Experiences of a recently-graduated physiotherapist working with a Cognitive Functional Therapy approach to back pain

Michael Ingle is a physiotherapist based in Sydney working in musculoskeletal private practice. Since graduating in 2010, he has previously worked in the public health outpatient setting, and is passionate about the crossover between research and clinical practice for people with persistent pain


In April 2013 I attended Peter O’Sullivan’s Cognitive Functional Therapy for persistent low back pain course at the Royal Free Hospital, London. Since that time I have had an opportunity to put it in to practice as a recently-graduated physiotherapist (2010).

I vividly remember at university sitting through pain neuroscience lectures being fascinated with the potential of the recent breakthroughs made by clinical researchers. We learnt about the concept of yellow flags – psychological states such as depression and anxiety can act as barriers to a person reducing their pain. Fundamentally though, these were only seen as barriers in the way of the “fix the tissues” approach – that if we could mobilise the stiff joint, stretch the tight muscle, free the trapped nerve, pain would go away.

The Cognitive Functional Therapy approach required me to radically shift my thinking. I learnt, and later saw in front of me, that how a person thinks and feels about their pain directly impacts on the amount of pain and disability they have. Indeed, a person’s beliefs and expectations about their recovery can be the main determinants in their clinical outcome. Moreover, by addressing those beliefs, we can have an immediate and lasting effect on someone’s pain and disability. This is before we have laid a finger on them.

Working within a Cognitive Functional Therapy framework as a recent graduate is both exciting and empowering whilst simultaneously being very challenging. The approach requires myths and maladaptive beliefs about pain and scans to be debunked. In my experience almost every person with persistent pain will come with a structural/patho-anatomical reason for their pain given to them by a previous healthcare professional. These are often simplistic and mechanical, with many people tending to think of their bodies as cars – machines to be oiled, serviced, aligned and fixed. We are asking a lot of our patients to change their beliefs about their body. Tackling maladaptive beliefs head on has proved in my experience a fruitless exercise. It needs to be done in a gentle and individualised way – where patients can discover for themselves new and positive ways of thinking about their spine. Another interesting point that I learnt recently from a podcast with Dr Kieran O’Sullivan is that beliefs can be influenced by combining our words with our hands-on therapy techniques. He uses his hands-on techniques to inspire confidence people to have confidence in their back and I would recommend listening to the podcast for examples of this (www.physioedge.com.au).

Another challenge of this approach has been working with other healthcare professionals in the field of low back pain management. Back pain has been acknowledged as being a complex and multi-dimensional health problem that has contributors from neurophysiological, cognitive, social, patho-anatomical, physical and genetic domains. Much of current physiotherapy and medical practice has been slow to address the complexity of the problem, preferring the embedded core-stability and manual therapy approach. It is not hard to see why this is the case – patients expect it (from our own advertising, the media and their past experience), it is what we have always done, and because it is a simple approach. As a young clinician, I feel it is my responsibility to educate other physiotherapists and members of a person’s health-care team on this approach – in language that is lucid, jargon-free and where necessary, quoting the literature that supports it. Many therapists are glad to have a new system to work with for people in persistent pain and have seen the limitations of current practice in giving our patients lasting reductions in pain and disability. In business, (and all private practices are businesses!) it is also a point of difference in a market which is saturated with pilates practitioners, core-stability classes and manual therapy expertise from multiple professions.

As young physiotherapists in 2014 we are more privileged than any generation before us. There is an explosion of clinical research in physiotherapy practice and pain science and moreover, it has never been more accessible. It is our opportunity to trial this new knowledge with our own patients and use our own experiences to drive forward fresh ways of thinking to advance our profession.

Michael Ingle (BSc (Phty), MMus (Perf), APAM)

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