Neck pain is a frequent reason for medical consultation in primary care [1] and is often a reason for referral to physiotherapy units due to chronic pain [1,2]. It is associated with disability and work absenteeism; it has a 10.4%-21.3% prevalence in the general population. It is more common in women than in men [2,3]. The experience of pain is a significant burden, leading to a deterioration in quality of life that affects both physical and emotional well-being and has an impact on the person’s work, social, and family environments. This results in a high cost for national health systems due to the increased use of health resources, along with important psychological repercussions for those affected, including the risk of associated pathologies, such as anxiety, depression, and sleep disorders. In general, these people report a negative impact on their social relationships: 22% lose their jobs, 4% change jobs, and 27% feel socially isolated and little understood by those around them regarding their condition. Despite the economic impact of the diagnosis and management of these processes, 48% of the individuals are dissatisfied with the long waiting times for treatment, 29% are dissatisfied with the type of treatment received, and a high percentage of health professionals would like to receive additional training to deal with these processes [2,4-6].

Neck pain represents the fourth cause of work incapacity. This musculoskeletal issue is second only to low back pain, with a prevalence of 10% in the population. Treatment techniques and modalities focus on reducing symptomatology through passive or pharmacological interventions [7]. The criteria for approaching these processes by physiotherapists vary according to their training and professional experience. Pain, generally considered as a symptom, is approached with mechanistic methods that tend to produce poor adherence to treatment and often unsatisfactory therapeutic results [8-10]. The National Institute for Health and Care Excellence does not recommend the use of drugs for the treatment of chronic pain, as they have not demonstrated medium- and long-term benefits [11]. It is necessary to seek new approaches based on scientific studies for the treatment of these processes, which guarantee their effectiveness and allow us to know the cost of treatment and the health benefits provided [10,12-17].

Scientific evidence points to the multifactorial nature of chronic pain and the need for educational-therapeutic strategies based on the biopsychosocial model [14,17-19]. The most recent studies show that psychosocial factors influence, favor, and increase the symptomatology and perpetuation of pain. Therefore, it is necessary to understand and manage these factors to provide comprehensive care for people with chronic pain [18,20-23]. Given the importance of physiotherapy in primary care in health promotion and prevention, it is essential to design and develop a strategy for the management of chronic pain. Advances in this field suggest an interdisciplinary intervention, although this is not always possible [24]. Therefore, a physiotherapy program is proposed, based on evidence to facilitate educational-therapeutic interventions [25]. Health education programs (HEPs) provide a valuable tool for physiotherapists to address these processes [26-28]. An HEP should integrate physical techniques that have been shown to be effective, such as therapeutic and recreational exercise; cognitive restructuring techniques; and training in the management of attention, maintained stress, and associated emotions [25-34].

The aim of this work is to design and develop an HEP that considers not only physical, cognitive, and behavioral factors but also other variables that have not been sufficiently taken into account so far, such as emotional factors, values, and beliefs of individuals with chronic neck pain (CNP).

Following the review of the literature and the consensus of the experts, the program was designed with the following general and specific objectives:

The role of the physiotherapist includes facing important challenges due to new strategies that have emerged in response to the health needs of people. The HEP programs are a fundamental tool in primary care, to be used by these professionals who play a very important role in influencing and promoting behavior change related to the lifestyles of people with chronic pain. Their activities should not only provide assistance but also promote health and prevent issues. The primary areas of application are musculoskeletal (69%) and therapeutic physical activity (20.6%) [28,46].

Scientific literature includes interventions for chronic pain that use pain education as a tool by explaining the neurophysiology of pain. These interventions usually yield positive results in the short and medium term, reducing pain intensity and functional disability while improving the quality of life for individuals with chronic pain, compared to conventional physiotherapy interventions [48,52-55].

Other studies have shown that this type of educational strategy can also have a positive short- and medium-term effect on catastrophizing and physical performance [31,48-50,53]. In light of the current literature available, education in pain neurophysiology is considered a necessary but not sufficient pillar of an effective approach. For this reason, interventions have been developed that combine education in pain neurophysiology with therapeutic exercise and other forms of care.

Current scientific evidence points to the effectiveness of combining pain education with physiotherapy interventions based on therapeutic exercise in the short and medium term. This approach has been shown to improve functional disability and reduce fear avoidance [43,53,55-58].

Literature suggests that individuals should be considered as biopsychosocial beings; their beliefs; cognitive, emotional, and behavioral factors; as well as their social context play crucial roles in the manifestation, development, and perpetuation of pain [20,23,59]. Therefore, psychosocial factors must be taken into account in actively addressing these processes.

