CARROLL UNIVERSITY

Doctor of Physical Therapy Program

Critically Appraised Topic

EFFICACY OF COGNITIVE FUNCTIONAL THERAPY IN THE MANAGEMENT IN

CHRONIC LOW BACK PAIN
Clinical Scenario:
Patient is a 50 yo male with low back pain for the previous 9 months, especially during lifting or bending activities. Squatting and
crawling on the floor are especially painful. He is a grandfather of an 8 month old girl and a 2 year old boy. He continues to try to
play with his grandkids whenever he gets a chance, but the pain is making it more and more difficult. He has been diagnosed with
chronic low back pain, one physician considered it related to disc degeneration while another did not. The patient would like to go
back to playing with his grandkids on the floor and picking them up without intense pain as soon as possible.

Clinical Question:
In a 50 y/o male with chronic low back pain lasting the last 9 months, does Cognitive Functional Therapy (CFT) reduce functional
disability as measured by the Oswestry Disability Index?

Clinical Bottom Line:

Yes, in the current research, it is indicated that CFT is an effective treatment in reducing functional disability in patients with CLBP.
CFT also has been shown to maintain these improvements long-term (at 12 months). CFT is a comprehensive intervention that
involves a biopsychosocial approach to the management of pain as well as movement re-education.

Refresh Date: 6/29/2019

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated:
Search Methodology: (This section should include enough detail to make the search repeatable)
Search Resources Search Terms Limits # of Articles
PubMed (CFT or "cognitive functional None 8
1 therapy") and (disability or "oswestry
disability index") and (low back)
CINAHL (CFT OR cognitive functional therapy) None 7
AND (disability OR oswestry
2
disability index) NOT compassion
AND low back
MEDLINE (CFT OR cognitive functional None 8
therapy) AND (disability OR
3
oswestry disability index) NOT
compassion AND low back
PsycINFO (CFT OR (Cognitive functional None 18
therapy)) AND (disability OR
4
(oswestry disability index )) AND
(low back )

Search Results Summary:

Results Reasons for Inclusion Reasons for Exclusion # of Articles
Included
-Case Series (1) -None -Study Protocol 5
-Case Report (3) -Adolescent
-Cross Sectional Qualitative (1) -Lower Limb Impairment
1
-Study Protocol for RCT (1)
-Multiple Case Cohort (1)
-RCT (1)
-Case Series (1) -None -Previously Cited 0
-Case Report (3) -Adolescent
2 -Cross Sectional Qualitative (1) -Lower Limb Impairment
-Multiple Case Cohort (1)
-RCT (1)
-Case Series (1) -None -Previously Cited 0
3 -Case Report (3) -Study Protocol
-Cross Sectional Qualitative (1) -Adolescent
Author(s): Andrew Johnson Date Created: 6/29/2018
Reviewer(s): Date Updated:
 -Study Protocol for RCT (1) -Lower Limb Impairment
-Multiple Case Cohort (1)
-RCT (1)
-Review (1) -None -Previously Cited 0
-Clinical Trial (2) -Correlational Study
-Handbook (2) -Cognitive Behavioral Therapy
-Cross Sectional Qualitative (1) -Functional Restoration
-Study Protocol (1) -Sleep
-Editorial (1) -Operant Behavioral Therapy
-RCT (5) -TENS
4
-Correlational Survey (2) -Chiropractic Intervention
-Empirical (3) -Integrated Care Program
-Review
-Handbook
-Editorial
-Mindfulness Based Functional
Therapy

Research Participant and Study Characteristics:

Reference Participant Key Clinical Control Intervention Experimental Level of
Characteristics (frequency/duration) Intervention/Interview Evidence
(frequency/duration)
Bunzli et al., 2016 -CLBP (6-456 months) -No control was used -CFT from trained PT Level 4
-Undergone CFT -Purposive sampling of -Interviews were conducted 3-
-Adult (22-61 y/o) patients who underwent CFT 6 months post-CFT
-6 M and 8 F -Qualitative design to assess -Semi-structured questions
-ODI outcomes post CFT feelings towards CFT were used to assess impact of
(no improve, large improve, intervention
small improve) -Questions were open-ended
and allowed participant to
respond freely
Meziat, 2016 -CLBP (4 months) -No control -CFT Level 4
-Adult (32 y/o) -12 sessions in 40 days

