14 Ochandorena-AchaM etal2024PTPQ2

Physiotherapy Theory and Practice
An International Journal of Physical Therapy
ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/iptp20
Acceptability of multimodal and multidisciplinary

group-based program for chronic low back pain: a
qualitative study
Mirari Ochandorena-Acha, Anna Dalmau-Roig, Christian Dürsteler, Francisco

Vilchez-Oya, Anna Ferrer, Ines Martin-Villalba, Amadeu Obach & Marc
Terradas-Monllor
To cite this article: Mirari Ochandorena-Acha, Anna Dalmau-Roig, Christian Dürsteler,

Francisco Vilchez-Oya, Anna Ferrer, Ines Martin-Villalba, Amadeu Obach & Marc Terradas-
Monllor (12 Jul 2024): Acceptability of multimodal and multidisciplinary group-based program
for chronic low back pain: a qualitative study, Physiotherapy Theory and Practice, DOI:
10.1080/09593985.2024.2377343
To link to this article: https://doi.org/10.1080/09593985.2024.2377343
Published online: 12 Jul 2024.
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PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2024.2377343
QUALITATIVE RESEARCH REPORT
Acceptability of multimodal and multidisciplinary group-based program for

chronic low back pain: a qualitative study
Mirari Ochandorena-Acha PhD, PT a,b, Anna Dalmau-Roig MD c
, Christian Dürsteler PhD, MD c,d,
Francisco Vilchez-Oya MD c, Anna Ferrerc, Ines Martin-Villalba e
, Amadeu Obache, and Marc Terradas-
Monllor PhD, PT a,b,c
a
Research group on Methodology, Methods, Models and Outcomes of Health and Social Sciences (M3O), Faculty of Health Sciences and
Welfare, Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVic-UCC), Vic, Spain; bInstitute
for Research and Innovation in Life Sciences and Health in Central Catalonia (IRIS-CC), Vic, Spain; cPain Medicine Section, Anaesthesiology
Dept, Hospital Clinic de Barcelona, Barcelona, Spain; dSurgery Department, Medicine Faculty, Universitat de Barcelona (UB), Barcelona, Spain;
e
Department of Clinical Psychology and Psychobiology, Section of Clinical Health Psychology, Clinical Institute of Neurosciences, Hospital
Clinic, University of Barcelona, Barcelona, Spain
ABSTRACT ARTICLE HISTORY

Background: The Programa d’Atenció Integral pels Pacients amb Dolor Crònic (PAINDOC) is Received 20 December 2023
a multimodal and multidisciplinary group-based program that integrates pain neuroscience edu Revised 1 July 2024
cation, mindfulness meditation, pain psychotherapy, Empowered Relief, and therapeutic exercise. Accepted 1 July 2024
It serves as a therapeutic option for individuals with chronic low back pain, providing them with KEYWORDS
comprehensive adaptive strategies for pain management. Qualitative research; chronic
Objective: This qualitative study explores participants’ retrospective acceptability of the PAINDOC low back pain; pain
Program. management; pain clinics;
Methods: To ensure demographic variability and information power, a purposive sampling multimodal treatment
approach was applied. Twelve participants were interviewed through three focus groups, supple
mented with four individual semi-structured interviews. Data was analyzed using reflexive the
matic analysis and evaluated based on the Therapeutic Framework of Acceptability.
Results: Participants provide positive feedback regarding active pain coping strategies and
improved self-management. While certain aspects of the Program were more emphasized, parti
cipants integrated tools from all components. Strategies included pain reconceptualization, posi
tive self-talk, or problem-solving. The Program’s ethicality was closely linked to individual values
and may also be influenced by time constraints of certain program elements, the immediate effects
of specific approaches, participant perceptions, and individual preferences.
Conclusions: The findings provide valuable insights into the acceptability of the PAINDOC
Program, guiding future improvements and the development of similar interventions.
What’s already known about this topic?

● Multidisciplinary approaches to chronic pain management have been explored and are recog
nized as an effective way to address the complexity of chronic pain conditions. These
approaches often involve the collaboration of healthcare professionals from various disciplines.
● Multimodal pain management programs typically combine various treatment modalities,
including physical therapy, cognitive-behavioral therapy, medication, and exercise.
● Studies have shown that multidisciplinary and multimodal interventions can be effective in
reducing pain intensity, improving physical function, and enhancing quality of life in chronic
low back pain patients.
● What does this study add? The multidisciplinary and multimodal group-based PAINDOC
Program is acceptable for chronic low back pain patients.
● Participants noted the effectiveness of the program in helping them adopt active pain coping
strategies and improve self-management.
● The ethicality of the multimodal Program depends on individual personal value systems, as
certain program components may be less suitable for some participants.
● There might be some barriers to program adherence, including limited available time, the
higher physical demands of exercise, the immediate effects of certain approaches, participants’
perceptions, and individual needs and preferences.
CONTACT Mirari Ochandorena-Acha [email protected] Faculty of Health Sciences and Welfare, University of Vic - Central University of
Catalonia, Sagrada Familia 7, Vic 08500, Spain
© 2024 Taylor & Francis Group, LLC
2 M. OCHANDORENA-ACHA ET AL.
Background might depend on its acceptability since participants are

