Cognitive functional therapy compared with a group-based exercise and education intervention for chronic low back pain: a multicentre randomised controlled trial (RCT).

The short version

This pragmatic randomised controlled trial with 206 adults explored whether an individualised, physiotherapist-delivered approach called cognitive functional therapy (CFT) works better than group exercise and education classes for chronic low back pain (CLBP, pain lasting six months or longer). CFT treats each person's pain as shaped by a mix of physical, psychological, and lifestyle factors specific to them, using a one-on-one interview and examination to identify what is driving that person's particular pain and disability, rather than applying the same program to everyone. Participants were recruited from three physiotherapy clinics in Ireland and randomly assigned to CFT (106 people) or a group programme (100 people), with the same three physiotherapists delivering both treatments to keep clinician skill and style consistent. CFT sessions were tailored to each person's clinical progress (on average, five one-on-one sessions over about 14 weeks); the group programme delivered similar pain-education, exercise, and relaxation content to up to ten people per class, over up to six classes across 6-8 weeks. The two main outcomes tracked were disability (using a standard 0-100 back-pain disability scale) and pain intensity (rated 0-10) at six and twelve months after starting treatment. People who received CFT had significantly less disability than the group at both check-ins, six months (a meaningful difference of about 9 points on the 100-point disability scale, p=0.001) and twelve months (about 7 points, p=0.004) — differences researchers would consider a moderate-sized real-world benefit. However, pain intensity itself did not differ significantly between the two treatments at either time point, meaning CFT helped people function better with their pain without necessarily making the pain itself notably lower than the group approach did. People in the CFT group also reported more confidence managing their pain and a lower predicted risk of their pain becoming a long-term problem. No safety concerns came up in either treatment. The researchers describe CFT's disability benefit as larger than what is usually seen in back-pain research, suggesting individualised, biopsychosocial physiotherapy care may be worth the extra training and time it requires compared to group classes. About three in ten participants did not complete the twelve-month follow-up questionnaires in either group, participants obviously knew which treatment they were getting, and this group had more baseline disability than many back-pain studies typically include, so results may look different in less severely affected patients. The authors call for future research on whether CFT is worth its added cost and training burden at a health-system level.

Key findings

• In a trial of 206 adults with chronic low back pain, individualised cognitive functional therapy (CFT) reduced disability significantly more than group-based exercise and education classes at both 6 months and 12 months.
• Despite the disability benefit, CFT did not reduce pain intensity more than the group programme at either follow-up point - the two treatments performed similarly on pain itself.
• People who received CFT also reported more confidence managing their pain (pain self-efficacy) and a lower predicted risk of their back pain becoming a long-term problem, compared with the group intervention.
• No safety concerns were reported in either treatment group across the 12-month trial.
• About three in ten participants in both groups did not complete the 12-month follow-up questionnaires, and neither participants nor treating physiotherapists could be blinded to which treatment was given, since both are known to influence self-reported outcomes.

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