Cognitive Functional Therapy
Introduction[edit | edit source]
Cognitive Functional Therapy (CFT) was developed as an approach to address and manage disabling Low Back Pain (LBP). It can be used for many different types of back pain. It can also be translated to other disorders as well. The underlying motive for this approach is to analyse the behavioural psychology and beliefs seen within patterns of movement. Within these patterns, the Physiotherapist would identify modifiable and unmodifiable factors associated with an individual's LBP . This gives therapists and clinicians the chance to explore the various factors and facets of one's LBP, considering the views of the individual. The goal of employing the CFT is to assist individuals and patients in understanding their pain within their viewpoint, and determining strategies for them to manage their pain within their goals of activities, participation, and lifestyle. 
How the Framework is Used[edit | edit source]
The framework assists the Clinician in helping the patient understand the multidimensional source of their pain. It is used on patients who suffer from chronic pain, and have negative pain beliefs, including pain hypervigilance, negative self-efficacy, and negative psychological, emotional, and cognitive factors. 
The CFT employs a multifaceted clinical reasoning framework to identify modifiable factors of an individuals presentation based on their personal characteristics and lifestyle that they describe, and assessing their response to pain. This technique helps the patient become autonomous, and self-manage their pain with their own personalised treatment. 
Process of the CFT[edit | edit source]
A CFT intervention would usually involve, over a given number of sessions: 
- Making sense of the patient's pain, and helping them to understand the pain.
- Exposure with Control (show and train the patient their movement with alterations in movement pattern and control):
- Training postural control
- Training their movement with or without gradual exposure
- Providing visual feedback with mirror or video
- Integrating these patterns in functional tasks
- Providing reassurance of safe movement of the body
- Making the patient feel more comfortable and accustomed to the movement
- Lifestyle changes, such as sleeping patterns, and breathing techniques.
- Outcome (leading to a positive outcome, where the patient would behave normally, and feel rejuvenated).
These are the three main components of the CFT framework (there was previously a fourth component): 
- Component 1, "Making sense of the pain", was previously called 'Cognitive training', helping the patient change their mindset about their pain.
- Component 2, “functional movement training,” and,
- Component 3, “functional integration,” are together called “exposure with control,” helping the patient understand the movement pattern changes that will help with correcting their pain.
- Component 4, "Lifestyle Changes", as seen above, was previously called “physical activity and lifestyle training”.
Classifying the injury into the Diagnostic Triage[edit | edit source]
When a person presents with low back related pain, it is classified into the diagnostic triage, and then progressed accordingly: the diagnostic triage is classified into: 
- LBP with significant neurological deficit (5-10%)
- Non-specific LBP (90%)
- LBP with a serious or systemic pathology (1-2%)
With the Neurological Deficit - the therapist would want to progress with resolving any neurological symptoms, and refer for imaging or surgical review with the presence of the neurological deficits or cauda equina symptoms. 
For Non-Specific LBP, along with resolving neurological symptoms, the therapist would start with assessing for risk factors, from a health, lifestyle, psychological, physical, and patho-anatomical cause. They would also collect any non-modifiable barriers and factors the patient can change. This can be done through administering screening tools and questionnaires. 
The patient can be classified into a low disability category, where they would require a minimal number of CFT intervention sessions. 
If they are classified into a moderate or severe disability, they would require several weeks of CFT intervention. They would also be suited for additional psychological or pain management support. 
With a Serious or Systemic Pathology the patient should be directly referred for urgent medical management. 
Highlights of the CFT Framework[edit | edit source]
As with all practitioner-patient healthcare interventions, the utility of the CFT takes a holistic approach with patient motivation, and an open, non-judgmental, and empathetic form of communication. 
It helps move the patient away from the negative beliefs by promoting positive health behaviours, and helps correct or convince patients of unhelpful beliefs and behaviours. This is done in a way not to enforce a belief or behaviour on the person, but rather have them try it and reflect on it. 
Factors taken into account include, patient's preferences and expectations, cultural factors, and willingness for intervention and change. 
Patient Interaction[edit | edit source]
Upon presentation of the patient, there are many steps that occur throughout the management of the patient. 