more likely to adhere to its recommendations and ben
While the underlying causes of chronic low back pain
efit from its potential effectiveness when they find it
(CLBP) might be unknown, understanding it as a long-
acceptable (Sekhon, Cartwright, and Francis, 2017).
lasting condition with variable courses is crucial
Acceptability, as defined by Sekhon, Cartwright, and
(Hartvigsen et al., 2018), as it requires patients to learn
Francis (2017), is the extent to which participants per
how to self-manage it (Gardner et al., 2015; Raja et al.,
ceive a healthcare intervention as suitable based on their
2020; Treede et al., 2015; Turk and Gatchel, 2018).
anticipated (prospectively) or experiences (retrospec
However, patients often perceive “chronic” as “forever”
tively) cognitive and emotional responses. The
(García-Martínez et al., 2022; Treede et al., 2019), which
Theoretical Framework of Acceptability (TFA) identi
might limit their understanding and hinder their ability
fies seven components: affective attitude, burden, per
to self-manage it effectively (Raffaeli et al., 2021).
ceived effectiveness, ethicality, intervention coherence,
In recent decades, the biopsychosocial model has
opportunity costs, and self-efficacy (Sekhon,
emerged as a framework to comprehend the complexity
Cartwright, and Francis, 2017). Examining the accept
of such conditions, integrating biophysical, psychologi
ability of the PAINDOC Program could deepen the
cal, social, genetic factors and comorbidities and their
understanding of how these approaches effectively
interaction (Foster et al., 2003; Hartvigsen et al., 2018;
address the challenges faced by individuals with chronic
Moseley, 2017). Consequently, various self-management
pain. Therefore, the present qualitative study aims to
approaches have been developed to address CLBP symp
explore participants’ retrospective acceptability of the
toms and consequences (Achten et al., 2022; Leventhal,
PAINDOC Program based on a multidisciplinary
Phillips, and Burns, 2016). These include Cognitive
group approach.
Behavioral Treatment (CBT), Acceptance and
Commitment Therapy (ACT), Mindfulness, physical
activity, and Pain Neuroscience Education (PNE), Materials and methods
which have shown effects in reducing pain, disability
and distress while improving functionality (Avila et al., Design
2023; Kun et al., 2023; Mekhail et al., 2023). These non- The present qualitative study is based on an interpreta
pharmacological approaches often are delivered as tive and deductive approach, guided by the TFA by
group-based interventions from a multidisciplinary per (Sekhon, Cartwright, and Francis, 2017). Assuming
spective (Breen et al., 2006; Guzmán et al., 2001; Norlund, multiple realities are based on each person’s experi
Ropponen, and Alexanderson, 2009; Tulder, Van, and ences, an interpretative approach is chosen to explore
Bombardier, 2002). participants’ feelings, perceptions, and experiences
Recently, a multimodal and multidisciplinary pro (Green and Thorogood, 2018).
gram called Programa d’Atenció Integral pels Pacients Data were collected through a dual approach compris
amb Dolor Crònic (PAINDOC) has merged as ing focus groups and individual semi-structured inter
a therapeutic option for CLBP. The PAINDOC views. Initially, focus groups were conducted, and
Program aims to provide patients with comprehensive subsequently, authors decided to supplement the data
adaptive strategies to cope with and manage their pain with individual semi-structured interviews during the ana
effectively by integrating five disciplines: PNE (Bodes lysis phase in order to increase richness, depth, and
Pardo et al., 2018; Leventhal, Phillips, and Burns, 2016; complexity.
Louw, Diener, Butler, and Puentedura, 2011; Louw, The data were analyzed with a reflexive thematic ana
Zimney, Puentedura, and Diener, 2016; Moseley and lysis (RTA), emphasizing the importance of the research
Butler, 2015; Ryan, Gray, Newton, and Granat, 2010), er’s subjectivity as an analytical resource and their
mindfulness meditation (Cherkin et al., 2016), pain reflexive commitment to theory, data, and interpretation
psychotherapy, Empowered Relief (Darnall et al., (Braun and Clarke, 2020, 2021). Aiming to ensure the
2021), and therapeutic exercise (Buford, Roberts, and study’s quality, rigor and ethical criteria for qualitative
Church, 2013; Cohen, Vase, and Hooten, 2021; Geneen research are applied (Tong, Sainsbury, and Craig, 2007).
et al., 2017; Malfliet et al., 2017, 2018). This Program is
considered “complex” because of the components
Ethical considerations
involved, the range of behaviors targeted, and the exper
tise and skills required by those delivering and receiving Following the principles of the World Medical
the intervention (Moore et al., 2015; Skivington et al., Association Declaration of Helsinki, the study protocol
2021). The successful implementation of such Program was approved by the Research Ethics Committee of the
PHYSIOTHERAPY THEORY AND PRACTICE 3
Hospital Clinic from Barcelona (HCB 2023/0177). Zimney, Puentedura, and Diener, 2016; Moseley and
Participants were informed about their confidentiality Butler, 2015; Moseley, Nicholas, and Hodges, 2004;
and the procedure of the interviews. Before participat Ryan, Gray, Newton, and Granat, 2010) (see
ing in the interview, all participants signed an informed Appendix 1).
consent for the recording and transcription of the inter Three consecutive 1-hour sessions of therapeutic
views and for anonymous quotation of their responses exercise (TE) provided by a physiotherapist. These ses
in the present report. sions focus on joint mobility and strengthening the
lumbopelvic muscles. The main goal is to equip partici
pants with movement-based self-management strate
Context of the study
gies, gradually reintroduce them to exercise, and
The PAINDOC Program is a multimodal and multi reduce maladaptive behaviors associated with chronic
disciplinary treatment approach based on the biopsy pain. After completing the sessions, participants receive
chosocial understanding of pain. It is delivered by written materials with exercise instructions (Buford,
various healthcare professionals in the Pain Unit of the Roberts, and Church, 2013; Cohen, Vase, and Hooten,
Hospital Clinic from Barcelona and consists of eight 2021; Geneen et al., 2017; Malfliet et al., 2017, 2018) (see
face-to-face sessions provided over two months. The Appendix 1).
program includes a total of 8 sessions, with
a combined duration of 9 hours, distributed as follows:
A 2-hour therapeutic education session led by Recruitment
a physician based on Dr Beth Darnall’s Empowered The recruitment of participants followed a purposive
Relief approach. This session aims to procure self- sampling approach (Green and Thorogood, 2018), aim
management tools based on CBT therapy: identifying ing to ensure both demographic variability and suffi
distressing thoughts and emotions, cognitive reframing, cient data saturation or information power pertaining to
a relaxation response exercise, and a self-shooting the study’s objectives and the characteristics of the study
action plan (Darnall et al., 2021). population. Participants included individuals with non
A 1-hour session of pain psychology with specific CLBP who were referred to the Pain Unit of the
a psychologist to explore the relationship between emo Hospital Clinic from Barcelona, all of whom were over
tions, thoughts, and behavior in pain coping. It 18 years old, experienced pain for at least 50% of the
addresses identifying irrational thoughts about pain time over a period of six months or more, and reported
and introduces a thought diary to promote adaptive an average weekly pain intensity equal to or exceeding 4
thinking. Concepts like kinesiophobia are explained out of 10 on a verbal numerical pain rating scale.
followed by guidance on time management and increas Demographic characteristics such as age and gender
ing rewarding activities (Darnall et al., 2021). were considered during participant selection to ensure
A 1-hour introductory session to mindfulness medi representation across different age groups and genders,
tation facilitated by an advanced practice nurse. This thus enhancing the variability of the sample.
session aims to enhance attention, emotional balance, Selected participants underwent the PAINDOC
understanding of mindfulness principles, self- Program one month before being contacted via phone
compassion, stress reduction, and overall well-being. by the first author, who served as the interviewer. Given
Participants also receive audio-guided meditation for the expected average level of participant nonattendance,
support and practice (Cherkin et al., 2016). a larger number of individuals were initially invited to
Two 1-hour PNE sessions based on the “Explain achieve the anticipated effective number for each focus
Pain” concept and book by Butler and Moseley (2016). group. Participants who did not respond to the phone
These sessions aim to shift the patient’s understanding call, declined the interview, did not provide consent, or
of pain by increasing knowledge about its biological did not appear on the scheduled day were excluded from
aspects. Key learning objectives include the variable the study. Interested participants were provided with
relationship between nociception and pain, the influ a comprehensive informed consent document and
ence of context and thoughts on pain, nociceptive sys were then scheduled for either a single focus group or
tem sensitization, the coexistence of protective systems an individual semi-structured interview.
in pain, and the adaptability and trainability of the
nervous system, including neuroplasticity. Participants
Data collection
also receive supplementary materials (Bodes Pardo
et al., 2018; Leventhal, Phillips, and Burns, 2016; The data collection process was conducted by the first
Louw, Diener, Butler, and Puentedura, 2011; Louw, author within the time frame of January to June 2023,
taking place at the Pain Unit of the Hospital Clinic from final transcriptions were returned to participants for
Barcelona. The data collection process involved focus validation, although no specific requests were made by
groups and individual semi-structured interviews. the participants. All final transcriptions, voice record
Initially, focus groups were conducted to gather collec ings, and informed consent numerically coded were
tive insights and perspectives from participants in securely stored using Microsoft Office 365, the compu
a group setting. Subsequently, during the data analysis ter cloud software infrastructure of the Hospital Clinic
process, it was determined that additional depth and from Barcelona. Only the research team knew the pass
nuance were needed to fully explore individual experi word, which was complex and changed regularly. The
ences and perspectives. As a result, individual semi- computer was located in a locked office with restricted
structured interviews were included to delve deeper access inside the Hospital. Additionally, multi-factor
into the unique insights of selected participants. authentication was implemented for accessing the
Notably, no prior relationship existed between the inter data. Backup procedures were also in place to prevent
viewer and the study participants. Each participant was data loss, and all data transfers were encrypted to pro
invited to a single interview. The authors created the tect against unauthorized access.
interview guide based on their research knowledge, The data collection was concluded when data satura
experience, and relevant literature, aiming to explore tion or information power was achieved in relation to
the participants’ experiences, acceptance, usefulness, the study’s objectives and target population, as well as
and barriers related to the PAINDOC Program the complexity and depth of the analysis (Braun and
(Sekhon, Cartwright, and Francis, 2017) (see Clarke, 2020).
Appendix 2). The interview guide comprised open-
ended questions and was conducted in either Spanish
Analysis
or Catalan, depending on the preferences of each focus
group or individual semi-structured interview partici Reflexive Thematic Analysis (RTA), according to
pant. The interviewer is proficient in both languages (Braun and Clarke, 2021) was followed based on the
and addressed the interviews with a receptive attitude, TFA by Sekhon et al 2017 (Braun and Clarke, 2021;
encouraging participants to provide detailed responses Sekhon, Cartwright, and Francis, 2017). RTA consists
when appropriate. of developing, analyzing, and interpreting patterns
During the focus group sessions, the interviewer across qualitative datasets, which involves systematic
played a facilitator role. She personally received the data coding processes to develop themes (Braun and
participants, moderated the discussion, created Clarke, 2021). The analysis was carried out collabora
a relaxed atmosphere, and ensured that all participants tively by the first and last authors, encompassing the
had the opportunity to share their experiences through following six steps applied consistently across all tran
active listening. If any participants became distressed scripts: 1) familiarizing with the data; 2) generating
during the interviews, the interviewer responded in initial codes; 3) searching for themes; 4) reviewing
a supportive and reassuring manner. All focus group themes; 5) defining and naming themes; 6) writing the
sessions followed a consistent structure, including pre results. Throughout the analysis process, both authors
sentation and introduction, group discussion based on approached the task reflectively, engaging in ongoing
flexible script-guided questions, and conclusion. discussions, consolidating their findings, and subjecting
The focus group sessions typically lasted around 60– each other’s interpretations to scrutiny. This collabora
90 minutes, while individual semi-structured interviews tive and reflective approach contributed to a more
took approximately 30–45 minutes. All the focus group nuanced and refined analysis,
and individual semi-structured interviews were audio The first author holds a PhD in Physiotherapist
recorded using two audio recorders to ensure no data and serves as an educator, clinician, and researcher
was lost. Besides, the interviewer took field notes during with expertise in chronic pain and qualitative meth
the interviews to capture any relevant observations, such odology. She oversaw the data collection process as
as participants’ behaviors. The recorded materials were she had no prior therapeutic or personal relationship
transcribed verbatim, with observational field notes with the participants. Additionally, she was respon
integrated as “comments.” Identifying information of sible for directing and actively participating in the
all the participants or any mentioned professional data analysis, leveraging her extensive experience in
name was removed during the transcription process to the field. The last author, also holding a PhD in
anonymize the data. Each participant and the corre Physiotherapist, is an educator, clinician, and
sponding focus groups or individual semi-structured researcher with specialized knowledge in chronic
interviews were coded with numerical identifiers. The pain. He played a pivotal role in the data analysis,
working with anonymized data. He was the only one Results

