Cognitive functional therapy and low-back pain

As low-back pain becomes increasingly prevalent, new treatment modalities offer hope for patients who do not respond to conventional treatments. Cognitive functional therapy is one such new and promising method.

1. Introduction
2. The CFT approach
3. Tackling false beliefs
4. Summary

Introduction:

Cognitive functional therapy (CFT) is a relatively new approach for treating patients with chronic low-back pain (LBP) and is gaining popularity due to its superior effectiveness in improving pain and function compared to usual care methods such as exercise and manual therapy (Kent et al., 2023). Patients also reported high levels of satisfaction with the intervention, finding it helpful (Vibe Fersum et al., 2013).

As therapists, we need to consider how we can reach patients who are in pain and fear and help them find a way out, and help them strengthen their own resources and self-efficacy. We need to think of a big end goal for them (with them), and then break that down into small and actionable steps.
This is what CFT does. On which we will provide a general overview in the following article.

LBP is a leading cause of disability worldwide, affecting hundreds of millions. Some LBP problems get better by themselves after a few weeks, due to the natural course of healing, while some stay persistent and lead to disability. O' Sullivan describes disabling LBP as follows: "disabling low back pain (LBP) in the absence of serious pathology is best seen as neurobiological and behavioral responses to individuals’ actual and/or perceived threat to their body, lifestyle, or social circumstances and/or disruption to their homeostasis" (O’Sullivan et al., 2018). Which is what this blog post will focus on. LBP without a specific cause, also known as non-specific low-back pain.

The CFT-Approach:

Before beginning with any treatment, it is very important to first screen for serious pathology.
These people make up the minority (around 1%) of people with low back pain, but need to be assessed for malignancy, infections or inflammatory disorders.
Then there are around 5-10% of people who have specific-low-back pain, as their pain can be correlated to a specific event or diagnosis (fracture, disc bulge, spondylolisthesis). If back pain follows a traumatic injury, a scan may be needed to check for fractures. Scanning is also necessary if back pain is accompanied by urinary retention, limb weakness or numbness, fever, or a history of cancer. If these symptoms are absent, you likely fall into the 90-95% of cases classified as non-specific low back pain. Meaning we do not know from which structure the pain is coming from. These 90%, categorised as non-specific LBP patients, will be the targets of CFT.

Main takeaway: Always screen for serious pathology first.

A big emphasis is laid on taking the patient history. Where we should give the patient adequate time to explain to us the development of his pain, his beliefs about why he is in pain, the emotional state he is currently in, how the pain impacts his social environment, what his ADLs look like and what his goals are for the future by coming to us. This can take up to 30 minutes of careful listening to the patient.

CFT builds on 3 core aspects, which are:

1. Making sense of pain:

Explaining pain science and basic neurology to our patients can be helpful when it comes to breaking through negative believes, as some basic understanding of how pain really works is necessary to do so. It's important for people to understand that thoughts and emotions can influence our chemistry via the autonomous nervous system, potentially leading to increased muscle stiffness and pain sensitivity.

Pain in itself is always influenced by our beliefs, culture, social environment, meaning and context. This means that nociception (tissue damage) and pain (a perception created in the brain) will not always be in perfect correlation.
It is well known, that minor tissue damages can lead to massive pain if adequate "danger" is given to the injury, while really big injuries can lead to minimal pain in the right context.
You can even have pain without any tissue damage at all as it can simply arise due to stress, which is the case with many headaches. The same can be true for back pain.

Main takeaway: Pain is a sign of tissue sensitivity rather than tissue damage.

2. Exposure with Control

Having understood the importance of pain perception, we now turn to the practical application of these concepts in therapy. We will look for movements that our patient fears or finds painful and ask them to demonstrate these tasks. All the while, we will be looking for changes in his breathing that might take place, his muscle tone going up, shifting of body weight to one side 0r other safety mechanisms that the patient might reveal.
Then we will make the person feel safe, affirm to them that they will not hurt their back from moving the spine and help them calm down via relaxation techniques, such as diaphragmatic breathing, with the goal of reducing muscle hypertonicity.
Then we will break down the movement he just performed (like forward bending) and chunk it down into bigger pieces.
This could look like the following: We might start by having him lie down and simply perform pelvis posterior tilts or bringing the knees to the chest. Then we might progress this by doing pelvic tilting in a seated position or in standing. Then we might ask the patient to slowly bend forward while being seated or quadruped, while still breathing through the stomach. Until we get him back to performing the bending exercise in standing.
By this, we will show our patient that they actually can perform movements (for example the posterior pelvic tilt, which leads to bending of the spine) that target the exact movement they are fearful of, without triggering any pain. And we can then progress this by going further and further, demonstrating and having the patient realize for themselves, that performing any movement does not have to lead to pain or disability. This is the foundation of helping them build a better, healthier mindset about their back health and back pain in general.
Patients are given a daily exercising regime for improving this area. Sometimes, using visual feedback (such as a mirror) to show people how they move, might be useful to normalise maladaptive movement patterns that people often adopt due to fear of loading the spine.

Main takeaway: We will take a big movement that is painful and concerning to our patient and we will then break it down into smaller exercises, that are targeting the same motion but will not trigger the same pain / fearful response in our patients. This approach can be utilised for every movement pattern. It's a graded exposure towards the feared activities.