There are several studies that demonstrate the importance of considering these factors and the awareness of the individual’s thoughts, feelings, and emotions in the face of pain to reduce symptomatology [12,20,23,26,28,46,48,50,53,57,59].

However, although physical therapists can often recognize the influence of these factors, few have developed the skills to successfully assess and manage them. It is essential that physical therapists acquire the knowledge, attitudes, and skills necessary to be able to perform an active and structured approach to physical therapy, focused on the person with chronic pain, and to be able to use scientifically based tools and techniques.

Some programs evaluate the effect of cognitive-behavioral therapy in the improvement of pain, disability, and quality of life of individuals with CNP. Changes were observed without clinical relevance in the long term. This might be due to the fact that although these psychosocial factors are mentioned, they are not specifically addressed in the interventions. Additionally, these interventions often do not take into account the impact of social pain on the perception of physical pain even though both types of pain activate common pathways and brain centers. Social pain, resulting from feelings of social exclusion or rejection in interpersonal conflicts, affects people’s daily lives in general and can intensify the perception of pain in individuals with chronic pain [21]. If social pain is not taken into account and addressed in interventions, achieving clinically relevant results becomes more challenging. Furthermore, there is often a lack of direct approaches to sustained stress or the individual’s internal emotional disturbances [38,60-64].

Patients with chronic pain are known to be subjected to high stress levels. The nervous system’s response to stress interferes with perceived pain [6]. Therefore, individuals with chronic pain must learn to manage stress. The lack of inclusion of tools to address this may partly explain the absence of clinically relevant results in the management of chronic pain. Other interdisciplinary programs show the importance of approaching patient education from a biopsychosocial point of view. Moreover, in all of these programs, the active participation of the patient is considered essential [10,14,25,26,56]. To achieve the objectives, it is necessary for the individuals to take control of their process and become involved in its resolution with the appropriate support of health professionals.

Therefore, an HEP has been proposed that presents strategies with scientific evidence to address psychosocial factors [26,38,45,65-67], such as breathing and relaxation techniques, motor imagination, as well as play and recreational activities through body movement. This program also considers physical factors and promotes the return to normal activity and social participation for individuals with chronic pain, the importance of which is shown by systematic reviews that provide evidence of the benefits of exercise for CNP [39,68-70]. The fact that the program is conducted in small groups also allows the participants to get to know each other, share experiences, and establish social bonds and support. These interactions, both within and outside the program, can facilitate social participation and aid in their reincorporation into social life.

Regarding the number of program sessions and their duration, the literature consulted includes programs ranging from 1 or 2 sessions to some with 11 or more sessions. As for the duration of the sessions, the proposals range from 30 minutes to 4 hours [33,51,71].

Due to this variety in program structures and based on different guides for the elaboration of educational projects, along with the authors’ extensive experience in the field of primary care, the educational proposal of this program is for 5 sessions of 2 hours each—a medium term among all those consulted [72-74]. This duration is considered sufficient to work on both physical and psychosocial factors, without delaying the process excessively, to achieve good adherence and minimize participant dropout. However, as future lines of action, we are considering increasing the number of sessions and their duration to allow for more gradual and in-depth interventions, both in addressing psychosocial factors and incorporating therapeutic exercises of greater intensity and strength, as indicated by current research in this field.

The review, revision, and possibility to raise doubts in each session help secure knowledge, reinforce new attitudes, support the changes that are taking place, and minimize possible and unlikely adverse effects. This approach has proven to be an effective and safe intervention.

We are working on extending the number of sessions and their duration with the aim of focusing deeply on psychosocial factors and incorporating more intense and strength-based therapeutic exercises, as indicated by current research in this field.

Currently, the approach to chronic pain, and in particular CNP, requires attention to the associated biological and psychosocial factors. The HEP program, with a biopsychosocial approach, emphasizes understanding one’s own processes and questioning beliefs about pain through pain education, alongside managing emotions and stress through body movement. In addition, HEP emphasizes the use of therapeutic and recreational exercises for restoring function and promoting social participation in individuals with CNP, both in the medium and long term in individuals with CNP. More scientific research should be devoted to studies with methodologies that effectively define practical methods for individuals to learn how to manage their feelings and emotions as well as identify interventions that account for these factors. In the meantime, all health care professionals should be aware that “invisible psychological factors” play a role in chronic pain processes. These factors influence how individuals perceive and experience their pain and how they respond and behave to this condition, which affects the person as a whole.