who had a prior relationship with the participants, as
Participants
he is the physiotherapist who provided part of the
PAINDOC Program. Notably, he was not part of the Eighteen eligible participants agreed to participate in the
data collection process. Both authors meticulously face-to-face focus groups, but 6 were excluded because
documented their reflexive processes, ensuring trans they did not attend for the interview. Four eligible
parency and rigor in the analysis. They recognize participants were invited to the individual semi-
that their diverse backgrounds and experience structured interview and all were included. Therefore,
added valuable perspectives to the study, contribut three sets of focus groups (n = 12) and four individual
ing to a comprehensive and sophisticated analysis. semi-structured interviews (n = 4) were conducted.
However, authors assume that their expertise might Participant characteristics are displayed in Table 1. All
inadvertently introduce biases or assumptions that participants completed the PAINDOC Program prior to
could influence the research process and findings, the interview.
as their familiarity with the field might lead to
taken-for-granted beliefs or blind spots. In this
Themes and participants’ reports
regard, the authors sought diverse perspectives
from the rest of the authors, especially those that Two main themes were identified throughout the
may differ from their expertise, to ensure RTA: 1) content, context, and quality of received care;
a comprehensive analysis by asking other research and 2) effectiveness and self-efficacy (see Table 2). Each
members. The preliminary analysis was presented to theme is developed and supported by participants’ quo
the research team for discussion and to deepen the tations, identified with the number of the corresponding
analysis further. focus group (FG) or individual semi-structured inter
The relevant sections of the interviews were subse view (ISSI). Parentheses (. . .) indicate that some extract
quently extracted from the transcripts and translated was removed because it was ineffectual or irrelevant
from Spanish or Catalan into English by a native speaker text. Square brackets [. . .] indicate the author’s clarifica
to include as quotes in the present study. The Atlas.ti tions, such as when the participant refers to previous
qualitative analysis software was used to develop the information. See Figure 1.
entire qualitative analysis.
Theme 1: content, context, and quality of received
care
Table 1. Participants characteristics. This theme includes the constructs defined by the TFA
Number of participants Age range (years) Sex (% female) as affective attitude, burden, coherence, and ethicality.
FG 1 3 65-75y 66,67% Affective attitude emerged to describe how interviewed
FG 2 5 55-75y 60%
FG 3 4 60-67y 50%
felt about participating in the program, and burden refers
ISSI 1 to 4 4 59-70y 25% to the perceived amount of effort it is likely to take to
FG: Focus Group; ISSI: Individual Semi-Structured Interview. engage with the program. During the analysis, both
Table 2. Finding summary based on each domain of the Theoretical Framework of Acceptability by Sekhon, Cartwright, and Francis,
(2017).
TFA Domain Domain description Finding summary
Affective How participants felt about participating in the program. Feeling optimistic and hopeful.
attitude
Burden The perceived amount of effort to engage with the program. Facilitated by flexible timetable and adapted language.
Opportunity The benefits, profits, or values participants had to give up when Good opportunity to acquire knowledge and pain coping strategies.
costs engaging in the program
Coherence Participants’ understanding of the perceived level of “fit” Components of the Program well-integrated and aligned with the overall
between the different components of the program and its goals.
intended aim Barriers when no providing specific strategies.
Demand for more extended support or additional sessions.
Ethicality How the program fits into the participants’ personal value Depends on personal value system.
system, which might be influenced by personal experiences. Barriers of some parts of the Program because limited time, not enough
practicing, lack of specific tools, subjective perception, and individual
needs and preferences.
Effectiveness How well the program achieves the desired outcome. Adaptive coping strategies and pain reconceptualizing in diverse grades.
Self-efficacy Participants’ confidence level in engaging in the behaviors Barriers incorporating strategies in daily living. Facilitated by provided
required to participate with the program. written material and resources and group-approach.
TFA: Theoretical Framework of Acceptability.
Figure 1. Main findings based on thE THEORETICAL FRAMEWORK OF ACCEPTability by (Sekhon, Cartwright, and Francis, 2017).
Statement of responsibility for the authors: Authors confirm that all authors have actively contributed to the research and its
reporting.
domains merged describing positive attitudes toward par on this, even though I like it, what am I going to do?”
ticipating in the program, as the participants felt more And when you leave, you see that, well, yes, yes, yes. You
optimistic and hopeful after the sessions, and felt no feel like a real lift. (FG2 P4)
increased effort, as it had a low impact on their activities,
responsibilities, or relationships. Besides, participants Regarding cognitive effort associated with participating
related that participating in the sessions did not require in the sessions, some participants highlighted healthcare
time or effort to balance commitments with other respon team adapted the language of the theoretical sessions to
sibilities in their daily lives, as the program offered facilitate the understanding of the concepts to all parti
a flexible timetable, and most of them were retired, on cipants, so it was not an effort to maintain attention or
a sick leave or had a disability that prevented them from assimilate the knowledge.
working.
Q2: No, the only thing was the part about theory, which
Q1: You come out of the sessions very optimistic, that some people might find a bit more difficult to under
is, you come out very positive. Because of this problem, stand, but as the therapist explained it in very easy lan
I was like, “I have to quit my job, I can’t go on working guage. . . so. . . it wasn’t an effort to attend to it. (ISSI P2)
Opportunity costs were considered during the analysis Regarding the specific content of each of the parts of the
as the benefits, profits, or values participants had to give program, PNE and TE were the part most highlighted
up when engaging in the program. In this regard, none by the interviewed participants. These two parts of the
of the interviewed participants considered they had to program were the parts that influenced most on them
give up on any of these constructs when participating in according to participants’ experience, as they felt that
the program. On the contrary, they perceived that par they provided them with immediate strategies for cop
ticipating in the PAINDOC Program was a good oppor ing with pain.
tunity to learn about pain and acquire strategies to cope
with it. Q6: I am happy to have participated in the program
and, naturally, I am more confident in. . . in the
Q3: I’m delighted with what they have done for us, more. . . let’s say, classical parts, which is the part of
I mean, it’s incredible. I find it incredible, coming from the physiotherapist that. . . not in the others [parts of
a country without public health, I think it’s marvelous. the program] for diverse reasons. . . one that is quite
I am delighted because it has been enriching on all levels immediate, whether or not it can produce effects,
and it has not been a disadvantage for me because I have noticeable effects, and. . . the other, well, if younger of
shared with other people in the same situation as me, course . . . it is related to age. They are approaches
I have learned things about pain (. . .). (FG1 P2) that. . . surely, they work, but they are slow to apply
and of course, you are of a certain age, and you go for
The construct of coherence reflects participants’ under what you think can produce the quickest effects or
standing of the perceived level of “fit” between the improvement. (FG3 P1)
different components of the program and its intended
aim. Participants considered the program’s various In fact, participants shared metaphors, data, and concepts
components to be well-integrated as they follow shared by the physiotherapist during the PNE sessions.
a logical link, and they are aligned with the overall
goals, as the diverse elements come together to achieve Q7: Well, do you know what worked really well for