3. Lifestyle Changes

We will then coach them on improving their sleeping habits, exercising regularly and eating healthy.

Health message: New beliefs that we should install into our patients:

• The back loves to bend
• A moving spine is a healthy spine
• Relaxation exercises (deep breaths...) help deal with pain
• Pain does not mean tissue damage
• Good sleep and a healthy diet is crucial for getting better
• Physical activity is important for back health

We need to bring confidence back to them, teach relaxation techniques to lead to better sleep, pain management and reduced muscle tension. We want to show them that they are in control of their pain.

Next up we have them slowly resume their hobbies and activities of interest, again by helping them progress towards more challenging exercises bit by bit. For example if a patient really cherishes running outside, we would have him begin walking his running route. If that's all right, walk faster. Then job for 15 seconds and walk for 30 seconds and so on. Until we are back at running the whole distance.
We as therapists don't try to "cure" back pain, but to manage it. LBP can recur throughout a lifetime and therefore our aim it to give the patients the tools with which they can treat themselves.

Main takeaway: Get people back to their valued activities by adopting a step-by-step training protocol.

The above three steps are what CFT builds on and takes a bio-psycho-social approach to LBP.
People with long standing, chronic back problems often hold very negative beliefs on back health and how movement affects them. In the following we will shortly discuss how to go about such beliefs.

Tackling false beliefs:

Limiting beliefs, fear about bending and thinking the spine is unstable and needs to be straight and the core needs to be stiff at all times are harmful and need to be addressed when seeing patients with chronic back pain.

A negative mindsets can often lead to negative emotional responses and lead to fear about back health. Especially if people believe that pain means their back structure has been damaged which will leave them disabled and that there is nothing they can do about it.
And just like that catastrophic thoughts develop and lead to fear of movement.

This is where the big problem lies. Because fear of movement will lead to the avoidance of movement. If a clinician tells you that you should not bend your spine, that the spine is fragile and you can only move it safely with a stiff core, that you need to constantly check your posture and that pain equals damage, then of course people will learn to avoid moving the spine best they can. But that is exactly what we do not want for our patients.
Movement has been consistently shown to be one of the most important factors regarding the management of back pain and disabling ideas such as those named above, with no scientific evidence (to suggest the back is fragile, that rounding the spine is bad or that core stiffness is necessary), is completely counterproductive.
Therefore, we as practitioners need to clear up those misguided beliefs our patients present with and clear up those misunderstandings. While encouraging them to move their spine in every way they want (although we do not suggest that people should go into the extremes of painful ranges of motions, a little pain when moving the spine is very unlikely to be harmful).
People with LBP have been shown to move slower and stiffer (probably due to their belief on the spine being unstable, trying to protect it) and have elevated trunk muscle co-contractions. But the back needs movement to be healthy.
People often think that not moving it will make it better. But in reality, not moving it, nor putting any load onto the musculoskeletal system will make it weaker. That's simple physiology. And weakening our spine, our center of movement, will certainly not make us healthier or assist in regaining spinal function. Communicating this to our patients, while validating their pain, is important.

Main takeaway: Movement is not damaging to spinal structures. On the contrary, it even helps.

A big strength of CFT are its low-costs and low risk compared to other treatment modalities. For patients with a low-disability profile, around 1-3 sessions of CFT are recommended (following the above structure), while for patients with a high-disability profile, supervision for 8-12 weeks of several CFT sessions is recommended (O’Sullivan et al., 2018).

Summary:

All in all, it can be confidently stated, that CFT is a treatment modality that certainly has unique advantages over other (common care) treatments. While that is true, it is not the only way to treat people with back pain, but might prove as being just the right asset for the right patients.

The cognitive functional therapy approach starts by screening for red flags, then screening for potential risk factors for non-recovery (such as negative believes, job dissatisfaction, low mood), provide evidence based education (information on the nature of pain...) and then go into a combined physical and psychological (referral to a psychologist for adjunct treatment is often recommended) treatment.
We need to see ourselves as coaches and not as treaters in this scenario, guiding patients to make the changes themselves.
By doing that we can guide patients towards increased self-efficacy, helping them take care of their pain themselves.

References:

Kent, P., Haines, T., O’Sullivan, P., Smith, A., Campbell, A., Schutze, R., Attwell, S., Caneiro, J. P., Laird, R., O’Sullivan, K., McGregor, A., Hartvigsen, J., Lee, D.-C. A., Vickery, A., & Hancock, M. (2023). Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): A randomised, controlled, three-arm, parallel group, phase 3, clinical trial. The Lancet, 401(10391), 1866–1877. https://doi.org/10.1016/S0140-6736(23)00441-5

O’Sullivan, P. B., Caneiro, J. P., O’Keeffe, M., Smith, A., Dankaerts, W., Fersum, K., & O’Sullivan, K. (2018). Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Physical Therapy, 98(5), 408–423. https://doi.org/10.1093/ptj/pzy022

Vibe Fersum, K., O’Sullivan, P., Skouen, J. S., Smith, A., & Kvåle, A. (2013). Efficacy of classification‐based cognitive functional therapy in patients with non‐specific chronic low back pain: A randomized controlled trial. European Journal of Pain, 17(6), 916–928. https://doi.org/10.1002/j.1532-2149.2012.00252.x