Changing beliefs for changing movement and pain: Classification-based cognitive functional therapy (CB–CFT) for chronic non-specific low back pain

Cognitive functional therapy for lower back pain: A meta-analytical assessment of pain and disability outcomes in randomized controlled trials

BackgroundCognitive functional therapy (CFT) aims to address low back pain (LBP) comprehensively by considering physical, psychological, and social factors.ObjectiveThe objective was to evaluate the effectiveness of CFT in reducing pain and disability in individuals with LBP over various time intervals.MethodA comprehensive literature search was conducted to identify relevant randomized controlled trials (RCTs) assessing the effects of CFT on LBP.ResultsIn this study, 1510 records were initially identified, and 7 studies were included in the analysis. Disability scores were significantly reduced after CFT had been applied for 6 to 8 weeks (SMD = - 0.46, 95% CI [- 0.74, - 0.19]), 12 weeks to 3 months (SMD = - 0.54, 95% CI [- 0.72, - 0.36]), 6 months (MD = - 5.82, 95% CI [- 9.82, - 1.82]), and 12 months (SMD = - 0.4, 95% CI [- 0.55, - 0.26]). There were also significant reductions in pain scores observed after 12 weeks to 3 months (SMD = - 0.49, 95% CI [- 0.68, - 0.3]), 6 months (MD = - 0.75, 95% CI [- 1.5, - 0.0001]), and 12 months (SMD = - 0.27, 95% CI [- 0.42, - 0.12]).ConclusionCFT showed potential for improving disability scores for individuals with LBP across various time intervals. However, its impacts on pain scores varied.

Comparison of cognitive functional therapy and neurofeedback training on kinetic gait in patients with chronic non-specific low back pain: a randomised controlled trial

PURPOSE OF THE ARTICLE

Walking disorders are a significant issue for patients with low back pain. The aim of clinical trials is to compare the effects of cognitive functional therapy (CFT) and neurofeedback training (NFBT) on gait kinetics in chronic non-specific low back pain (CNSLBP) patients.

MATERIALS AND METHODS

Sixty females with chronic non-specific low back pain were recruitment for clinical trials. They were randomly divided into experimental and one control groups (Each group 20 patients). The experimental group received the relevant interventions for eight weeks. The primary outcome was pain, kinesiophobia and disability. The secondary outcome was vertical ground reaction force (VGRF) parameters. Two-Way Repeated Measures ANOVA statistical method was used for data analysis.

RESULTS

Within-group comparisons showed that neurofeedback training and cognitive functional therapy groups experienced significant improvement in pain intensity, disability and kinesiophobia after eight-week (p < 0.05). However, the cognitive functional therapy group improved the vertical ground reaction force parameters better than the neurofeedback training group (p < 0.05).

CONCLUSIONS

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.

The effectiveness of cognitive functional therapy on patients with chronic neck pain: A systematic literature review

OBJECTIVE

Recently, psychological, and behavioral interventions such as cognitive functional therapy (CFT) has gained significant attention in musculoskeletal rehabilitation. We aimed to compare interventions with a CFT component in adults (>18 years old) suffering from chronic neck pain (CNP) or chronic whiplash associated disorders (>3 months) with another intervention or no intervention, in pain, disability, kinesiophobia, or any other reported outcome measure.

RESULTS

One case-study and three randomized controlled trials met the eligibility criteria. Statistically and clinically significant improvement in pain was found in favour of CFT combined with scapular exercise compared to exercise alone (MD = -19.91; 95%CI: -24.18 to -15.64) and controls (MD = -48.91; 95%CI: -53.88 to -43.94) at the very-short term follow-up. A significant difference in kinesiophobia was found at the short-term follow-up in favour of CFT and exercise compared to exercise alone (MD = -13.23; 95%CI-16.94 to -9.52) and controls (MD = -40.81 95%CI: -44.55 to -37.07). Finally, statistically and clinically significant improvement was found in favour of CFT compared to controls at the short-term follow-up in stress (MD = -36.62, 95%CI: 43.47 to -29.77), fear avoidance (MD = -35.44; 95%CI: 42.57 to -28.31), anxiety (MD = -34.43; 95%CI: 41.90 to -26.96), pain catastrophizing (MD = -25.19; 95%CI: 32.49 to -17.89), depression (MD = -30.72; 95%CI: 38.37 to -23.07), but a significant and clinically difference in favour of the control group at self-efficacy (MD = 29.56; 95%CI20.70 to 38.42).

CONCLUSIONS

Very low certainty evidence suggests that CFT alone or in combination with exercise may produce better outcomes than no treatment or exercise alone. The results should be interpreted with caution, given that the number of studies assessing CFT in CNP is limited.

