Research Review By Dr. Demetry Assimakopoulos©


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Date Posted:

March 2019

Study Title:

Cognitive Functional Therapy: An Integrated Behavioural Approach for the Targeted Management of Disabling Low Back Pain


O’Sullivan PB, Caneiro JP, O’Keeffe MO et al.

Author's Affiliations:

School of Physiotherapy, Curtin University, Shenton Park, Western Australia; Sydney School of Public Health, University of Sydney, Australia; Department of Allied Health, University of Limerick, Ireland; Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation sciences, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Global Public Health and Primary Care, Universitetet i Bergen Institutt for indre-medisin, Bergen, Norway; Sports Spine Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.

Publication Information:

Physical Therapy 2018; 98(5): 408-423.

Background Information:

Low back pain (LBP) is the leading cause of disability worldwide (1). Disabling LBP in the absence of serious pathology is now regarded as a neurobiological and behavioural condition, opined by many to occur as a result of disruption of one’s body, lifestyle or social circumstances. The body’s response is modulated by several neuroendocrine-immuno-motor reactions, that are influenced by a combination of genetic, pathoanatomical, physical, psychological, social, lifestyle and health-related factors. These factors interact to influence inflammation, pain intensity, pain perception, distress and behavioural responses (2). Understanding these interconnected factors demands the clinician utilize a flexible multidimensional clinical framework, invariably enabling patients make sense of their pain and develop an individualized management plan aligned with their personal goals. This paper is a review of Cognitive Functional Therapy; an approach towards managing disabling LBP using these above-mentioned foundational principles.


Multidimensional Factors Associated with Disabling LBP

Pain Characteristics:
A spectrum of pain characteristics can influence the individual presentation of pain and guide management (3). Pain characteristics are highly variable over time and may require different levels of attention at different times. A history of LBP is one of the strongest predictors for future disabling LBP, suggesting that the disease process is ongoing for many sufferers (4). Certain sufferers have localized pain emanating from a clear, peripherally mediated nociceptive process. Nociceptive pain is suspected when pain can be provoked and/or relieved with specific spinal postures, movements and activities (5), and present with reduced movement variability and learned fear behaviours. Other patients may present with more widespread, ill-defined pains; such patients often display disproportionate, amplified, inconsistent and/or sustained pain responses to minor mechanical stimuli, and/or sensitivity to pressure, cold, movement and loading. The latter pain phenotype reflects a dominant pattern of central nervous system amplification of nociceptive inputs (5, 6). A mixed picture of these permutations is also possible.

Pathoanatomical and Physical Factors:
A single patho-anatomical cause of pain cannot be accurately determined in 90-95% of LBP cases (7). Approximately 5-10% of cases stem from specific spinal pathology that may require surgical intervention or urgent medical review, such as disc prolapse with radicular pain, neurological loss or cauda-equina symptoms. Although some findings such as vertebral endplate and degenerative changes have weak-to-moderate associations with disabling LBP, it is also understood that these findings are prevalent in aging and pain-free individuals and correlate poorly with pain intensity and disability. Nociceptive inputs can be modulated by several individual factors, which impact pain intensity, affective distress and disability (8). When the above-mentioned findings are not communicated optimally by the clinician, the news can lead elevated anxiety, distress and iatrogenic disability (i.e. a nocebo effect, as opposed to a placebo effect). Consideration of pathology is important in some cases, but should be only part of a comprehensive multidimensional examination.

Factors such as the intensity, frequency and pattern of exposure to mechanical spinal loading during ADLs, work and/or sport have been linked to disabling LBP. These factors interact with other individual lifestyle circumstances such as habitual movement patterns, conditioning, perception of fatigue, general health and psychological factors to increase the risk of pain.

Several pain-related functional motor behaviours can occur in response to pain, threat of pain and/or distress. Examples of these activities include stiffer, slower, less variable and more guarded spinal movements, elevated trunk muscle activity and inability to relax back muscles during movement. These behaviours can be a normal response to acute pathology/trauma. However, these behaviours can be considered maladaptive, unhelpful and even provocative when they are disproportionate to the degree of trauma/pathology or persist beyond normal tissue healing times. For example, behaviours may be associated with the lumbar spine being actively braced into extension during forward bending, propping up with the hands, avoiding loading a limb, or repetitive touching or “checking” the painful area. Rapid, shallow breathing, high muscle tension, flickering eyelids and restlessness are evidence of elevated SNS output in response to pain or threat of pain. These pain-related behaviours are linked to pain-related fear, distress, tissue sensitivity, and altered body perception, and highlight the close body-mind relationship (9).

