will be referred to group or individual treatments. The main objective is to improve functionality and quality of life of patients with chronic pain, so that pain ceases to be the protagonist in their lives. More specific objectives are as follows:

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  To provide the necessary tools for patients to recover their healthy lifestyle based on the principles of the primary care.56

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  To demystify certain taboos about chronic pain.

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  To help patients understand the mechanisms that perpetuate the painful experience.

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  To enhance patients' self-efficacy with emphasis on their role as the active part of the treatment.

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  To improve possible somatosensory alterations.

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  To reduce and/or eliminate kinesiophobia, fear-avoidance behaviors, and catastrophizing.

For referral to the individual treatment, physical, cognitive, emotional, and/or social impairments are taken into account. When two or more domains are severely affected, the patient is referred for individual treatment. Furthermore, specific factors such as severe somatosensory disturbances (e.g. allodynia), breakthrough neuropathic pain, social phobia, significant decline in executive functionality, pre-contemplative motivational stages, and severe impairment in activities of daily living are signs and symptoms to prioritize individual treatment. Finally, the consensual decision made between the healthcare provider and the patient to participate individually or in a group will also be considered. Once the patient improves these variables with individual treatment, group treatment can be introduced. Within the individual treatments, specific therapies such as physical exercise, neuro-orthopedic manual therapy, somatosensory reeducation, graded motor imagery, virtual reality, and psychotherapy are used.

Group programs are not only a cost-effective strategy by addressing multiple patients at once, but also promote greater adherence to treatment in each participant. This approach allows patients to feel heard by interacting with equals, which facilitates mutual empathy and promotes a sense of support among the group members. It is well known that spontaneous social interactions with others and participation in social roles can generate and maintain a generalized sense of trust in others. In addition, this interaction promotes feelings of well-being, alleviating the harmful effects of stress, promoting social connectedness, and reducing sensitivity to pain.57

We have three types of group programs, which have similar objectives and therapies based on active coping strategies and functional goals. The programs vary in their frequency and type of sessions. Furthermore, for patients with severe emotional disorders, for example for those who experience severe mental trauma in the past, adding psychotherapy interventions delivered by a psychologist and/or psychiatrist should be considered. Some patients also require specific interventions and guidance for the correct use of drugs, for example, for opioid withdrawal in case of addiction.

Group programs are mainly based on Therapeutic Exercises and Pain Science Education. These therapies are the first line of treatment according to current clinical practice guidelines.18–22 The combination of these therapies has been shown to be more effective in the treatment of patients with chronic pain than when used in isolation.58,59 There are a number of other multidisciplinary therapeutic approaches such as psychotherapy, nutrition, relaxation techniques, mindfulness, sleep quality behavioural techniques, somatosensory retraining, graded motor imagery, etc., that can be offered based on patient needs.

Pain Science Education is an educational intervention that tries to reconceptualize maladaptive pain related beliefs to promote a behavioural change in patients with chronic pain. Previously known as Pain Neuroscience Education, the term has been recently updated to PSE following the consensus of the Pain Education Team to Advance Learning (PETAL). This new concept implies a bidirectional communication strategy avoiding magister classes, while enabling and empowering people toward behavioral change.60,61 PSE within a multimodal group program also promotes an increase in the cognitive-behavioral, emotional, and social abilities of the patients (increased ability to concentrate, working memory, short and long-term memory, mood, etc.).62,63 All UAAD group programs begin with PSE that is provided by a healthcare professional. It does not consist only of unidirectionally informing the patient. The aim is to provide information, pain management tools, and coping strategies that help modify patients' beliefs and attitudes towards pain, motivating them to adopt a more active and engaged role rather than a passive one. The sessions explain in depth how thoughts, beliefs, and emotions modify the painful experience and how the misinformation received can modify the pain processing mechanisms. PSE is conceived as a constant learning process, which implies daily work for patients in its own contexts using self-managing tools and information carefully provided. PSE seeks to generate learning and cognitive belief updating. Therefore, the degree of belief reconceptualization within these patients, as well as the knowledge they acquire during the sessions, must be constantly evaluated.64

Therapeutic exercise has been shown to be helpful in reducing symptoms and improving disability in different patients with chronic pain compared to no treatment or passive therapies.65,66

In the past, it was thought that physical exercise exerts its effects on pain and disability only through improvements in physical capacities (strength, muscular endurance, power, etc.). However, physical exercise can also cause changes in other dimensions, such as, the improvement of emotional state, cognitions and behaviors (reduction in catastrophizing, fear of pain, avoidance behaviors, and improvement in self-efficacy, etc.). Furthermore, at the neurophysiological level, exercise promotes hypoalgesia, increasing the efficiency of pain inhibition pathways and brain functional and structural adaptations.67,68

It is essential that patients move and engage in physical activity, not only for pain improvement, but also because of the physical deconditioning and comorbidities they often present. Multiple factors must be taken into account when prescribing exercises to patients with chronic pain compared to patients with acute pain or healthy individuals. Not all patients are ready for movement, and even in some cases, physical exercise can exacerbate symptoms. Although there are general recommendations69 for people with chronic pain (in terms of frequency, intensity, duration, and type of exercise), motivational and contextual variables should also be considered when implementing an exercise program. Fig. 2 illustrates a representative example of an exercise session conducted with patients with chronic pain.