the intended outcome: providing them with strategies to me? I used to think, “if I’m this bad at my age, how will
cope with pain. I be in 10 years?” Well, they explained to us an article
that says that 80% of the things we worry about never
Q4: I think the program is well structured because it happen, right? And then, I think, “what’s causing me
deals with all the pain-related points. I don’t know, this unease,” do I have to worry about something that
I mean. . . it has helped me, maybe, to understand will happen in 10 years? It’s true. . . and that, you see?
a little bit what pain is and how it happens, and how This has been one of the clicks for me. (FG2 P4)
I can fight it (. . .) the main tool maybe is the fact that
you realize that you can overcome pain with exercise, On the contrary, psychotherapy was highlighted as the one
with. . . I mean, I don’t know how to say it. . . realizing they remembered the least, as it was, in the opinion of
that pain is more mental than not. . . in the body and, some of the interviewed participants, too general, which
therefore, it doesn’t have to stop you from doing any had not provided them with specific strategies for daily life.
thing, you can do whatever you have to do, even if it’s
hard sometimes. (ISSI P3) Q8: They are complex subjects to be dealt with in one
session [referring to psychology], because they are more
All the interviewed participants agreed that they per theoretical topics, quite. . . heavy, to say it. Because,
ceived a unified approach and goals from all the multi sometimes, the psychology part was a bit overwhelming.
disciplinary healthcare professionals. As the sessions were They wanted to cover so much from the beginning that
theoretical and practical, they felt the program’s coher it was a bit confusing in the end, and it should have been
ence and purpose, as all the different strategies or activ more practical. The meditation part, for example, “let’s
ities showed consistency and alignment between them. meditate,” but practice it. Stop the bullshit. . . (FG3 P1)
Q5: The combination of a theoretical part and However, all interviewed participants except one agreed
a practical part is good. . . the theoretical part, I liked they would like to receive ongoing support advocating
quite a lot, honestly. And the practice of the therapeutic for a more extended program or additional sessions to
exercise too, because now I have the exercises, I have to achieve more meaningful outcomes. In fact, some of
do and. . . (. . .) they have given as the tools we needed, them felt that the number of sessions provided in the
so it’s good, it’s good. (ISSI P4) program regarding Mindfulness, psychotherapy, and
even therapeutic exercise, was insufficient for them to doesn’t suit me. No. And that’s not to take credit away
incorporate those strategies into their daily lives. from anyone, but. . . it just doesn’t suit me, and that’s it.
And I, the things that don’t suit me, eee. . . well, they
Q9: The program was short. I found the sessions very don’t suit me, and I don’t practice them. (FG1 P3)
good, but I think it would be good if they continued over
time. . . to help us to consolidate the exercises, to keep However, those participants did not doubt the potential
practicing them for longer. But yes, they have been very benefits of such techniques, nor its compatibility with
good for me to change my mind a bit. Yes. (FG2 P4) the other parts of the program. In fact, they shared their
willingness to participate and complete all the different
Although the analysis did not merge one-size-fits-all parts of the program. Although this lack of engagement
answers, participants stated their desire to have regular with these techniques did not impact participants’ atten
sessions (weekly) or intensive sessions (with more fre dance and involvement, or even their relationship with
quent sessions over a shorter period, such as daily or the therapist, it might on their homework completion,
several times a week), combined with a long-term fol as they recognized not applying the strategies in their
low-up (ongoing support even after the initial program daily lives.
ends, with periodic follow-up sessions to help patients
reinforce the strategies). Theme 2: effectiveness and self-efficacy
When it comes to ethicality, this construct relates This theme includes participants’ perceived effective
how the program fits into the participants’ personal ness in PAINDOC Program, which refers to how well
value system, which might be influenced by personal the program achieves the desired outcome, and self-
experiences. Significantly, some of the interviewed efficacy, which means participants’ confidence level in
reported that the program was in line with their perso engaging in the behaviors when participating in the
nal value system, as the primary treatments offered were program.
pharmacological therapies, and the lack of alternative Participants’ impression of a program’s effective
options was frustrating and led to feelings of being ness contributes to its acceptability. In this line, most
stuck. participants reported a meaningful improvement in
their pain and improved health self-management due
Q10: Yes, yes, yes, I would recommend the program. to the program. They showed diverse psychological,
It’s very good to have tools to apply and to notice a bit of behavioral and cognitive strategies, considered adap
improvement, you know? It’s that. . . sometimes we get tive coping strategies: practicing mindfulness medita
a bit frustrated with the issue of pain. . . and medication tion and deep breathing, distraction (focusing and
is what they always offer you, so this is an alternative, engaging in enjoyable activities to distract from
you know? If you go to the doctor, the first thing they pain), activity pacing (balancing staying active with
give you is medication, but they don’t explain all this to rest), problem-solving skills (identifying challenges
you, do they? All this that they have explained to us in related to pain management and finding ways to
the program is not explained to you, of course, and it’s solve it), acceptance of pain presence in daily life
good to understand why this happens to you. (ISSI 4) and adapting to its presence, and positive self-talk
(avoiding negative thoughts and using positive affir
The program’s ethicality is associated with participants’ mations and self-encouragement). These strategies
ethical principles, values, and standards. In this line, helped participants maintain active despite experien
some participants showed some hesitancy regarding cing pain.
some parts of the program, especially on mindfulness
techniques, as some were skeptical about this techni Q12: Yes, because after the program, I’ve also
que’s effectiveness. Those participants did not explain encouraged myself to go back to Pilates. . . to take up
further their concerns, only that they had preferences exercising again because I hadn’t done anything for
for the other parts of the program, such as the thera a few years, I mean. . . I used to work, come home, eat
peutic exercise, because they are more accustomed to and, lie down on the sofa, and do nothing, you know
them and might be quicker to show effectiveness or do what I mean? so now it has helped me to take up
not require as much consistent effort and time. exercising again. (ISSI P4)
Q11: eeemmm. . .. No. I don’t believe so much in these Q13: I wasn’t moving from home. If it wasn’t for
techniques (. . .) I don’t feel good, because I’m doing something really important. But now I do. I have pain,
a thing that I, actually, eee. . .. mmm. . . no. (. . .) No, it but well, I try to do things, things I used to do, but
I couldn’t for a while now. As a result of the program, Improved knowledge about pain mechanisms. Some
I’ve started doing some things again, yes, yes. Before, participants’ language no longer discussed pain in
when the pain was so bad, I used to say, “I’m not going purely biomedical terms, as they included new neuro
out.” And now, even if I’m in pain, I go out. Now I need physiological terms when explaining pain, such as the
to. It’s a need to face it. Staying at home is not going to central sensitization or the influence of cortisol on
help you at all. (FG3 P2) the CNS.
Although pain reduction was not the primary aim of the Q16: Especially the part about the functioning of the
program, but providing participants with strategies to pain mechanism and all that, of course, if they don’t
cope with pain, some participants reported some impact explain it to me. . . the doctor doesn’t explain it to you. . .
on pain intensity, which led them to reduce the dosage of When you go to the doctor doesn’t explain that to