The interview gathers all the relevant information about the patient's presenting problem - it gathers their story, history and contextual factors, their aggravating and easing factors with different postures and movements, their beliefs about their pain, pain pattern, severity, emotional responses, behavioural responses, limitations to functional activities, general health with respect to their pain, barriers to a healthy lifestyle, and the patient's goals and barriers to achieving those goals. 
A Functional Behavioural Assessment is conducted to assess movement patterns, any strategies that are used such as muscle guarding or tensing, strength/weakness and endurance, and beliefs while performing such movements. Subsequent to this, movement experiments are performed. The goal is to minimise symptom response, and any safeguarding actions that the individual may have adopted by exposing the individual to their fearful avoided motions. 
Following these steps leads to the CFT intervention, which, as mentioned, includes helping the patient "make sense of their pain", exposure control, and lifestyle changes. 
CFT is said to be a reflective therapy rather than prescriptive. The therapist and patient work together to attempt different movements, and movement patterns, to help the patient move without pain, fear, muscle guarding, and limiting motions. Visual feedback through video or mirror is used, and hands-on feedback helps with tactile sensation, and validate and challenge the patient's beliefs on body structures and anatomy. Reinforcement from the therapist is also a key component of the intervention. However, hands-on feedback should not be a substitute for active movements conducted by the patient. 
Efficacy of CFT[edit | edit source]
It is shown that Clinicians have been able to reproduce different aspects of the clinical reasoning model using the CFT.  In a randomised trial, CFT has shown a high long term efficacy to physiotherapist facilitated exercise and manual therapy. 
Through qualitative collected data, it is shown that people who benefit from CFT have an enhanced mindset toward understanding the multifaceted nature of the pain, being able to control the pain, and having the mental and physical ability to reach their functional and lifestyle goals. 
Results from RESTORE, a two year clinical trial, was released in June of 2023. The clinical trial had a total of 492 patients assigned to 3 treatment groups: CFT only, CFT plus biofeedback and usual care. The two CFT treatment groups showed greater treatment effects than usual care.
Support from a randomized controlled trial showed significant improvement in disability, fear avoidance scores and anxiety/depressions symptoms compared to manual therapy with exercise over a 3 year period. No significant change between CFT and manual therapy with exercise were noted.
A systematic review and meta-analysis did not show support of CFT over usual care, specifically manual therapy with core exercises. Control of bias and summary effect attempted via Cochrane Risk of Bias 2 and the Grading of Recommendation, Assessment, Development and Evaluations (GRADE) Approach.
Resources[edit | edit source]
To see the full study explaining CFT, with various diagrams, flowcharts, and models, including a web with CFT qualifiers, check out the paper here.
Additional Video Resources[edit | edit source]
An instructional video by Peter O'Sullivan, one of the authors of the RESTORE clinical trial:
References[edit | edit source]
- O’Sullivan PB, Caneiro JP, O’Keeffe M, Smith A, Dankaerts W, Fersum K, O’Sullivan K. Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Physical therapy. 2018 May;98(5):408-23.
- Kent P, Haines T, O'Sullivan P, Smith A, Campbell A, Schutze R, Attwell S, Caneiro JP, Laird R, O'Sullivan K, McGregor A. 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. 2023 Jun 3;401(10391):1866-77.
- Vibe Fersum K, Smith A, Kvåle A, Skouen JS, O'Sullivan P. Cognitive functional therapy in patients with non‐specific chronic low back pain—a randomized controlled trial 3‐year follow‐up. European Journal of Pain. 2019 Sep;23(8):1416-24.
- Devonshire JJ, Wewege MA, Hansford HJ, Odemis HA, Wand BM, Jones MD, McAuley JH. Effectiveness of cognitive functional therapy for reducing pain and disability in chronic low back pain: a systematic review and meta-analysis. journal of orthopaedic & sports physical therapy. 2023 May;53(5):244-85.
- Cognitive Functional Therapy Masterclass Part One - Peter O'Sullivan Available from: https://www.youtube.com/watch?v=fNnYglNVI0k [last accessed 11/18/2023]