Effectiveness of cognitive functional therapy for reducing pain and disability in chronic low back pain: a systematic review and meta-analysis

Key Points

1. Cognitive Functional Therapy (CFT) includes making sense of pain, exposure to movement, and lifestyle changes to reduce pain intensity and improve function.
2. CFT may not reduce pain intensity and disability in short or long term chronic low back pain more than other established interventions (manual therapy and core exercises).
3. The certainty of these conclusions is very low due to small sample sizes and high risk of bias.

BACKGROUND & OBJECTIVE

Cognitive functional therapy (CFT) is being promoted and adopted as a treatment approach for the management and treatment of chronic pain (1). CFT as a treatment approach follows the conceptual model of a biopsychosocial framework with an intentional inclusion of the person’s individual lived experience and the interpersonal and social aspects of pain.

Due to the limited number of studies and only one systematic review, the authors of this study were motivated to evaluate the effectiveness of CFT for reducing pain and disability in adults with chronic low back pain (LBP) (2,3). Specific questions were on the effect of CFT compared to usual care, waitlist controls, or placebo as well as the safety of CFT.

Cognitive functional therapy is promoted as a treatment approach for the management and treatment of chronic pain.

Cognitive functional therapy provides a path to operationalize a high standard of care that purposefully includes the individual preferences, priorities, and goals.

METHODS

• This systematic review followed internationally accepted guidelines (PRISMA and SWiM) and was pre-registered on PROSPERO.

• Published and unpublished randomized controlled trials in any language were included.

• Studies on sciatica or specific pathologies were excluded (stenosis, malignancy, fracture, inflammation, neurological disease, and infection).

• Studies included were on interventions that included the 3 components of CFT: making sense of pain, exposure with control, and lifestyle change.

• “Usual care” included: manual therapy, exercise, analgesic medicines, spinal injections, acupuncture, and psychological therapies.

RESULTS

• Specified primary outcomes :

  • Pain intensity and disability measured at the end of treatment.
  • Clinical significance for pain was determined as 1 point on a 0-10 pain scale.
  • Clinical significance for disability was determined as 10 points on a 0-100 scale.

• Specified secondary outcomes:

  • Safety, quality of life, fear avoidance, pain catastrophizing, pain self-efficacy, depression, anxiety, global improvement, and patient satisfaction measured at the end of treatment.

• The risk of bias was measured and reported in the appendix and a high level of heterogeneity was assumed reflecting large variations in the data. All included studies used the Oswestry Disability Index allowing for the pooling of disability scores.

• Of the 718 records initially located, 30 full-text articles were assessed for eligibility with 22 reports of 15 trials meeting eligibility. Nine trials were still ongoing, one was terminated in recruitment, and five trialswere included for review.

• 507 participants were randomized in the five included trials: 262 to CFT and 245 to control. Due to the heterogeneity of the subjects included in these trials and the high risk of bias, the authors rate the certainty of the evidence for the comparison of CFT to manual therapy/core exercises to be very low for all pooled outcomes.

• Pain Intensity Outcomes: There was no significant clinical difference between groups at the end of study, six months, 12 months, and 3 years.

• Disability Outcomes: There was no significant clinical difference between groups at the end of study. At both six months and 12 months, one of the five studies reported a significant difference favoring CFT (4). At three years, one of the five studies reported a significant difference favoring CFT (5).

• Safety Outcomes: No adverse effects were reported in the three trials that reported safety.

LIMITATIONS

• Because of the high level of heterogeneity, the authors modified their protocol and used narrative synthesis to summaries studies for analysis.

• There are five trials included in this review, the pooled data limited in value and the conclusions may change as more studies are done on CFT. There are nine ongoing trials of CFT with an additional 1000 participants that are not included in this analysis and the effectiveness data may change when those studies are completed.

CLINICAL IMPLICATIONS

One of the challenges we face as clinicians is to individualize our care in a way that fits the patient’s lifestyle, available time for interventions, interests, abilities, preferences, and to do all of that with effective interventions that will help them to meet their individual goals for pain and function. This is no small task.

These points are included in the current understanding of “best practice”. It requires a framework that can be operationalized across institutions and by individual providers who may not have organizational support. CFT with its foundation in the biopsychosocial model first proposed by Engel provides a path to operationalize a high standard of care that purposefully includes the individual preferences, priorities, and goals (6).

Conceptually CFT is intriguing and has potential. It is a time-consuming training pathway as discussed in a previous review for PhysioNetwork in June 2023 on the RESTORE trial (7). Interestingly, the RESTORE trial was not included in this systematic review. Many of the qualities promoted in CFT belong in standard practice. It may be hypothesized that the lack of difference between groups is that they are slowly being added into regular treatment for LBP.. howeverfurther studies and better care for individuals living with chronic pain remain a priority.

+STUDY REFERENCE

Devonshire J, Wewege M, Hansford H, Odemis H, Wand B, Jones M, McAuley J (2023) Effectiveness of Cognitive Functional Therapy for Reducing Pain and Disability in Chronic Low Back Pain: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther, 0(5), 1-42.

SUPPORTING REFERENCE

1. O’Sullivan, P.B. et al. (2018) ‘Cognitive functional therapy: An integrated behavioral approach for the targeted management of disabling low back pain’, Physical Therapy, 98(5), pp. 408–423.
2. Devonshire, J.J. et al. (2023) ‘Effectiveness of cognitive functional therapy for reducing pain and disability in chronic low back pain: A systematic review and meta-analysis’, Journal of Orthopaedic& Sports Physical Therapy, 53(5), pp. 244–285.
3. Miki, T. et al. (2022) ‘The effect of cognitive functional therapy for chronic nonspecific low back pain: A systematic review and meta-analysis’, BioPsychoSocial Medicine, 16(1).
4. O’Sullivan, K. et al. (2019) ‘Managing low back pain in active adolescents’, Best Practice & Research Clinical Rheumatology, 33(1), pp. 102–121.
5. Vibe Fersum, K. et al. (2019) ‘Cognitive functional therapy in patients with non‐specific chronic low back pain—a randomized controlled trial 3‐year follow‐up’, European Journal of Pain, 23(8), pp. 1416–1424.
6. Smith, R.C. (2002) ‘The Biopsychosocial Revolution’, Journal of General Internal Medicine, 17(4), pp. 309–310.
7. Kent, P. et al. (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), pp. 1866–1877.