the medication they were taking, as well as an improve you. . . that functioning (. . .) Now, the day I have more
ment in their overall well-being and functioning. pain I understand that my spinal cord is overexcited and
that I have. . . the issue of the little boxes, right? The little
Q14: I have also reduced the painkillers. I thought, boxes that the physiotherapist explained to us. And
“why not?” and yes. . . it’s fine, I’ve reduced them. I think, I really think about it. Then I think “oops. . .,”
I still have the same pain, I mean, it hasn’t increased. when I’m like that, I have to do everything I’ve been told
So, it means that I don’t need this high dose. With about breathing and then I think about everything else.
a lower dose, I’m fine. (FG3 P4) The breathing, the meditation, or the exercises. I already
know that I have these three tools. (ISSI P4)
Pain reconceptualizing is a cognitive shift in how indi
viduals understand and interpret pain, moving away Reinforcement of previous adaptive cognitions. Some
from the traditional view of pain and embracing participants reported considered that the sessions
a more comprehensive, biopsychosocial understanding. helped them reaffirm their habits and self-efficacy to
In this line, the reports of interviewed participants cope with pain, as they might have presented previous
reflected a better understanding of pain mechanisms some adaptive strategies, which, therefore, validated
(considering the nervous system’s role in pain percep their experiences.
tion and the distinction between acute and chronic
pain), a recognition of psychosocial factors (such as Q17: The education sessions were the most useful for
beliefs and past experiences), empowerment (under me, the talks. Seeing that “look, you are not wrong.” It
standing their ability to adapt and control over the reinforces what I knew and did. (FG2 P3)
pain), reducing fear and catastrophizing, and adopting
active coping strategies (described previously). Reduced fear and catastrophizing, viewing pain as
Among the participants’ responses, various degrees a protective response rather than an indicator of
of pain reconceptualizing were perceived. While these ongoing damage.
degrees are not standardized terms, the analysis grouped
them into the follow categories: minimal changes, Q18: The theory class explaining “chronic” was key
improved knowledge, reinforcement, reduced fear and for me, that is, telling my brain “I don’t have an injury”
catastrophizing, better understanding of pain, and because I thought there was an injury. . .. (. . .) so I was
transformational change. on the wheel “I didn’t move, I didn’t use that movement
Minimal changes perceived in participants’ pain per for fear of injury.” I think the theoretical part was key
ception and beliefs, giving some basic knowledge about together with the practice of the exercises (. . .) The
pain, which might not alter their prior overall under combination of theory, that my brain understood and
standing or behavior related to pain. then, that they accompany you and are by your side. . .
the program perfectly combines the practice with the
Q15: But it’s indeed the perception of pain that theory and that was what made me come out of. . . and
changes, right? Not the pain itself. Of course, when the to stop the medication. (ISSI P2)
perception changes, the pain changes. That is
a consequence. It opens that mentality a little bit and Q19: In my opinion. . . what has influenced me the
makes your perception different, OK? You’re thinking of most has been understanding the whole part of how
pain as something unbearable, continuous, or mmm. . . pain works because it was a way of seeing how, physi
that can’t be solved, or that will always be there, the same cally and psychologically, emotions and everything
or worse. And now, I simply play it down. (FG3 P3) affect how you are and your state of mind (. . .) Now,
for example, when I have a ruminative thought, like A few interviewed participants stated mixed results as
“everything will be a disaster for my life and my health,” they felt there had not been improvements in their
well, I recognize those thoughts, then I also think “you symptoms but still were positive about the potential
are already thinking about the scary movie” and I try to benefits from the Program. In this line, their account
tell myself that everything will be fine. At least I break reflected some degree of pain reconceptualizing as the
out of the scary movie of catastrophism. (FG2 P1) reinforcement of previous adaptive cognitions.
One participant stated that the different sessions
Better understanding of pain, feeling more confident of helped her to elaborate on further reflections, which
staying active (increasing their self-management), she described as “take away bus reflections.”
actively applying the concepts from education to their
daily life, and increasing exposure to activities they Q23: After the sessions, at least on the bus, I kept
previously avoided, as previously described. thinking about what I had been told and. . . and
I thought about it. For me, I find it very positive. It
Q20: Well, every time I remember the pain, has given me reflections for when I go on the bus. (FG1
I remember the phrase that the physiotherapist in the P1)
program said to me “I am generating this and I have no
injury,” “I am fine.” This is what I am repeating, which Regarding the self-efficacy, overall, participants
for me was the key. It sends the cortisol knowing that reported high self-efficacy in performing behaviors
there is no injury. (ISSI P2) required to participate in the different sessions of the
Program. When it comes to incorporating strategies in
Transformational change in pain perception and beliefs, daily living, some participants admitted it was challen
completely shifting their understanding of pain. A few ging to allocate time for practicing all the strategies.
interviewed participants reported they had clicked in However, most of them successfully incorporated at
how they understood the pain and one’s identity with least a few strategies into their daily lives and stayed
pain, increasing acceptance of pain sensations instead of motivated to follow through with them, especially
fighting it. those that saw immediate results as previously
described.
Q21: For me, it’s positive, especially because when
I finished the program, I was in a different position. Q24: I always try to do mindfulness breath control
I mean, when I finished, I thought, “oh, I’m not what and I always do it throughout the day (. . .).
I was, I’m in another place, I have a series of possibili Mindfulness is one thing that I have practiced quite
ties, of perspectives in front of me, and I can choose”. continuously since it was explained to us. (ISSI P1)
(. . .) I’m not the same as I was and don’t think as
I thought about pain. (. . .) So, I have pain, but now In this line, interviewed participants considered that
I know it, I know. . . we can be friends. (. . .) I used to provided written material and resources (such as audio
think of it as a negative thing. Now I think it’s just recordings) were valuable components that enhanced
another thing that there is. . . and that well. . . because their engagement, compliance, and retention, ensuring
I have blue eyes, so I have pain. And then, if I assume they continued applying the different strategies even
that I have blue eyes, I can assume that I have pain and after the program ended. They agreed that the material
cope it. Yes, it’s “hello, pain,” I greet you. (FG3 P4) was aligned with the program’s goals and was high-
quality.
Q22: The education session exploded my head. Finally, participants valued the opportunity to par
Because, my goodness, it was all the opposite of what ticipate in such a multidisciplinary program and join
I thought. (. . .) The “chronic illness” thing, too, totally a group with others in a similar situation or with
blew my mind. . . the chronic illness thing. I would never comparable experiences, as they considered that peer
have thought that “chronic illness” meant that you had support helped them participate in the program and
a disease or pain that lasted more than 3 months. stay motivated, as well as relativize their actual
I hadn’t, I had always thought that “chronic” was for situation.
life. (FG2 P5)
Q25: [When asking about group-based approach] For
Positively, none of the interviewed referred to the rein me it’s perfect, it’s just that, in my group, we had such
forcement of the biomedical understanding because of a big, big, big connection, so big, so big, that we looked
participating in the PAINDOC Program. like family. In my group, at least, it was great. (FG2 P5)
Discussion and Silfies, 2015; Bialosky, Bishop, and Cleland, 2010).

