Cognitive functional therapy for chronic low back pain?

This study investigated the efficacy of cognitive functional therapy (CFT) versus a sham procedure for pain intensity and disability for patients with non-specific chronic low back pain (CLBP). It is a randomised sham-controlled trial conducted in a primary care public health service. A total of 152 participants were randomly assigned to the CFT group (n=76) and the sham group (n=76). The CFT group received six 1 hour individualised sessions; the sham procedure group received six individual sessions of neutral talking+detuned photobiomodulation (low-level laser therapy) equipment. Both groups received an education booklet with information on strategies for CLBP self-management. Primary outcomes were pain intensity and disability at 6 weeks. Participants were assessed preintervention, postintervention (at 6 weeks), and 3 and 6 months after randomisation.

The researchers obtained primary outcome data from 97.4% (n=74) of participants in the CFT group and 98.7% (n=75) from the sham group. The CFT group showed greater effects in pain intensity (mean difference (MD)=-1.8; 95% CI -2.5 to -1.1) and disability (MD=-9.9; 95% CI -13.2 to -6.5) postintervention compared with the sham group. The effect remained at the 3-month and 6-month follow-ups.

The authors concluded that CFT showed sustained clinical efficacy compared with a sham procedure for treating pain intensity and disability in patients with CLBP.

In recent months, there have been many studies of CFT showing promise for LBP, e.g.:

• In people with lifting-related LBP undergoing CFT, increased trunk velocity during lifting showed potentially large correlations with reductions in disability and improvements in pain self-efficacy.
• Within-person changes in lifting technique varied among individuals. Greater trunk ROM and velocity, lower knee ROM and velocity, and faster lifting movements often co-occurred with lower levels of pain and functional limitation. This reflects a transition along a continuum from squat-like towards semi-squat-like and stoop-like lifting techniques.
• Following eight weeks of intervention, both ET and ET + CFT improved functional disability, pain, lumbar pelvic motor control, and biopsychosocial indicators in individuals with CNLBP. Notably, while the combined intervention group (ET + CFT) showed greater improvements across most outcomes, it was significantly different from the exercise-only group only on the Kinesiophobia scale. These findings suggest that cognitive functional therapy may enhance the effectiveness of exercise therapy by addressing psychological factors, such as fear of movement, that contribute to pain and disability in CNLBP.
• Improvements in pain catastrophizing (PC) and pain self-efficacy (PSE) were strongly correlated with increased trunk velocity-but not trunk or lumbar ROM-in people with CLBP who were undergoing CFT. These findings are consistent with CFT that explicitly trains “nonprotective” spinal movement in conjunction with positively reframing pain cognitions
• Cognitive functional therapy intervention had a greater effect on the vertical ground reaction force parameters. The reason for the greater effect of cognitive functional therapy intervention on vertical ground reaction force parameters can be partially explained due to the multimodal therapy used through cognitive exercises and motor control.

So, what exactly is this new wonder therapy? CFT is an approach invented and promoted by physiotherapists to analyse the behavioural psychology, beliefs and patterns of movement of LBP patients. Subsequently, the therapist would assist patients in understanding their pain and determine strategies to manage it within their goals of activities, participation, and lifestyle. CFT employs a multifaceted clinical reasoning framework to identify modifiable factors of an individuals presentation based on their personal characteristics and lifestyle and assessing their response to pain. CFT is supposed to help patients become autonomous, and self-manage their pain with their own personalised treatment.

A CFT intervention would usually involve, over several sessions: 

• Making sense of the patient’s pain, and helping them to understand the pain.
• Exposure with Control (show and train the patient their movement with alterations in movement pattern and control)
• Training postural control
• Training their movement with or without gradual exposure
• Providing visual feedback with mirror or video
• Integrating these patterns in functional tasks
• Providing reassurance of safe movement of the body
• Making the patient feel more comfortable and accustomed to the movement
• Lifestyle changes, such as sleeping patterns, and breathing techniques
• Outcome (leading to a positive outcome, where the patient would behave normally, and feel rejuvenated).

It seems to me that CFT condenses and formalizes much of what good clinicians have been doing intuitively all along – simply because it is common sense and physiologically plausible. It also seems to me that it is not the huge breakthrough that it is currently hyped to be. It probably is a step in the right direction but not a magic wand for getting rid of back pain.