The effect of cognitive functional therapy on the plantar pressure distribution symmetry in patients with chronic non-specific low back pain: A randomized controlled trial

OBJECTIVE

This study aimed to evaluate the effect of Cognitive functional therapy (CFT) on plantar pressure distribution symmetry in chronic non-specific low back pain (CNSLBP) patients.

METHOD

forty females with NSCLBP (age range 30-50 years) were recruited for clinical trials. They were randomly divided into experimental and control groups (Each group had 20 patients). The patients in the experimental group received CFT for 8 weeks. The primary outcome was psychological variables inclusive of pain, kinesiophobia and disability. The secondary outcome was plantar pressure distribution symmetry which assessment in standing condition. The Covariance statistical method was used for data analysis.

RESULTS

The results of covariance analysis for primary outcome showed a significant difference (p < 0.05) with a reduction of 52 % in pain (p = 0.001), 12 % in kinesiophobia (p = 0.001) and 41% in disability (p = 0.001). Also, the results of covariance analysis for secondary outcome showed a significant difference in plantar pressure distribution symmetry of inter-limbs foot (p = 0.007), forward and backward in the right foot (p = 0.002) and forward and backward in the left foot (p = 0.001).

CONCLUSION

CFT reduces of pain, kinesiophobia and disability. In addition significant difference in the plantar pressure distribution symmetry was observed, which it is argued the plantar pressure asymmetric can be influenced by psychological factors.

The use of a biopsychosocial model in the treatment of patients with chronic

OBJECTIVE

To explore the available knowledge on the application of biopsychosocial model (BPS) in patients with chronic low back pain (CLBP).

METHODS

A scoping review, including 32 papers that used a BPS to manage adult patients with CLBP, published in any language. Six different databases were searched.

RESULTS

According to the description of the protocols, most of them use BPS for assessment of the patients. In this first stage the most often evaluated were pain and disability, kinesiophobia and quality of life, and work-related factors. The intervention most used associate psychological and physical domains using pain education or cognitive functional therapy and active exercise. Even though was not the most common, in the social domain occupational, behavioral and family interventions were observed.

CONCLUSION

BPS is more often used as combination of physical and psychological aspects, being the social domain restricted to work-related factors. Patien'ts perception of their health status is little explored, and it is suggested that the International Classification of Functioning, Disability and Health be used.

PRACTICE IMPLICATION

Patient perception as well as social factors in addition to occupational ones should be included in the clinical approach of the patient with CLBP and should be further explored in research.

Comparison of cognitive functional therapy and movement system impairment treatment in chronic low back pain patients: a randomized controlled trial

BACKGROUND

This study aimed to compare the effects of cognitive functional therapy (CFT) and movement system impairment (MSI)-based treatment on pain intensity, disability, Kinesiophobia, and gait kinetics in patients with chronic non-specific low back pain (CNSLBP).

METHODS

In a single-blind randomized clinical trial, we randomly assigned 91 patients with CNSLBP into CFT (n = 45) and MSI-based treatment (n = 46) groups. An 8-week training intervention was given to both groups. The researchers measured the primary outcome, which was pain intensity (Numeric rating scale), and the secondary outcomes, including disability (Oswestry disability index), Kinesiophobia (Tampa Kinesiophobia Scale), and vertical ground reaction force (VGRF) parameters at self-selected and faster speed (Force distributor treadmill). We evaluated patients at baseline, at the end of the 8-week intervention (post-treatment), and six months after the first treatment. We used mixed-model ANOVA to evaluate the effects of the interaction between time (baseline vs. post-treatment vs. six-month follow-up) and group (CFT vs. MSI-based treatment) on each measure.

RESULTS

CFT showed superiority over MSI-based treatment in reducing pain intensity (P < 0.001, Effect size (ES) = 2.41), ODI (P < 0.001, ES = 2.15), and Kinesiophobia (P < 0.001, ES = 2.47) at eight weeks. The CFT also produced greater improvement in VGRF parameters, at both self-selected (FPF[P < 0.001, ES = 3], SPF[P < 0.001, ES = 0.5], MSF[P < 0.001, ES = 0.67], WAR[P < 0.001, ES = 1.53], POR[P < 0.001, ES = 0.8]), and faster speed, FPF(P < 0.001, ES = 1.33, MSF(P < 0.001, ES = 0.57), WAR(P < 0.001, ES = 0.67), POR(P < 0.001, ES = 2.91)] than the MSI, except SPF(P < 0.001, ES = 0.0) at eight weeks.

CONCLUSION

This study suggests that the CFT is associated with better results in clinical and cognitive characteristics than the MSI-based treatment for CNSLBP, and the researchers maintained the treatment effects at six-month follow-up. Also, This study achieved better improvements in gait kinetics in CFT. CTF seems to be an appropriate and applicable treatment in clinical setting.

