Pain and lack of function are the two main factors that motivate people with non-specific chronic low back pain (CLBP) to seek care [1]. When you ask a person with CLBP what treatments they have tried, the answer is often in the form of a shopping list: manual therapy, stabilising exercises, Pilates, yoga, medication, injections… and so might the list go on in the search for a relief from pain and its impact on daily life. Indeed, a look into the literature reveals that a wide range of active and passive interventions have at best small and modest effects on pain and function in people with CLBP [2].
One intervention that has reported large, clinically important improvements in pain and function associated with CLBP is Cognitive Functional Therapy (CFT). In brief, CFT can be summarised as an individualised behavioural intervention grounded in biopsychosocial principles that challenges maladaptive beliefs and associated dysfunctional behaviours, to enhance pain control and take the patient on the journey back to their valued goals (for a more detailed description click here [3]). Having established the efficacy of CFT in a randomised controlled trial [4], our research team wanted to understand how CFT works from the perspective of the patient undergoing the intervention.
To do this, we recruited 15 people with diverse treatment outcomes 3-6 months following CFT for CLBP and asked them to share their treatment experiences with us. Through one-to-one interviews, we explored participants’ perceptions of change in the pain experience through CFT and their explanations for any change or lack of change. To analyse our interviews we grouped participants as improvers or non-improvers and looked for common, defining experiences of each group.
Our findings recently published in Physical Therapy [5], suggest that improvement after CFT depends on the degree to which patients i) Adopt biopsychosocial beliefs about their pain and ii) Feel they can independently self-manage their condition.
“Now I know there can be pain without physical or structural problems”
Whilst most participants entered the intervention with strong biomedical beliefs about the cause of their pain, the acceptance of a biopsychosocial model of pain was a key ‘ingredient’ that differentiated improvers from non-improvers. A trusting relationship with the therapist facilitated effective communication and set the scene to challenge existing beliefs with a new explanatory model of pain. Participants described a new ‘body awareness’, an understanding of how physical and psychosocial stressors influenced their behaviour and pain. They were encouraged to challenge this new information and body awareness through behavioural experimentation and the experience of control over pain was key to the consolidation of a new belief system.
“When I get the pain now, I’m able to check myself. I can unravel it myself”
The second key ingredient to successful outcome was achieving independent self-management of their pain. This was built on the foundation of solid problem solving skills and improvement in pain self-efficacy that enabled improvers to confront threatening or pain provoking activities. Pain self-efficacy differentiated ‘large improvers’, those who reported a return to normality with renewed optimism for the future, and ‘small improvers’, who reported residual concerns about their ability to cope with a relapse in pain, particularly when faced with contextual life stressors.
The finding that some patients may experience a positive response to some aspects of CFT but not to others (i.e. some patients may adopt biopsychosocial beliefs about their pain but struggle with pain self-management), highlights the value of qualitative studies like these in understanding treatment responses. This level of detail is difficult to capture in large randomised controlled trials.
Whilst the sample size for this study was small, the results provide insights into how the delivery of CFT might be optimised:
- The role of the clinician using CFT is as a mentor, equipping patients with knowledge and skills for independent self-management.
- Clinicians need to challenge existing unhelpful beliefs through open discussion in a motivational, empathetic manner.
- Patients need to be actively engaged in learning based on personal experience and meaningful activities. Patients should be encouraged to gather their own information through behavioural experimentation i.e. learning-through-doing.
- Belief change alone is not sufficient to sustain improvements through CFT. Skills for independent self-management are necessary to ensure patients can cope with new pain experiences and have the confidence to return to normal activities.
- Patients who appear uncertain about their capabilities, who show signs of stress and/or anxiety may have difficulties with independent self-management. In such cases, clinicians may emphasise to the patient the impact of stress or anxiety on the pain experience, maintain longer follow-up and/or refer to multidisciplinary care to optimise function.
About Sam Bunzli
Sam Bunzli graduated from Otago University with a Bachelor of Physiotherapy in 2000. She worked as a physiotherapist in New Zealand, the UK and Australia before completing a PhD at the School of Physiotherapy and Exercise Science, Curtin University in 2015 with Prof. Peter O’Sullivan. Her doctoral research was titled: “A prospective qualitative investigation of pain-related fear in people with chronic low back pain”. Sam is currently conducting qualitative research in the field of joint replacement surgery at The University of Melbourne, Department of Surgery.
References
[1] Mortimer M, Ahlberg G. To seek or not to seek? Care-seeking behaviour among people with low back pain. Scandinavian Journal of Public Health 2003;31(3):194-203 Online First.
[2] Artus M, van der Windt D, Jordan K, Hay E. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: A systematic review of randomized clinical trials. Rheumatology 2010;49:2346-56 Online First.
[3] O’Sullivan K, Dankaerts W, O’Sullivan L, O’Sullivan P. Cognitive Functional Therapy for disabling nonspecific chronic low back pain: Multiple case-cohort study. Physical Therapy 2015;30([Epub ahead of print]) Online First.
[4] Vibe Fersum K, O’Sullivan P, Skouen J, Smith A, Kvale A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. European Journal of Pain 2013;17(6):916-28 Online First.
[5] Bunzli S, McEvoy S, Dankaerts W, O’Sullivan P, O’Sullivan K. Patient perspectives on participation in Cognitive Functional Therapy for chronic low back pain: A qualitative study. Physical Therapy 2016;Accepted 13.03.2016 Online First.
Commissioning Editor: Ben Wand; Associate Editor: Hopin Lee