Psychological Factors:
Cognitive and emotional factors have been shown to influence pain processing, pain perception, pain-related distress and coping responses. Cognitive factors are negative implicit or explicit thoughts people have about their pain, the meaning of pain and future consequences. Examples include catastrophic thinking (i.e. rumination, hypervigilance, magnification of threat and helplessness), and low confidence for performing pain-provoking activities (i.e. pain self-efficacy). Many negative cognitions originate from encounters from healthcare providers, underlying negative emotional responses, behavioral conditioning, culture and societal attitudes (11).

Emotional factors reflect an individual’s feelings, which may be driven by pain cognitions, context, societal stressors or co-morbid mental health issues (12, 13). A common emotional response to pain is fear, which is closely linked to pain perception, controllability and predictability, particularly when it is linked to beliefs of tissue damage, further pain or suffering. High levels of perceived stress and negative responses to emotional stressors, pain-related anxiety, depressed mood, heightened frustration, anger and perceived injustice are all linked to pain perception and disability.

Social factors:
Historical and contextual social factors and distress also affect disabling LBP (14). Examples include societal conditioning (family history of pain, socioeconomic status, education, etc.), exposure to stressful situations/life events (abuse, financial hardship, negative work environment, litigation) and unhelpful relationships (punishing or solicitous). Social factors may be modifiable or non-modifiable, depending on the individual. When appropriate, their contribution of pain should be discussed with the patient.

Lifestyle Factors:
These are known to be important potentially modifiable and variable in disabling LBP patients. For example, sleep is highly co-morbid with disabling LBP, predicts the development of worsening or disabling LBP and influences psychological well-being. Disabling LBP also conversely predicts sleep problems (15, 16).

Interestingly, there is a U-shaped relationship between physical activity and disabling low back pain, with both low levels of physical activity/sedentary behaviours (i.e. < 90 mins/week) and high levels of physical activity (i.e. > 100 mins of vigorous activity/day) demonstrating positive relationships with LBP (17, 18). Being sedentary can negatively affect inflammatory processes and bone health. Smoking is also an independent modest risk factor for LBP, but the mechanism remains unclear.

General health problems such as mental health disorders, sleep apnea, fatigue, insomnia and IBS can strongly influence disability levels and provide barriers to management.

Cognitive Functional Therapy (CFT): Assessment and Treatment:

CFT is an integrated behavioural approach for individualizing the management of people with disabling LBP once red flags or specific pathologies have been excluded. The approach utilizes a multidimensional “clinical reasoning framework” to identify key modifiable targets for management.

A strong therapeutic alliance is the central tenet of CFT. The alliance is underpinned by a motivational approach and by open, reflective, empathetic and validating communication. This type of relationship facilitates disclosure, reinforces positive health behaviours and encourages reflection on discrepancies in beliefs and behaviours, while avoiding unhelpful conflict.

Patients complete a body pain chart and a multidimensional questionnaire (Orebro Pain Questionnaire) to provide insight into their perception of pain. The questionnaire provides an opportunity to explore pain beliefs and emotional responses to pain. The interview then begins with an open question such as “tell me your story” which allows patients to communicate how they make sense of their pain. Multiple lines of questioning are then probed, including:
  1. Pain history and the social, cognitive, emotional, physical, lifestyle and health care circumstances around the time pain began. This enables the clinician and patient to differentiate acute LBP associated with an acute traumatic event, minor mechanical triggers or an insidious pain onset.
  2. Pain provocative and relieving postures, movements, loads and rest to determine possible stimulus-pain response patterns.
  3. Beliefs regarding the cause of their pain, future time course, pain controllability, predictability and severity. Radiology is reviewed and discussed, particularly if they reinforce negative beliefs.
  4. Emotional responses to pain (fear, distress, current social context)
  5. Behavioural responses to pain (coping strategies, avoidance/persistence, protective guarding, postural and movement habits and lifestyle).
  6. Painful, feared and avoided valued functional activities.
  7. Perceived barriers to engaging in a healthy lifestyle.
  8. Relevant goals, barriers to achieving goals and expectations.
The interview concludes by the clinician summarizing the story to check its accuracy.

The assessment is directed towards the patient’s valued functional tasks, such as spinal postures, movements and activities that the patient described as painful, feared and/or avoided. The clinician observes the behavioural strategies adopted during these functional tasks, including the presence of safety and communicative behaviours, and sympathetic responses. The clinician palpates the patient’s painful area to assess levels of tissue sensitivity, trunk muscle guarding and respiratory patterns during these tasks. The patient is asked about their beliefs, feelings, body perceptions and pain responses while performing these tasks.

