The fifth and last of our ‘Oldies but Goodies’ series is by Peter O’Sullivan:
This story of a 28 year old man with disabling low back pain illustrates the CB-CFT intervention trialled in the RCT in Bergen, Norway.
‘Eight years ago I had a lifting injury at work. It was terrible pain, I was worried so I went to the doctor who ordered a scan. The doctor said I had a back of a 70 year old. He said I couldn’t surf again and or do manual work. I was devastated.
I underwent lots of treatments to stabilise my spine with exercises, spine injections and medication. Over this time the pain just got worse. Before I started the CFT program I had stopped work, I was spending 6 hours a day lying down and had stopped socialising. My back pain had consumed my life, I felt desperate and had nearly lost hope.
Through the CFT program I have learnt that my back isn’t damaged – I now realise that my whole nervous system was really wound up. I have learnt to relax and move normally again, I don’t fear movement now – my mindset has changed. Best of all I can go out for dinner, I can exercise and am now back doing my job. I still flare up when I am stressed but I don’t worry about it so much – the pain doesn’t limit my life like it did.
Looking back I now realise that for 8 years I was living with fear, I had lost confidence in my body and I was continually protecting my back by tensing it because I thought it was damaged. I avoided things that hurt, I couldn’t relax – I was so stressed.’
This is not an isolated story. It’s a sad reflection of the potential negative consequences of communication and treating back pain as a damaged structure. It is also a story of hope that disabling back pain can change for the better with a different narrative and coping strategies.
This RCT was a collaboration between Bergen University, Norway and Curtin University, WA, Australia and was conducted by Dr Kjartan Vibe Fersum. It tested an approach to managing mechanically provoked ‘non-specific’ persistent low back pain – which we called ‘classification based – cognitive functional therapy – CB-CFT’. It’s a bit of a mouthful but we called it this as it represents a person centred, body/mind approach to understanding and managing this complex problem.
The multi-dimensional classification system that underpins it, guides the therapist in a clinical reasoning process that considers the contribution of: patho-anatomical factors where present, neurophysiological mechanisms, cognitive and psychosocial, lifestyle and physical factors, such as maladaptive movement behaviours, body schema distortions and muscle conditioning. It acknowledges that for each individual there is a unique contribution of factors across these different domains that act to maintain a vicious cycle of pain and disability. It is not a subgrouping system.
Cognitive functional therapy (CFT) is a patient centred approach to management that targets the beliefs, fears and associated behaviours (both movement and lifestyle) of each individual with back pain. It leads the person to be mindful that pain is not a reflection of damage – but rather a process where the person is trapped in a vicious cycle of pain and disability. This is fuelled by a nervous system that is stressed and sensitized due to negative beliefs, fear, lost hope, anxiety and avoidance, linked to mal-adaptive (provocative) movement and lifestyle behaviours.
It is integrated using a motivational interviewing approach to communication where it identifies discrepancies between beliefs and behaviours and acknowledges that the solutions that ‘stick’ are usually found by the person themselves. It is strongly behaviourally orientated and explores different movement options using visual feedback in order for people to reestablish their body schema and relearn the basic building blocks of relaxed normal movement. It empowers the person to do the very things they fear and / or avoid, but in a graduated relaxed and normal manner. It conditions them if they are weak. It motivates them to engage with exercise and active living based on their preferences and goals.
This approach ticks a lot of boxes for management of chronic disorders, as it aims to build self-efficacy, confidence, adaptability and provides hope and opportunity for change for the person with pain in a person centred manner.
The results of the trial suggest that CB-CFT worked a lot better than traditional manual therapy and exercise. There were greater reductions in pain, disability, fear of movement and work, improved mood, less need for ongoing treatment and less time off work. The patient satisfaction levels at 12 months were remarkably high (96%).
This approach isn’t rocket science, but it we think it requires a different perspective on back pain on the part of the treating therapist. It requires confidence that pain is to be respected but not feared. It also requires trust and engagement on the part of the person with pain.
The trial had limitations that are outlined in the paper and clearly needs replication in higher disability groups and this is ongoing in different parts of the world. Not all people responded – and we are looking at what the mediators of outcome were in this intervention.
The EJP paper is open access so the full paper and appendices can be uploaded for the readers. Here they are in PDF form
About Peter O’Sullivan
Peter is a Specialist Musculoskeletal Physiotherapist who works with people with persistent pain and is a Professor of Musculoskeletal Physiotherapy at Curtin University where his research team conducts clinical research into the complexity of pain and its management.
Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, & Kvåle A (2012). Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain PMID: 23208945