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated:
 -Female
-Flexion Pattern of
Movement
O’Sullivan et al., -CLBP (2-43 yr)
2018 -Adult (26-64 y/o)
-Had tried multiple
interventions prior to CFT
-No relief from prev.
interventions
• Exercise,
acupuncture,
chiropractic manip,
etc.
-2 Men and 1 Female
O’Sullivan et al., -CLBP of > 6 months
2015 -Low back was primary
location
-Reduced activity as result
of CLBP
-Adult (18-65 y/o)
-No evidence of spinal
pathology
-Pain was aggravated with
motion/posture
Fersum et al., 2013 -CLBP > 3 months
-Pain present from
T12Gluteal Folds
-ODI > 14%
-Pain > 2/10
Author(s): Andrew Johnson
Reviewer(s):
-Study was a case report of
one individual receiving CFT
-Study was a review of CFT -CFT Level 4
as well as a case series -28 y/o M (8 sessions in 3
-The case series included 3 months)
participants and their -64 y/o M (5 sessions in 3
outcomes associated with CFT months)
-26 y/o F (3 sessions in 3
months)
-Study was a case cohort -CFT Level 3
design -Phase B
-Control was used to attain -Minimum duration of 6
baseline measurements weeks
-Phase A1 -7.7 Average # Sessions
-Lasted 3 months at onset of -Outcomes were measured at
study conclusion of phase
-3 baseline interviews were -Phase A2
performed 6 weeks apart -Expectation of performing
therapy on their own over 12
months
-Follow ups at 3, 6, 12 months
-Manual Therapy and -CFT Level 1
Exercise -1x/week for 3 weeks
-8 session on average -Every 2 weeks for next 9
-MT was at the discretion of weeks
PT
Date Created: 6/29/2018
Date Updated:
 -Pain provoked with -Motor control therapy was
posture, movement and targeted around the abdominal
activities muscles

Outcomes:
Reference Event/Outcome Time to Mean (SD) ES &/or
(may have more than one per Event Control Group Experimental Group NNT
reference)
Meziat, 2016 Pain (VAS) 0 wks N/A 4/10 -Unable to
12 wks N/A 1-2/10 calculate with
Functional Disability (ODI) 0 wks N/A 42% a sample size
12 wks N/A 14% of 1
PT Observation/Subjective 0 wks N/A -Fear of lifting, bending, -This is due to
sitting the study
-Palpable co-contraction being a case
of Erector Spinae and Abs report
-Flexion movement
pattern
2 wks N/A -Bend normally (no co-
contraction)
-30 minute walks daily
-Sit for 20 minutes
6 wks N/A N/A
12 wks N/A -Return to Work
-1 Hr walking daily
Fersum et al., Functional Disability (ODI) 0 wks 24, (16-32) 21.3, (13.8-28.8) -ES: d = .92
2013 Measured in % 3 months 18.5, (10.4-26.6) 7.6, (.9-14.3) -This
95% CI Provided 12 months 19.7, (8-31.4) 9.9, (.1-19.7) represents a
large effect
size at 12 mo.
Pain (VAS) 0 wks 5.3, (3.4-7.2) 4.9, (2.9-6.9) -ES: d = .73
95% CI Provided 3 months 3.8, (1.9-5.7) 1.7, (0-3.4)
Author(s): Andrew Johnson Date Created: 6/29/2018
Reviewer(s): Date Updated:
 12 months 3.8, (1.7-5.9) 2.3, (.3-4.3) -This
represents a
medium effect
size at 12 mo.
O’Sullivan et al., Functional Disability (ODI) A1 0 weeks 42, (26-51) -ES: d = .85
2015 Measured in % A1 6 weeks 42, (26-53) -This is a
A1 12 weeks 42, (22-51) larger effect
B 0 weeks 19, (8-35) size
A2 3 month 17, (8-38)
A2 6 month 17, (8-37)
A2 12 month 16, (10-41)
Pain (numerical rating scale) A1 0 weeks 5, (3-7) -ES: d = .65
A1 6 weeks 5.5, (3.5-7.5) -This is a
A1 12 weeks 5, (3-7) medium effect
B 0 weeks 3.5, (1-6) size
A2 3 month 3.6, (1-6.2)
A2 6 month 3.6, (.8-6.5)
A2 12 month 3.5, (.7-6)
Themes Time of Subthemes Demographic
Interview Information
Bunzli et al., -Changing Pain Beliefs 3-6 months -Pain Beliefs -57% Female
2016 • Strong biomedical post-CFT • Therapeutic Alliance-building a trusting -Mean Age:
belief as source of pain relationship b/t PT and pt. 42
• Acceptance of o Decreased disability and pain -Mean CLBP
biopsychosocial model was linked to a stronger alliance Duration: 9
improved pain • Body Awareness-new perspective of yrs
-Achieving Independence self both physically and mentally
• Experiencing Pain Control-whether or
not control was felt reaffirmed their
beliefs on CFT
-Achieving Independence

