Author Names
Castro, J., Correia, L., de Sousa Donato, B., Arruda, B., Agulhari, F., Pellegrini, M., Belache, F., de Souza, C., Fernandez, J., Nogueira, L., Reis, F., de Sa Ferreira, A., Meziat-Filho, N.
Reviewer Name
Samantha Anderson, SPT
Reviewer Affiliation(s)
Duke University Doctorate of Physical Therapy Program
Paper Abstract
Cognitive functional therapy (CFT) is a physiotherapy-led intervention that has evolved from an integration of foundational behavioral psychology and neuroscience within the physiotherapist practice directed at the multidimensional nature of chronic low back pain (CLBP). The current evidence about the comparative effectiveness of CFT for CLBP is still scarce. We aimed to investigate whether CFT is more effective than core training exercise and manual therapy (CORE-MT) in pain and disability in patients with CLBP. A total of 148 adults with CLBP were randomly assigned to receive 5 one-hour individualized sessions of either CFT (n = 74) or CORE-MT (n = 74) within a period of 8 weeks. Primary outcomes were pain intensity (numeric pain rating scale, 0-10) and disability (Oswestry Disability Index, 0-100) at 8 weeks. Patients were assessed preintervention, at 8 weeks and 6 and 12 months after the first treatment session. Altogether, 97.3% (n = 72) of patients in each intervention group completed the 8 weeks of the trial. Cognitive functional therapy was more effective than CORE-MT in disability at 8 weeks (MD = -4.75; 95% CI -8.38 to -1.11; P = 0.011, effect size= 0.55) but not in pain intensity (MD = -0.04; 95% CI -0.79 to 0.71; P = 0.916). Treatment with CFT reduced disability, but the difference was not clinically important compared with CORE-MT postintervention (short term) in patients with CLBP. There was no difference in pain intensity between interventions, and the treatment effect was not maintained in the mid-term and long-term follow ups.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?
Yes
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
3. Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
4. Were study participants and providers blinded to treatment group assignment?
No
5. Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
9. Was there high adherence to the intervention protocols for each treatment group?
Yes
10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
Cognitive Functional Therapy showed more improvement in disability at 8 weeks than CORE-MT.
Key Finding #2
Cognitive Functional Therapy showed no difference in disability when compared to CORE-MT in the 6 and 12 month follow ups.
Key Finding #3
There was no difference in pain intensity or patient satisfaction between the Cognitive Functional Therapy group and the CORE-MT group.
Key Finding #4
This study used a larger sample size, had different physical therapists for each treatment group, and lost fewer to follow-up, when compared to previous studies, to provide more accurate and reliable data regarding this subject. This study pointed out that prior studies showing large differences across multiple time points had conflicts and biases that alter the research. While there is a difference, it is seen only in regard to levels of disability and only seen at the 8 week follow-up.
Please provide your summary of the paper
This study examined the differences in pain and disability when treating chronic low back pain from a biopsychosocial perspective compared to a body structure and function perspective. Prior studies found differences in the short, mid, and long term follow ups, but this study sought to reexamine those findings due to multiple conflicts and biases in the previous studies. The results showed that when a patient was treated using Cognitive Functional Therapy (CFT) short term improvements in disability were greater than with core exercises and manual therapy (CORE-MT). The physical therapist for the CFT group worked on gaining patient understanding of causes of their pain, worked to increase self efficacy, taught patients good body mechanics and gradual exposure to reduce fear avoidance, and discussed the benefits of sleep and general physical activity. The following tools were used to quantify outcomes: a numeric pain rating scale for pain intensity, the Oswestry Disability Index for disability, the Global Perceived Effect Scale for overall patient perception of effect, and a questionnaire for patient satisfaction. The improvement in disability within the CFT group was greater in the short-term (8 week) follow-up; no differences were found between the groups for the other outcomes at the 8 week follow-up. However, the mid and long term follow-ups showed no differences between the groups for disability, pain, global perceived effect, or patient satisfaction.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
If a patient’s main goal is to have less disability related to their chronic low back pain, CFT can make that happen sooner than CORE-MT. Since physical therapists can use multiple methods to treat their patients, rather than sticking strictly to one method as this clinical trial did, a combination of these could be used as a treatment plan for a patient. CFT can be used to treat patients in addition to treating them with manual therapy and exercises. This is one way to incorporate the biopsychosocial model into treatment as more research is showing that chronic low back pain is not a purely physical condition.