TRIAL REGISTRATION

The researchers retrospectively registered the trial 10/11/2022, at https://www.umin.ac.jp/ with identifier number (UMIN000047455).

A critical review of the biopsychosocial model of low back pain care: time for a new approach?

PURPOSE

Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate how physiotherapy LBP literature enacts the BPS model.

MATERIAL AND METHODS

We conducted a critical review using discourse analysis of 66 articles retrieved from the PubMed and Web of Science databases.

RESULTS

Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1: Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4: Expanded aspects of care].

CONCLUSION

Results imply that multiple important factors such as interpersonal or institutional power relations, cultural considerations, ethical, and social aspects of health may not be incorporated into physiotherapy research and practice when working with people with LBP.IMPLICATIONS FOR REHABILITATIONWhen using the biopsychosocial model with patients with low back pain, researchers narrowly focus on biological and cognitive behavioural aspects of the model.Social and broader aspects such as cultural, interpersonal and institutional power dynamics, appear to be neglected by researchers when taking a biopsychosocial approach to the care of patients with low back pain.The biopsychosocial model may be inadequate to address complexities of people with low back pain, and a reworking of the model may be necessary.There is a lack of research conceptualising how physiotherapy applies the biopsychosocial model in research and practice.

Cognitive functional therapy (CFT) compared with core training exercise (CTE) in patients with failed back surgery syndrome (FBSS): A study protocol for a randomized controlled trial

OBJECTIVE

This study aims to investigate the efficacy of cognitive functional therapy (CFT) compared to core training exercise (CTE) on pain and specific disability of patients with failed back surgery syndrome (FBSS).

DESIGN

This will be a randomized controlled clinical trial of two groups with blinded evaluators.

SETTING

The study will be conducted at the Federal University of Santa Catarina (UFSC) and a private clinic in Florianópolis, SC, Brazil.

PARTICIPANTS

A total of 80 participants, of both sexes, with FBSS.

INTERVENTION

Subjects will be randomized into two groups: one group receiving CFT or CTE. Individuals will be assisted once a week, for a maximum period of 12 weeks, with four being the minimum number of visits and 12 being the maximum number of visits.

MEASUREMENTS

The primary outcomes will be pain and specific disability.

CONCLUSIONS

This is the first study investigating whether CFT is efficacious for patients with FBSS and chronic low back pain. The study's sample size was calculated to detect the effect of clinically relevant treatment with a low risk of bias. This clinical trial was designed to be able to reproduce an approach as a physiotherapist trained in CFT would do. That is, in a pragmatic way, increasing the significance of this study. CTE comprises a strategy widely used by physiotherapists to treat low back pain. Given that the scientific evidence of its efficacy for pain management is limited, the findings of this study will assist physiotherapists in their clinical decision-making.

Are Changes in Fear-Avoidance Beliefs and Self-efficacy Mediators of Function and Pain at Discharge in Patients With Acute and Chronic Low Back Pain?

OBJECTIVE

To examine the mediating role of changes in fear-avoidance beliefs and self-efficacy on pain and physical functioning at discharge in patients with acute and chronic low back pain (LBP).

DESIGN

Retrospective study.

METHODS

Baseline and discharge data from 418 participants with acute and chronic LBP were analyzed. At discharge, functional status and pain intensity were analyzed to assess their role as a predictor of acute and chronic LBP status and as a mediator of fear-avoidance beliefs and self-efficacy from baseline to discharge.

RESULTS

In multivariable analyses, patients with chronic LBP had lower discharge functional status (β = -7.4; 95% confidence interval [CI]: -10.5, -4.3), lower self-efficacy for physical function (β = -5.3; 95% CI: -10.2, -0.4), higher pain intensity (β = 0.9; 95% CI: 0.3, 1.5), and no difference in discharge fear-avoidance beliefs compared to patients with acute LBP. Change in self-efficacy for physical function had a small indirect association (β = -1.1; 95% bias-corrected CI: -2.5, -0.004), mediating the relationship between chronic LBP and discharge functional status.

CONCLUSION

Fear-avoidance beliefs were not a mediator of pain or function at discharge in patients with chronic LBP. Self-efficacy may be an important mediating factor for function at discharge in patients with chronic LBP who receive physical therapy. J Orthop Sports Phys Ther 2020;50(6):301-308. Epub 6 Jan 2020. doi:10.2519/jospt.2020.8982.

Lumbar range of motion in chronic low back pain is predicted by task-specific, but not by general measures of pain-related fear

BACKGROUND

Most studies fail to show an association between higher levels of pain-related fear and protective movement behaviour in patients with chronic low back pain (CLBP). This may be explained by the fact that only general measures of pain-related fear have been used to examine the association with movement patterns. This study explored whether task-specific, instead of general measures of pain-related fear can predict movement behaviour.

METHODS

Fifty-five patients with CLBP and 54 healthy persons performed a lifting task while kinematic measurements were obtained to assess lumbar range of motion (ROM). Scores on the Photograph Daily Activities Series-Short Electronic Version (PHODA-SeV), Tampa Scale for Kinesiophobia and its Activity Avoidance and Somatic Focus subscales were used as general measures of pain-related fear. The score on a picture of the PHODA-SeV, showing a person lifting a heavy object with a bent back, was used as task-specific measure of pain-related fear.

RESULTS

Lumbar ROM was predicted by task-specific, but not by general measures of pain-related fear. Only the scores on one other picture of the PHODA-SeV, similar to the task-specific picture regarding threat value and movement characteristics, predicted the lumbar ROM. Compared to healthy persons, patients with CLBP used significantly less ROM, except the subgroup with a low score on the task-specific measure of pain-related fear, who used a similar ROM.

CONCLUSIONS

Our results suggest to use task-specific measures of pain-related fear when assessing the relationship with movement. It would be of interest to investigate whether reducing task-specific fear changes protective movement behaviour.

SIGNIFICANCE

This study shows that lumbar range of motion in CLBP is predicted by task-specific, but not by general measures of pain-related fear. This suggests that both in clinical practice and for research purposes, it might be recommended to use task-specific measures of pain-related fear when assessing the relationship with movement behaviour. This may help to disentangle the complex interactions between pain-related fear, movement and disability in patients with CLBP.

Effects of spinal manipulation and pain education on pain in patients with chronic low back pain: a protocol of randomized sham-controlled trial

Background

Low back pain (LBP) has more than doubled in the last 20 years, probably influenced by biopsychosocial factors. Noninvasive treatments have been applied in individuals with chronic nonspecific LBP as spinal manipulation and pain education. However, the neurophysiological effects of these treatments are not clear. The aim of this research is to verify the pain control, functional and neurophysiological effects of spinal manipulation, and pain education in individuals with chronic nonspecific LBP.

Methods

This research is an assessor and subject blinded, 2-arm, randomized sham-controlled trial and will be conducted at Governador Celso Ramos Hospital, Florianópolis, Brazil. One hundred and twenty-eight individuals with chronic nonspecific LBP will be recruited for this study. Individuals will be randomly allocated into one of the two groups: (1) spinal manipulation plus pain education or (2) sham treatment plus pain education. Each group will be received two sessions per week over six weeks of treatment. The measures will be applied at baseline, six weeks, and three months after randomization. The primary outcome will be a pain intensity at six weeks postrandomization. Secondary outcomes will be pressure pain threshold, disability, fear and avoidance beliefs, kinesiophobia, risk of poor prognosis, quality of life, and inflammatory biomarkers.

Discussion

Evidence has shown that psychosocial factors are more involved in chronic pain than we thought a few years ago. Then, studies investigating both functional and neurophysiological effects of these interventions to evaluate the effectiveness of treatment and what else is happening at the cellular level in nervous system are needed.

Physical Therapy in the Treatment of Central Pain Mechanisms for Female Sexual Pain

INTRODUCTION

The complexity of female sexual pain requires an interdisciplinary approach. Physical therapists trained in pelvic health conditions are well positioned to be active members of an interdisciplinary team addressing the assessment and treatment of female sexual pain. Changes within physical therapy practice in the last ten years have resulted in significant utilization of pelvic floor muscle relaxation and manual therapy techniques to address a variety of pelvic pain conditions, including female sexual pain. However, sexual pain is a complex issue giving credence to the necessity of addressing all of the drivers of the pain experience- biological, psychological and social.

AIM

This review aims to reconcile current pain science with a plan for integrating a biopsychosocial approach into the evaluation and subsequent treatment for female sexual pain for physical therapists.

METHODS

A literature review of the important components of skilled physical therapy interventions is presented including the physical examination, pain biology education, cognitive behavioral influences in treatment design, motivational interviewing as an adjunct to empathetic practice, and the integration of non-threatening movement and mindfulness into treatment.

MAIN OUTCOME MEASURE

A single case study is used to demonstrate the biopsychosocial framework utilized in this approach.

RESULTS

Appropriate measures for assessing psychosocial factors are readily available and inform a reasoned approach for physical therapy design that addresses both peripheral and central pain mechanisms. Decades of research support the integration of a biopsychosocial approach in the treatment of complex pain, including female sexual pain.

CONCLUSION

It is reasonable for physical therapists to utilize evidence based strategies such as CBT, pain biology education, Mindfulness Based Stress Reduction (MBSR), yoga and imagery based exercises to address the biopsychosocial components of female sexual pain.