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated:
 • Problem Solving/Self-Efficacy-
understanding of pain and ability to
control in the future
• Fear-less fear was reported when they
understood their pain and felt control
• Stress Coping-coping mechanisms
helped diminish stress which led to
decreased pain
• Normality-increased confidence in
control of pain allowed participants to
feel “normal” again

Subjective Reports Post-CFT Time of Biopsychosocial Factors of CLBP Primary

Interview Average Change Post-CFT Aims of CFT
O’Sullivan et al., -“I don’t fear my back/pain” -Conclusion -Reductions indicate improvements in each area -Make sense
2018 -“I have control over my pain” of final associated with perception, acceptance or of pain
-Not seeking care anymore for session coping ability with their pain -Develop
pain -Scores were graded by researcher on their positive
-Increased self-efficacy and impact they had on CLBP coping
positive coping strategies -Scores were out of 10 strategies for
-Increased activity level -Cognitive: -7 pain
-Emotional: -6 -Adopt
-Physical: -7 healthy
-Pathoanatomy: -2 lifestyle
-Lifestyle: -4.7 behaviors
-Social: -2
-Sensory: -5
-Health: -1.7

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated:
Key Findings

➢ Breadth: There is a lack of evidence examining the efficacy of CFT in the management of CLBP.
o The evidence available is of lower quality due to lack of randomization and control consisting of levels 3, 4.
o The primary designs are case series and cohort studies. However, with the preliminary effectiveness of CFT, the utilization of a large-
scale RCT is not far off.
➢ Flaws: The main concern is the lack of participants included in all of the studies. Another limitation is a lack of true control group in order to
compare CFT against.
➢ CFT has been shown to significantly reduce functional disability post-intervention.
o CFT also has the potential to maintain these improvements long-term.
➢ Limitations of CFT: Require extra PT training, requires strong PT-patient alliance in order for long-term behavioral change.

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated:
References:

Bunzli S, Mcevoy S, Dankaerts W, Osullivan P, Osullivan K. Patient perspectives on participation in cognitive functional therapy for
chronic low back pain. Physical Therapy. 2016;96(9):1397-1407. doi:10.2522/ptj.20140570.

Meziat Filho N. Changing beliefs for changing movement and pain: Classification-based cognitive functional therapy (CB–CFT) for
chronic non-specific low back pain. Man Ther. 2016;21:303-306.

O’Sullivan PB, Caneiro JP, O’Keeffe M, et al. Cognitive functional therapy: An integrated behavioral approach for the targeted
management of disabling low back pain. Physical Therapy. 2018;98(5):408-423. doi:10.1093/ptj/pzy022.

O'Sullivan K, Dankaerts W, O'Sullivan L, O'Sullivan PB. Cognitive functional therapy for disabling nonspecific chronic low back
pain: Multiple case-cohort study. Phys Ther. 2015;95(11):1478-1488.

Vibe Fersum K, O'Sullivan P, Skouen J, Smith A, Kvåle 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):916-928.

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated: