July 2023
Cognitive functional therapy shows large and durable benefits for chronic low back pain

A few sessions with a physical therapist provided substantial relief for at least one year.

Chronic low back pain is the greatest contributor to years lived with disability. Cognitive functional therapy (CFT), which addresses the complex physical and psychological contributors to chronic low back pain through self-management of contributing cognitions, emotions and behaviours, has shown large and lasting benefits in small trials.

Australian researchers enrolled 500 patients with low back pain (four or higher on a 10-point pain scale) that was present for at least three months and causing at least moderate interference with usual activities. Patients were randomised to usual care or to CFT with or without biofeedback from wearable motion sensors. Usual care (e.g. medication, injections, physical therapy) was determined by patients and their primary care providers. CFT consisted of as many as seven sessions with a trained physical therapist during 12 weeks and a booster session at 26 weeks, using a flexible clinical-reasoning approach to explore patients’ ‘pain journeys’ and formulate individualised treatment plans. In the biofeedback group, providers used sensor data to refine treatments.

At both 13 and 52 weeks, CFT significantly reduced activity limitation, pain, catastrophising and fear, compared with usual care. Outcomes with and without biofeedback were similar. Either CFT intervention was significantly less costly overall than usual care, primarily due to more productivity among recipients.

Comment: The reported magnitude and duration of relief with CFT exceed those reported with most other interventions in a recent systematic review (NEJM JW Gen Med May 15 2022 and BMJ 2022; 376: e067718). Because CFT can be delivered by a single trained physical therapist in a few sessions, it also is likely to be less expensive than approaches involving multidisciplinary teams. CFT for back pain does not appear to be widely available in the USA (according to an informal internet search), but clinicians might consider asking experienced physical therapists in their geographic area if they are familiar with this approach.

Bruce Soloway, MD, Associate Professor Emeritus of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.

Kent P, et al. Cognitive functional therapy with or without movement sensor bio-feedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. Lancet 2023 May 2; e-pub (https://doi.org/10.1016/ S0140-6736(23)00441-5).

This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine, Psychiatry.