What is cognitive functional therapy? How can it reduce low back pain and get you moving?

If you haven’t had lower back pain, it’s likely you know someone who has. It affects around 40% of adults^[1] in any year, ranging from adolescents to those in later life. While most people recover, around 20%^[2] go on to develop chronic low back pain (lasting more than three months).

There is a common view^[3] that chronic low back pain is caused by permanent tissue damage including “wear and tear”, disc degeneration, disc bulges and arthritis of the spine. This “damage” is often described as resulting from injury and loading of the spine (such as bending and lifting), ageing, poor posture and weak “core” muscles.

We’re often told to “protect” our back by sitting tall, bracing the core, keeping a straight back when bending and lifting, and avoiding movement and activities that are painful. Health practitioners often promote and reinforce these messages^[4].

But this is not based on evidence^[5]. An emerging treatment known as cognitive functional therapy^[6] aims to help patients undo some of these unhelpful and restrictive practices, and learn to trust and move their body again.

Read more: Having ‘good’ posture doesn't prevent back pain, and 'bad' posture doesn't cause it^[7]

People are often given the wrong advice

People with chronic back pain are often referred for imaging scans to detect things like disc degeneration, disc bulges and arthritis.

But these findings are very common in people without low back pain and research shows they don’t accurately predict^[8] a person’s current or future experience of pain.

Once serious causes of back pain have been ruled out (such as cancer, infection, fracture and nerve compression), there is little evidence^[10] scan findings help guide or improve the care for people with chronic low back pain.

In fact, scanning people and telling them they have arthritis and disc degeneration can frighten them^[11], resulting in them avoiding activity, worsening their pain and distress.

It can also lead to potentially harmful treatments such as opioid^[12] pain medications, and invasive treatments such as spine injections^[13], spine surgery^[14] and battery-powered electrical stimulation of spinal nerves.

Read more: Opioids don't relieve acute low back or neck pain – and can result in worse pain, new study finds^[15]

So how should low back pain be treated?

A complex range of factors typically contribute^[16] to a person developing chronic low back pain. This includes over-protecting the back by avoiding movement and activity, the belief that pain is related to damage, and negative emotions such as pain-related fear and anxiety.

Addressing these factors in an individualised way is now considered^[17] best practice.

Best practice care^[19] also needs to be person-centred. People suffering from chronic low back pain want to be heard and validated. They want^[20] to understand why they have pain in simple language.

They want care that considers their preferences and gives a safe and affordable pathway to pain relief, restoring function and getting back to their usual physical, social and work-related activities.

An example of this type of care is cognitive functional therapy.

What is cognitive functional therapy?

Cognitive functional therapy^[21] is about putting the person in the drivers’ seat of their back care, while the clinician takes the time to guide them to develop the skills needed to do this. It’s led by physiotherapists and can be used once serious causes of back pain have been ruled out.

The therapy helps the person understand the unique contributing factors related to their condition, and that pain is usually not an accurate sign of damage. It guides patients to relearn how to move and build confidence in their back, without over-protecting it.

It also addresses other factors such as sleep, relaxation, work restrictions and engaging in physical activity based on the person’s preferences^[22].

Cognitive functional therapy usually involves longer physiotherapy sessions than usual (60 minutes initially and 30-45 minute follow-ups) with up to seven to eight sessions over three months and booster sessions when required.

Read more: Ouch! The drugs don't work for back pain, but here's what does^[23]

What’s the evidence for this type of therapy?

Our recent clinical trial of cognitive functional therapy, published in The Lancet^[24], included 492 people with chronic low back pain. The participants had pain for an average of four years and had tried many other treatments.

We first trained 18 physiotherapists to competently deliver cognitive functional therapy across Perth and Sydney over six months. We compared the therapy to the patient’s “usual care”.

We found large and sustained improvements in function and reductions in pain intensity levels for people who underwent the therapy, compared with those receiving usual care.

The effects remained at 12 months, which is unusual in low back pain trials. The effects of most recommended interventions such as exercise or psychological therapies are modest in size^[26] and tend to be of short duration^[27].

People who underwent cognitive functional therapy were also more confident, less fearful and had a more positive mindset about their back pain at 12 months. They also liked it, with 80% of participants satisfied or highly satisfied with the treatment, compared with 19% in the usual care group.

The treatment was as safe as usual care and was also cost-effective. It saved more than A$5,000 per person over a year, largely due to increased participation at work.

What does this mean for you?

This trial shows there are safe, relatively cheap and effective treatments options for people living with chronic pain, even if you’ve tried other treatments without success.

Access to clinicians^[28] trained in cognitive functional therapy is currently limited but will expand as training is scaled up.

The costs depend on how many sessions you have. Our studies show some people improve a lot within two to three sessions, but most people had seven to eight sessions, which would cost around A$1,000 (aside from any Medicare or private health insurance rebates).

Read more: Why does my back get so sore when I'm sick? The connection between immunity and pain^[29]

References

1. ^{^} around 40% of adults (pubmed.ncbi.nlm.nih.gov)
2. ^{^} around 20% (pubmed.ncbi.nlm.nih.gov)
3. ^{^} common view (bjsm.bmj.com)
4. ^{^} promote and reinforce these messages (theconversation.com)
5. ^{^} not based on evidence (bjsm.bmj.com)
6. ^{^} cognitive functional therapy (pubmed.ncbi.nlm.nih.gov)
7. ^{^} Having ‘good’ posture doesn't prevent back pain, and 'bad' posture doesn't cause it (theconversation.com)
8. ^{^} don’t accurately predict (pubmed.ncbi.nlm.nih.gov)
9. ^{^} AJNR (theconversation.com)
10. ^{^} little evidence (pubmed.ncbi.nlm.nih.gov)
11. ^{^} frighten them (pubmed.ncbi.nlm.nih.gov)
12. ^{^} opioid (pubmed.ncbi.nlm.nih.gov)
13. ^{^} injections (pubmed.ncbi.nlm.nih.gov)
14. ^{^} surgery (pubmed.ncbi.nlm.nih.gov)
15. ^{^} Opioids don't relieve acute low back or neck pain – and can result in worse pain, new study finds (theconversation.com)
16. ^{^} typically contribute (pubmed.ncbi.nlm.nih.gov)
17. ^{^} now considered (pubmed.ncbi.nlm.nih.gov)
18. ^{^} Pexels/Yan Krukau (www.pexels.com)
19. ^{^} Best practice care (pubmed.ncbi.nlm.nih.gov)
20. ^{^} want (pubmed.ncbi.nlm.nih.gov)
21. ^{^} Cognitive functional therapy (pubmed.ncbi.nlm.nih.gov)
22. ^{^} person’s preferences (www.restorebackpain.com)
23. ^{^} Ouch! The drugs don't work for back pain, but here's what does (theconversation.com)
24. ^{^} The Lancet (www.thelancet.com)
25. ^{^} Shutterstock (www.shutterstock.com)
26. ^{^} modest in size (pubmed.ncbi.nlm.nih.gov)
27. ^{^} short duration (pubmed.ncbi.nlm.nih.gov)
28. ^{^} Access to clinicians (www.restorebackpain.com)
29. ^{^} Why does my back get so sore when I'm sick? The connection between immunity and pain (theconversation.com)