Furthermore, the duration of CLBP might be para
The present qualitative study investigated the retrospec
mount in tailoring support strategies to individuals
tive acceptability of the PAINDOC Program,
with pain, as variations in the duration of pain may
a multidisciplinary group approach encompassing PNE,
impact their own experiences, treatment outcomes,
introduction to mindfulness meditation, Empowered
and intervention needs in clinical practice. Therefore,
Relief, pain psychotherapy, and TE. The TRA based on clinicians should routinely assess and consider the dura
the seven constructs of the TFA by Sekhon, Cartwright, tion of CLBP when designing personalized treatment
and Francis (2017) revealed a general acceptance of the plans and support strategies. In this context, it remains
PAINDOC Program among participants. Findings indi a challenge to determine the extent to which the
cated that participants felt optimistic and hopeful, experi PAINDOC Program may have promoted participants’
enced low burdens, and reported no negative impact on long-term self-management, as the results suggest that
their opportunity cost. Furthermore, the different parts of participants generally continued to recognize the need
the Program were considered coherent. However, ethical for ongoing support, follow-up, or continuity of care.
considerations arose regarding certain program elements, A recently published qualitative study, which
particularly mindfulness meditation and psychotherapy, involved a non-pharmacological brain-targeted inter
which were perceived differently depending on indivi vention, reported on the acceptability of the interven
dual value systems. To address this, adjustments could be tion and participants’ experiences regarding its impact
made to ensure program components align more closely on their attitude toward movement, increased function,
with participants’ values. Furthermore, participants high improved social participation, heightened self-
lighted the program’s efficacy in fostering active pain awareness of unnecessary guarding, and better pain
coping strategies and enhancing self-management skills, control (Rizzo et al., 2023). In their study, the authors
expressing high levels of self-efficacy in their engagement identified a range of both positive and negative emo
with the program and noting the contribution of pro tional and cognitive responses associated with the
vided materials to the adoption of pain management acceptability and potential efficacy of the intervention.
strategies in their daily lives. In terms of positive responses, the authors emphasized
The primary objective of the PAINDOC Program, in the effectiveness of communication strategies, such as
line with current practice guidelines for CLBP (Amir active listening, open-ended questions, pain science
et al., 2017), is to provide patients with comprehensive education, experiential activities, and patient-centered
adaptive strategies for effective pain coping and man communication (respecting participant’s needs and
agement. Aligning with the perceived purpose and wants) (Rizzo et al., 2023). This is consistent with
effectiveness reported by participants, the PAINDOC other research findings, which have suggested that
Program could be considered successful. Interviewed explaining to patients that pain is a marker of an over
participants indicated that, during the month following protective system might encourage their engagement in
the completion of the Program, they had acquired and self-management (Chou et al., 2017; Foster et al., 2018).
implemented a wide range of psychological, behavioral, The present qualitative study aligns with these recom
and cognitive strategies for self-managing their pain. mendations, as the participants in our study also
Participants in the PAINDOC Program demonstrated reported positively about the communication strategies
a diverse set of self-management tools based on various employed by health-care professionals. They appre
components of the Program. These tools included iden ciated unified and consistent messages, education ses
tifying distressing thoughts and emotions from the sions, and experiential activities offered by the
Empowered Relief session, using audio-guided medita PAINDOC Program, which further supported its over
tion from mindfulness sessions, and gaining a deeper all acceptability.
understanding of the biology related to pain from the While, on the whole, the interviewed participants
PNE sessions. It is important to note that research on considered the various components of the Program to
self-management strategies continues to advance with be coherent and valuable in terms of content and stra
more extensive specific frameworks (Lorig and Holman, tegies used, a few of them also perceived a lack of
2003). A recent qualitative study highlighted that many personal fit with some parts of the Program, which
patients with low back pain often struggle to maintain could be seen as a potential barrier. These results align
healthy behavior during pain-free periods between with findings suggesting that some individuals might
relapses (Nøst et al. 2021). This challenge may impact find approaches like Mindfulness meditation to be
the effectiveness of concentrated and short-duration somewhat vague or less aligned with their personal
treatment approaches in empowering patients (Beattie value system (Ruskin et al., 2017). This perception
might not necessarily be linked to the effectiveness of an self-management strategies, providing post-program
intervention but rather to the participant’s difficulty in support resources, and adopting participant-centered
grasping the concepts involved. A recently published approaches might refine the programs to better meet
qualitative study on participants’ experiences in the evolving needs of individuals with CLBP, ultimately
a multidisciplinary approach suggests a potential solu enhancing their effectiveness and impact in clinical
tion: addressing the fact that some individuals may find practice.
these concepts confusing and initiating a discussion on
the matter (Nøst et al., 2021). The authors used the
metaphor of “the restaurant” to illustrate that some self- Limitations
management interventions are akin to a “fast-food”
concept, catering to a broad audience with While the present research aimed to be systematic
a straightforward menu. In contrast, approaches like throughout the process, there are certain limitations
mindfulness meditation offer a menu with “gourmet” that need to be acknowledged. Firstly, participants’
choices, which may appeal more to individuals with acceptability was not addressed before their experience
specific preferences (Nøst et al. 2021). Similarly, a few with the intervention, and the perspective of healthcare
participants in the present study expressed a preference professionals who delivered the intervention was not
for approaches such as PNE or TE, perceiving them as included in the interviews. Future research should con
quicker to produce results or as requiring less consistent sider the viewpoints of healthcare professionals, as their
effort and time. However, as previously mentioned, acceptability may have an impact on the overall effec
participants in the PAINDOC Program exhibited tiveness of the intervention (Sekhon, Cartwright, and
a variety of self-management tools derived from all Francis, 2017). Additionally, patients should be actively
parts of the Program. Consequently, while certain com engaged in the design of healthcare services and the
ponents may stand out for participants, the overall decision-making process, seeking their input on prefer
effectiveness of such programs may depend on the inte ences, and determining the frequency of sessions (Jung
gration of diverse tools and approaches to address the et al., 2022).
multifaceted nature of CLBP. The present study was based on the seven con
Furthermore, the RTA revealed several potential bar structs described within the TFA, which reflect the
riers that could explain why some participants might subjective nature of acceptability, as these constructs
not fully connect with specific aspects of the Program: 1) can significantly differ between individuals and groups
the time constraints within certain sessions of the (Jung et al., 2022). Therefore, it is essential to utilize
PAINDOC Program may limit participant’s ability to this multi-dimensional framework when assessing the
fully engage with every aspect discussed, potentially acceptability of health intervention. Furthermore, the
affecting their ability to remember or emphasize the existing literature on acceptability and treatment pre
impact of these aspects on their experience; 2) the active ferences among CLBP patients is limited, and there is
participation and practice of exercises within the pro no one-size-fits-all approach, as the uniqueness of
gram may have a more significant impact on patients, each patient should be taken into account. The hetero
enhancing their engagement, particularly when they are geneity and the complexity of behaviors related to
more familiar with these exercises; 3) certain tools or treatment choice and patient preferences need more
techniques within the program might offer participants in-depth understanding. Besides, the interview ques
more immediate relief, leading them to emphasize these tions were not tested for face validity with the target
aspects and shaping their perception of the program’s population prior to interviews. The absence of piloting
effectiveness; 4) participants’ subjective perception of the interview guide may have hindered our ability to
specific tools and approaches within the multidisciplin refine or modify the questions based on participant
ary program may be influenced by their prior experi feedback, potentially limiting the depth and richness
ences and beliefs, including preconceived notions about of the data collected. Lastly, the last author who parti
certain approaches, which are closely related to their cipated in the qualitative analysis was the physiothera
individual personal value system; and 5) individual pist who delivered the PNE and TE sessions of the
needs and preferences vary, and as a result, specific Program. His involvement in delivering the Program
components may resonate more with certain partici might have influenced the analysis process. However,
pants than others. Considering these findings during it is worth noting that the author responsible for
the design and implementation of such programs contacting participants, conducting interviews, and
could enhance their effectiveness and overall acceptabil transcribing and anonymizing the data had no prior
ity. For example, incorporating tailored integration of relationship with the participants or the program
deliverers. All data were anonymized and validated by Data availability statement
each participant before the analysis commenced.
The data that support the findings of this study are available
from the corresponding author, [MOA], upon reasonable
request.
Conclusions
This qualitative study sheds light on the retrospective
acceptability of a multimodal and multidisciplinary Author contribution statements
group treatment based on the biopsychosocial nature All authors contributed to the present research and
of pain, assessed through the lens of the seven constructs manuscript.
of the TFA. Participants in the study reported positive
outcomes, including the adoption of active pain coping
strategies, and enhanced self-management, encompass Ethical statement
ing elements such as pain reconceptualization, positive The study protocol was approved by the Research Ethics
self-talk, or problem-solving. The Program’s ethicality Committee of the Hospital Clinic from Barcelona (HCB
appears to be closely linked to an individual’s personal 2023/0177). All participants signed an informed consent for
value system, which in some instances, acted as the recording and transcribing the interviews and anonymous
quotation of their responses in the present report.
a potential barrier to the Program’s acceptability.
However, this ethicality concern may also be influenced
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Appendices
Appendix 1. Description of materials provided to participants
Document title Purpose Layout Content overview Key information