The observations allow the clinician to guide the patient through a series of experiments, which explicitly seek to reduce sympathetic responses and to abolish safety and communicative behaviours prior to and while gradually exposing the patient to fearful, avoided and painful tasks. These techniques include relaxed diaphragmatic breathing, body relaxation and control. Graded exposure may include imagined movements into painful postures prior to performing an actual task. Visual feedback using mirrors, video and clinician demonstration are used to solidify concepts. Attention is also brought to discrepancies between pain expectations and pain experiences, to confront the patient’s belief that movement is threatening. This enables the patient to understand that moving and loading the spine without protection and avoidance is safe. Care is taken not to cause undue pain escalation, distress or sympathetic responses during assessment.

CFT for Disabling LBP Management:

Both modifiable and non-modifiable factors contributing to pain are uncovered during the history and physical examination. Some of these barriers necessitate interdisciplinary care, and in such cases, co-management with another healthcare professionals is required.

CFT Interventions Include:
  1. Making Sense of Pain: Educating the patient in a reflective way that uses the individual’s story, words and metaphors combined with their experiences during the examination to disconfirm their previously held beliefs and provide a new understanding of their pain is the first step in CFT. How contextual factors, negative pain beliefs and unhelpful emotional/behavioural responses set up a vicious cycle of pain, distress, disability, and inability to engage in a fulfilled life is communicated to the patient. The patient is then invited to reflect on what they can do to break this cycle to reach their goals through a clear and realistic self-motivated strategy towards behavioural change.
  2. Exposure with Control: This phase is a process of behavioural change through experimental learning. The patient learns to control sympathetic responses and safety behaviours, allowing them to return to valued functional activities without pain escalation and associated distress. The clinician may guide a patient though a series of body relaxation exercises, then gradually expose the patient to painful or feared movements or activities. Functional conditioning is provided when there are deficits in muscle strength and endurance, which act as barriers to achieving goals. When pain control is not achievable, focus is placed away from pain and towards relaxation and replacing safety behaviours with relevant functional and lifestyle goals. These functional strategies are gradually integrated into daily living to improve self-efficacy. Patients are usually seen weekly for 2-3 sessions. Sessions are then extended to every 2-3 weeks to build confidence for self-management. Booster sessions can be used after discharge if needed.
  3. Lifestyle Change: The clinician first assists the patient in creating a self-guided exercise program, based on their preferences, accessibility, cost and social engagement. If the person is highly sensitized, this approach may be directed in a graduated, time-contingent manner, while considering safety behaviours. Sleep deficit and disturbance can also be addressed in a variety of ways if required, through sleep hygiene education. If sleep disturbance is secondary to pain, worry or stress, this may be addressed by using relaxation, breathing and guided meditation techniques. If pain during sleep is associated with movement, teaching the patient how to roll and posture in a relaxed manner is explored.
Skills Required to Implement CFT:

CFT requires skills across several domains, including behavioural psychology, neuroscience, communication skills, clinical reasoning, observational skills and movement re-education skills. Barriers to clinicians adopting this approach relate to the clinician’s confidence in dealing with psychosocial factors, time constraints, privacy for sensitive conversations and a reliance on passive treatments. It should be noted that practitioners who have been trained to broaden their skill set towards a multidimensional approach to pain report positive changes to their clinical practice.

Clinical Application & Conclusions:

Cognitive Functional Therapy (CFT) is an integrated individualized behavioural approach for those with disabling LBP, based on a multidimensional clinical reasoning framework. Clinicians and patients together attempt to identify and target modifiable biopsychosocial factors that drive pain, pain-related distress and disability. The goal is to help the patient to develop strategies to break the cycle of distress and disability, enabling their return to valued functional activities and healthy lifestyle behaviours. CFT is not only meant for treating disabling LBP. It can be applied to a range of clinical MSK scenarios where the patient is hampered from living their desired life due to pain.

Study Methods:

This article was written as a clinical primer for readers. As such, no statistical analysis or search strategy was performed or published.

Study Strengths / Weaknesses:

These authors did a great job of outlining the various processes involved in application of CFT, while acknowledging that further research on its utilization in clinical settings needs to be continued. Interestingly, much of the research performed on this very topic comes out of their laboratory, which introduces the potential for considerable bias in terms of its efficacy, particularly when compared against other treatment modalities. It would be interesting to see a multicentre trial comparing CFT to other common LBP treatments, including cognitive behavioral therapy (CBT).

Additional References:

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  2. Hodges PW, Tucker K. Moving different¬ly in pain: a new theory to explain the adaptation to pain. Pain. 2011;152(Sup¬plement): S90–S98.
  3. Fillingim RB. Individual differences in pain. Pain 2017; 158(suppl 1): S11–S18.
  4. Taylor JB, Goode AP, George SZ, Cook CE. Incidence and risk factors for first-time incident low back pain: a system¬atic review and meta-analysis. Spine J 2014; 14: 2299–2319.
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