Ongoing or recurring low back pain affects a significant portion of the population. It impairs their daily activities, work productivity and overall well-being. 

Conventional treatments like massage, spinal manipulation, medication, injections and surgery often fall short in addressing the multifaceted nature of this condition. They often result in small effects that don’t last long and some of these treatments sometimes cause harmful side effects. 

A shift in how we understand back pain

In recent years, there has been a big shift in our understanding of back pain. It is now recognised as a complex interplay between biological, psychological, social and cultural factors that requires an approach that focuses on each individual's unique needs and addresses the barriers to recovery.

But there’s an evidence-practice gap — many clinicians say they don’t have the skills or confidence to deliver this type of care. To overcome this gap, clinician-researchers developed a person-centred approach. It's called Cognitive Functional Therapy.

Introducing Cognitive Functional Therapy

Cognitive Functional Therapy is a behavioural intervention aligned with best practice guidelines. It takes a person-centred approach that considers the individual's beliefs, emotions, movement patterns and functional limitations. 

Unlike traditional treatments, Cognitive Functional Therapy empowers patients to take an active role in their recovery. It addresses all the personal factors that we know are barriers to recovery for people with chronic low back pain — like negative beliefs about back pain, emotional distress, and unhelpful behavioural responses to pain such as movement and activity avoidance. 

This approach places the person at the centre of their care. Their concerns, worries, ways that they move and their functional limitations and goals are the focus of treatment. The clinician works as a coach rather than a ‘fixer’.

These are the factors associated with resilience and vulnerability to disabling low back pain:

You can read more about Cognitive Functional Therapy here.

The recent RESTORE Trial

The RESTORE trial was conducted to evaluate the clinical and economic benefits of Cognitive Functional Therapy. The study compared three groups: 

• Cognitive Functional Therapy alone
• Cognitive Functional Therapy CFT with sensor biofeedback — wireless wearable movement sensors were placed on the participant to give personalised feedback on their movement and posture, as directed by their physiotherapist.
• Usual care — people were able to seek care as usual with no restrictions.

A diverse group of 492 participants with persistent and disabling low back pain were recruited.

A group of 18 physiotherapists from Perth and Sydney, with at least 2 years of experience in treating chronic low back pain, received 6 months of training in Cognitive Functional Therapy. 

The trained physiotherapists reported a change in mindset and behaviour. They adopted a coaching role and gained new understanding and skills to manage low back pain. 

Some of the physiotherapists also received additional training in the use of movement biofeedback.

What the study measured

The study measured these clinical outcomes:

• Pain-related disability 
• Pain intensity
• Pain catastrophising
• Pain self-efficacy
• Pain-related fear of movement
• Patients’ perceptions of their improvement
• Satisfaction
• Adverse outcomes

It also measured economic costs by looking at work absenteeism and reduced productivity while at work.

What the study found

The results of the trial were striking: 

• Both Cognitive Functional Therapy groups showed significant and sustained reductions in pain-related disability and intensity compared to usual care. 
• These effects persisted even at the 12-month follow-up — unusual in the low back pain field
• Those who received Cognitive Functional Therapy reported improved beliefs about pain, increased self-efficacy and reduced fear of movement
• 82% of people receiving Cognitive Functional Therapy were satisfied with the treatment compared to 19% who received usual care
• There was no additional clinical benefit of sensor biofeedback. 
• Cognitive Functional Therapy was safe.

Not only was Cognitive Functional Therapy more effective, but it was also more cost-efficient than usual care. The savings were more than $5,000 a person in a year due to reduced healthcare costs and increased productivity. 

What does this mean for us?

The findings of the RESTORE trial are good news for clinicians, healthcare services, governments, insurers and the general public. 

Clinicians

With dedication, time and mentored training, clinicians who treat people with persistent and disabling low back pain can be trained to develop the skills needed to deliver Cognitive Functional Therapy effectively.

Person-centred care puts the patient in charge of their health and targets the person’s biopsychosocial barriers to recovery. The role of the clinician is a ‘coach’ rather than a ‘treater’ — they take the patient on the journey to learn to self-manage their condition in line with their goals. 

Healthcare services 

A lack of time is a big barrier for clinicians to deliver high-value care. To deliver Cognitive Functional Therapy, Healthcare services must invest in training and properly compensate clinicians for longer consultations. 

Governments and insurers 

There is a need to prioritise high-value care over low-value care like scans, injections, surgery and opioids. There is an urgent need to fund access to treatments like Cognitive Functional Therapy given its potential to reduce the burden of disabling back pain and healthcare costs. 

The public

It's critical to dispel misconceptions about back pain and promote a more positive narrative that can empower people to take control of their health.

The takeaway message

Cognitive Functional Therapy represents a fundamental shift in the way persistent low back pain can be treated. It offers a cost-effective, person-centred, holistic approach that has excellent and sustained clinical benefits.

By embracing this innovative approach, we can revolutionise how persistent low back pain is managed and provide lasting relief for thousands of people.

You can find a useful Infographic summarising the trial and more information about it here.
 
Original research

Kent, P., Haines, T., O'Sullivan, P., Smith, A., Campbell, A., Schutze, R., ... & Hancock, M. (2023). Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. The Lancet.