Fig. 2.

Structure of a therapeutic exercise session, consisting of a warm-up phase, the workout, and a cool down phase.

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Many patients with chronic pain may present an exacerbation of pain during or after exercise. Psychosocial aspects such as catastrophizing and fear-avoidance seem to influence the occurrence of exercise-induced hyperalgesia, which does not manifest in the same way as it does in healthy individuals. Instead, the opposite effect, exercise-induced analgesia, may occur.70 Therefore, these psychosocial aspects need to be addressed during the PSE prior to the beginning of the exercises. Patients need to understand this possible pain exacerbation as a normal physiological process and not perceive it as harmful. For this reason, physical therapists who prescribe and lead exercise sessions must have a thorough understanding of pain neurophysiology. They also need to be aware of potential symptom exacerbations and know how to manage patients if these occur.71 Exercise progression should not only be based on a gradual increase of loads or intensity of the exercise according to the patient's physical capacities, but also on the cognitive-behavioral, emotional, and social dimensions of the patient. For example, gradual exposure to movement should be prescribed when the patient presents catastrophizing, kinesiophobia, and avoidant attitudes. Strategies such as gamification, double tasks, distraction techniques, and playful components in the sessions can help reducing fear and hypervigilance, as well as encourage social interaction.72 A key concept is that priority should be given to getting the patients to move, and not only “how” they move. Excessive correction on exercise technique can lead to increased hypervigilance and, therefore, increase the symptoms.

The following is a description of the treatment programs at UAAD and which type of patient attends each one (Fig. 1).

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  Galan program: It is designed to treat patients with low to moderate level of physical, social, emotional, and cognitive-behavioral impairment. The duration of the program is 12 weeks. In the first five weeks, there are 5 PSE sessions (1 session/week), each lasting 120 mins. From the 6th to the 12th week, 18 multicomponent exercise sessions (3 sessions/week) are performed. The exercise sessions last between 60 and 70 mins. These programs include therapeutic exercise with dual tasks, gamification, as well as relaxation and mindfulness. At the end of the program there is a final 2-hour refresher PSE session (Fig. 3).

  
  

  Fig. 3.

  An illustrative example of the organization of the 3 programs. The days of the week chosen are merely an example and can be adjusted as needed; each center should choose the organization that suits them best. The PSE sessions are marked in green. The Therapeutic Exercise sessions are marked in blue. *At the end of each program, there is a final 2-hour PSE review session.

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  An example of a patient functional profile for this program: patients with no perceived fatigue in their ADLs. The level of physical impairment is low to moderate (decrease in strength and aerobic capacity). The pain mechanisms have a mixed predominance, the pain is not disabling, and mild somatosensory alterations are present. With regards to cognitive-behavioral variables, there is no severe memory loss or deficit of cognitive abilities, but there is a tendency to have catastrophic beliefs. Emotional variables are low to moderately affected (moderate kinesiophobia, anxiety and mild depression, and there are presence of fear and avoidance behaviours for certain activities or contexts). The social context is usually favorable, which means the patient has a good network of family and friends. This patient profile is usually in the “action” phase of the transtheoretical model.49

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  Palma program: It is focused on patients with a moderate to high level of physical impairment, and low to moderate level of impairment in the other domains. The duration of the program is 14 weeks. In the first six weeks, there are 6 PSE sessions (1 session/week) lasting 90 mins per session. From the 7th to the 14th week, 22 multicomponent exercise sessions are performed (2 sessions/week for weeks 7th and 8th, and 3 sessions/week from the 9th to the 14th week). The exercise sessions last between 60 and 70 mins. This program uses the same treatment techniques as the Galan Program in addition to motor imagery and psychoeducation techniques. At the end of the program, there is a final 2-hour review session of PSE (Fig. 3).

  An example of a patient functional profile for this program: patients with moderate to high level of impairment of their physical capacities, with strength and aerobic capacity being severely affected. They show a predominant nociplastic and widespread pain pattern and also have maladaptive perceptual fatigue. The patient may have somatosensory impairment such as dysaesthesia or hypoaesthesia (but not allodynia), as well as low to moderate impairment in the cognitive behavioral variables: cognitive and concentration deficits, memory loss, and executive function impairment. The patient also presents low to moderate levels of catastrophism, bad sleep quality, and moderate self-efficacy. Low to moderate emotional disorders are present: despite having high kinesiophobia, depression and/or anxiety are mostly moderate, not severe. In terms of social variables, the patient has a lack of support networks, as well as a tendency to isolate themselves, but there is no social phobia. Patients in this program are in a contemplative and preparation for action phases of the transtheoretical model.49

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  Montero program: It is focused on patients with low to moderate social impairment and moderate to high impairment in the other domains. The duration of the program is 16 weeks. In the first six weeks, 9 PSE sessions are performed (1 session/week during the first 3 weeks of treatment and 2 sessions/week from the 3rd to the 6th week), lasting 70 mins each session. From the 7th to the 16th week of treatment, 26 multicomponent exercise sessions are carried out (2 sessions/week of somatosensory, proprioceptive, and motor imagery work are performed from the 7th to the 10th week, and active treatment is introduced at a rate of 3 sessions/week from the 11th to 16th week, lasting 1 hour each session). In addition to the same treatment techniques as the Palma program, this program also includes social interaction, cognitive stimulation, and sleep re-education techniques. At the end of the program, there is a final 2-hour PSE review session (Fig.3).