Guided The purpose of the document is The document is organized in The document consists of The document includes
mindfulness to provide participants with a clear and user-friendly a guided mindfulness guidance on how to engage
meditation a guided mindfulness layout, with sections to guide meditation session. It includes in the meditation practice
meditation session to participants through the instructions on posture, effectively, reminders to
facilitate their daily meditation practice. breathing techniques, and maintain a non-judgmental
meditation practice. guided prompts to help attitude, encouragement to
participants focus their set aside dedicated time for
attention and cultivate daily practice, and any safety
mindfulness. precautions or
contraindications to be aware
of while meditating.
Guided The purpose of the files is to The files consist of four separate The files include four guided Key information provided in the
mindfulness provide participants with audio tracks, each focusing on mindfulness meditation files includes instructions on
meditation guided mindfulness a specific aspect of sessions, each centered how to access and use the
files meditation sessions. mindfulness meditation. around a different theme: guided meditation tracks, as
awareness of breathing, well as additional guidance or
gratitude, progressive muscle tips on incorporating
relaxation, and body mindfulness practice into
awareness. daily routines.
Empowered The purpose of the document is The document is distributed The document includes sections Includes instructions on how to
relief session to provide participants with during the Empowered Relief for participants to record their fill out each section
workbook a structured tool to create session and serves as a guide plan for each of the three effectively, as well as
their personalized self- for participants to fill out techniques proposed during encouragement for
management plan during the during the session. It is the session: Mindfulness participants to incorporate
Empowered Relief session. designed to help participants Meditation (specifying the their personalized plan into
develop their personalized time(s) of day they will their daily routine.
plan to take home with them. practice mindfulness
meditation and how many
times per day), Cognitive
Reframing (identifying
negative or catastrophic
thoughts and, for each one,
recording a kinder, neutral, or
positive alternative thought),
and a Comforting Activities
List (where participants create
a list of comforting activities
to engage in daily, promoting
self-care and well-being).
Pain psychology The purpose of the document is The document follows The content of the document Key information provided in the
workbook to provide participants with a structured layout, with includes a grid or worksheet document includes
tools and strategies from pain sections dedicated to different for participants to record their instructions on how to use the
psychology to help them aspects of pain psychology, thoughts related to pain daily. pain psychology grid
manage their pain and related including sections for daily Participants are encouraged effectively, guidance on
thoughts and activities. thought recording, identifying to note which thoughts they identifying and challenging
alternative thoughts, and could substitute with more unhelpful thoughts related to
planning comforting helpful ones, as well as to plan pain, and suggestions for
activities. comforting activities to comforting activities to
engage in daily. incorporate into daily
routines.
Pain The purpose of the document is The document follows This includes explanations of the Key information provided in the
neuroscience to provide participants with a structured layout, with concepts and principles of document includes an
education knowledge about the sections dedicated to different pain neuroscience, drawing overview of the main
guide biological processes aspects of PNE. It includes an on the “Explain Pain” book by objectives and principles of
underlying pain and change introduction to the concept of G.L. Moseley and D.S. Buttler PNE, references to the
their understanding of pain. pain neuroscience, (Moseley and Butler, 2015). It scientific literature supporting
explanations of key principles, also covers the key learning its effectiveness, and details
and strategies for applying objectives of PNE, such as the about the specific learning
this knowledge to manage relationship between warning objectives of the PNE sessions.
pain effectively. messages (nociception) and
pain, the influence of context
and thoughts on pain, and the
sensitization of the
nociceptive system in chronic
pain. Additionally, the
(Continued)
Document title Purpose Layout Content overview Key information

