Changing the way people think and move can have a huge impact on their experience of unexplained lower back pain

A recent clinical trial involving members of the Pain-Ed team based at Bergen University, Norway and Curtin University, Perth, Australia analysed 121 adults with chronic lower back pain. In the study, one group received classification-based cognitive functional therapy (CFT) while the control group received manual therapy and exercise.

The study demonstrates that using CFT was significantly more effective at reducing pain, disability, fear of movement, work absenteeism, the need for ongoing treatment and at improving mood. These findings were maintained at follow-up 12 months later. Patient satisfaction levels at 12 months were remarkably high (96%).

As described elsewhere on the Pain-Ed site, CFT is a patient-centered approach to management that targets the beliefs, fears and associated behaviours (both movement and lifestyle) of each individual with low back pain. It leads the person to be mindful and understand that pain is not necessarily a reflection of damage to the tissue – but rather a process where the person is trapped in a vicious cycle of pain and disability. This can further be fuelled by a nervous system that is stressed and sensitised due to pessimistic beliefs, fear, lost hope, anxiety and avoidance, linked to unhelpful movement and lifestyle behaviours.

The multi-dimensional classification system that underpins it, guides the therapist in a clinical reasoning process that considers the contribution of many different factors: patho-anatomical factors where present, neurophysiological mechanisms, cognitive, psychosocial, lifestyle and physical factors. It acknowledges that for each individual there may be a unique contribution of factors across these different domains that act to maintain a vicious cycle of pain and disability.

This approach aims to build self-efficacy and confidence, as well as providing hope and opportunities for change for the person with chronic pain. It uses 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 behaviorally orientated and explores different strategies to help people reestablish the basic building blocks of relaxed normal movement. It empowers the person to challenge the very things they fear and / or avoid, but in a graduated relaxed and normal manner. It motivates them to engage with exercise and active living based on their preferences and goals.

The trial had limitations that are outlined in the paper and clearly needs replication 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 study has been published in an open-access format, and we have attached it here, along with the appendices.

Fersum et al study

Fersum study-appendix 1

Fersum study-appendix 2

Fersum study-appendix 3

In addition, the study has been discussed on radio here

and online here

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