An example of a patient functional profile for this program: a great maladaptive perceptual fatigue stands out with direct impact on ADLs. The patient presents a high level of limitation in their physical capacities, which means a deficit in strength and aerobic capacity, with a predominantly nociplastic widespread pain pattern. The patient usually presents somatosensory disturbances such as generalized dysaesthesia or hypoaesthesia (but not allodynia) and proprioceptive disturbances. Comorbidities are present: functional digestive disorders like irritable bowel syndrome, sleep disturbances, migraines, etc. Cognitive-behavioral variables are moderate to highly affected (mental fog, poor sleep hygiene, short-term memory loss, significant concentration deficit) with high levels of catastrophizing (rumination, magnification, and defenselessness). The patient also shows low levels of self-efficacy. At the emotional level, the patient is moderately to highly affected with characteristics of moderate depression, moderate anxiety, and moderate to high kinesiophobia. Social variables are also affected, reducing social relations drastically, but social phobia is not present. Patients are predominantly in a contemplative phase of change.49

Once treatment is completed, if there are clinically significant improvements in quality of life, and always with therapist-patient consensus, patients may be discharged from the UAAD or continue with their process of change through continued care as an "Active Patient" (concept explained below in section 2.2). In cases where there is no significant improvement, a comprehensive reassessment is performed, and individual treatment may be offered to the patient. As a last option, the patient is referred to other healthcare services based on their needs. Fig. 4 provides a flow diagram of the procedures for the UAAD.

Fig. 4.

Flow diagram of referral of patients with chronic pain to the UAAD: Unit of Active Coping Strategies for Chronic Pain; PC: Primary Care.

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After the patients complete the programs, a 6-month and 12-month follow-up is systematically performed, as some patients may experience relapses in their recovery process.73 When a patient relapses, it is crucial to perform a detailed re-evaluation to understand what is happening: if it is a mild relapse, we can adjust the treatment individually; if it is more severe, the patient may be referred to our Relapse Program, a shorter version of the Galan Program. When the clinical presentation is too complex to be managed solely by the UAAD, we will collaborate with other services or specialists for comprehensive care.

The Unit must have at least the following human resources: physical therapist, administrative staff, physician, nurse, and mental healthcare professionals, as recommended by the IASP. A common space should be available to perform all tasks and ensure proper patient care and communication among the service professionals. This common space should be strategically located to guarantee access for patients from the corresponding healthcare area. There should be different rooms for specific purposes: consultation, waiting, exercise, education, administrative, and storage rooms. It is also necessary to have equipment for the proper functioning of the service. For example, the use of treatment tables, assessment material, exercise material, software tools, and administrative material will be necessary.

In setting up and implementing a multidisciplinary chronic pain treatment unit, it's essential to leverage technology effectively. Digital tools for precise recording and storage of clinical data should be incorporated, as this ensures accurate and accessible patient information. Utilizing artificial intelligence can further enhance performance by analyzing these data to inform treatment strategies and improve patient monitoring. Additionally, integrating digital tracking tools can provide continuous, personalized support, which is crucial for optimizing patient care and treatment outcomes.76

Certainly, not all regions or countries possess identical resources or healthcare system structures. Strategic planning is essential to leverage the organizational strengths inherent to each area. For instance, in Spain, the UAAD is integrated within primary care services. This integration facilitates the transfer of specific programs to various primary healthcare centers. Consequently, a larger population can be served with minimal or no additional expense.

The goal of active coping is not for patients to just perform the treatment programs, but it is also to ensure that after knowledge and tools are acquired, they feel empowered to manage their own health.

The ultimate intention is to create "Active Patients''. This figure of “Active Patient” resembles individuals who have properly acquired self-management skills using tools and resources provided during the program or even self-developed ones. They are now independent and responsible for taking an active care of their own health. Active patients could also participate in future programs assisting and encouraging novice patients, showing that functional improvement is possible. These patients are also free to collectively create new strategies and use public resources at hand to maximize engagement in their new healthy habits. This concept is consistent with the Alma-Ata declaration,56 recently updated in the new "Astana" declaration.77 Both conferences highlight the idea of individual and collective participation in the maintenance of public health from primary care initiatives, using all available social resources. Accordingly, primary care professionals should be responsible for coordinating and instructing Active Patients to join and continue with exercise programs and other activities in social spaces provided outside the public healthcare system.

For this socio-healthcare coordination, it is necessary to collaborate and create agreements between the healthcare system and local and regional political institutions. Agreements can also be made with neighborhood and patient associations to have the support of stakeholders. The aim is to create a network of resources (public centers, green spaces, association premises, sports facilities, etc.) so that patients have the means to continue to take care of their health.