document discusses the
theoretical framework,
biological plausibility, and
scientific evidence supporting
PNE interventions.
Therapeutic The purpose is to provide The document consists of The content of the document Key information provided in the
exercise patients with therapeutic a booklet outlining the includes instructions and document includes detailed
sessions exercises aimed at improving exercises and techniques demonstrations for instructions on how to
guide joint mobility and muscle covered in the therapeutic therapeutic exercises. It is perform each exercise
strength in the lumbopelvic exercise sessions. divided into two main correctly, accompanied by
region. sections: “Fisiodol 1 clear and illustrative
(mobility)” and “Fisiodol 2 photographs demonstrating
(lumbar spine motor control, proper technique.
strength training and neural Additionally, guidance on
mobilization).” progression and modification
based on individual needs and
abilities is provided.
Appendix 2: Focus Group and Semi-Structured Interview Guide

The facilitator will ask the group or individual participant variations of the following questions (Please note these
questions are guides to facilitate discussion, and their formulation and order may vary according to participant
responses):
○ Could you explain your personal experience with the PAINDOC Program?
○ Did you find any part of the PAINDOC Program useful/applicable in your daily life? In which way?
○ How appropriate do you find the different strategies provided throughout the Program?
○ How useful do you find the material provided to you in the different sessions (written, meditation, audios, etc.)?
○ Could you explain your experience with the different sessions?
○ How did you feel during the different sessions?
○ What do you think about combining the different parts of the Program together to approach your situation?
○ What do you think about the coherence/complementarity of the different parts of the Program?
○ Do you remember experiencing critical situations/difficulties during the Program? Could you share any difficulties/critical
situations you encountered in attending the PAINDOC Program?
○ Do you think the PAINDOC Program might have influenced you? If yes, in which way?
○ What is your opinion about the duration, frequency, and number of the sessions?
○ Do you remember experiencing difficulties/critical situations in applying the different strategies or tips provided during the
Program?
○ Is there any aspect of the Program you think could/should be improved/changed? If yes, which one?
○ In your opinion, is there any aspects of the Program you would highlight for being more significant? If yes, which one?
○ Could you share your opinion regarding the Program’s fit with your values or ethicality?
○ How able or motivated did you feel participating in the Program? Was there something you remember as a facilitator or
a barrier in this regard?
○ If you think about you one year ago – is there any difference regarding how you feel/cope today with your pain/situation/
condition?
○ Is there anything else you want to add about your experience with the PAINDOC Program?

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Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/iptp20

Acceptability of multimodal and multidisciplinary

Mirari Ochandorena-Acha, Anna Dalmau-Roig, Christian Dürsteler, Francisco

To cite this article: Mirari Ochandorena-Acha, Anna Dalmau-Roig, Christian Dürsteler,

To link to this article: https://doi.org/10.1080/09593985.2024.2377343

Published online: 12 Jul 2024.

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QUALITATIVE RESEARCH REPORT

Acceptability of multimodal and multidisciplinary group-based program for

ABSTRACT ARTICLE HISTORY

What’s already known about this topic?

Background might depend on its acceptability since participants are

working with anonymized data. He was the only one Results

Discussion and Silfies, 2015; Bialosky, Bishop, and Cleland, 2010).

Document title Purpose Layout Content overview Key information

Document title Purpose Layout Content overview Key information

Appendix 2: Focus Group and Semi-Structured Interview Guide

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