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

Key points

1. 01CFT is an individualised treatment combining pain education, graded movement exposure, and lifestyle coaching, tailored to each person.
2. 02CFT beat group exercise and education on disability at both 6 and 12 months, a moderate-sized benefit.
3. 03Pain intensity improved similarly in both groups, with no significant difference between them.
4. 04CFT also did better on pain self-efficacy, risk of becoming chronic, and coping.
5. 05No adverse events were reported in either group.

How it was conducted

Design

Two-group, pragmatic, multicentre randomised controlled trial at three sites in Ireland, intention-to-treat with linear mixed models

Participants

206 adults aged 18 to 75 with non-specific chronic low back pain of at least 6 months and an Oswestry Disability Index of 14 percent or more

Groups

Cognitive functional therapy, one-to-one (n=106, mean 5 treatments) versus group-based exercise and education (n=100, up to 6 classes over 6 to 8 weeks)

Primary outcomes

Disability (Oswestry Disability Index, 0 to 100) and pain intensity over the past week (0 to 10 Numerical Rating Scale) at 6 and 12 months

What they found

• Disability favoured CFT at 6 months (mean difference 8.65, 95% CI 3.66 to 13.64, p=0.001; effect size 0.67).
• Disability favoured CFT at 12 months (mean difference 7.02, 95% CI 2.24 to 11.80, p=0.004; effect size 0.55).
• No between-group difference in pain intensity at 6 months (mean difference 0.76, 95% CI -0.02 to 1.54, p=0.056).
• No between-group difference in pain intensity at 12 months (mean difference 0.65, 95% CI -0.20 to 1.50, p=0.134).
• Per-protocol disability favoured CFT at 6 months (mean difference 11.87, 95% CI 6.59 to 17.14, p<0.001) and 12 months (mean difference 9.03, 95% CI 3.60 to 14.45, p=0.001).
• At 6 months CFT favoured risk of chronicity (mean difference 8.07, 95% CI 2.03 to 14.11, p=0.009) and pain self-efficacy (mean difference -6.66, 95% CI -10.93 to -2.39, p=0.002).
• At 12 months CFT favoured coping (mean difference -2.89, 95% CI -4.96 to -0.82, p=0.006) and pain self-efficacy (mean difference -5.99, 95% CI -10.52 to -1.46, p=0.010).

Limitations

• Participants and physiotherapists could not be blinded to which treatment they received, which can bias self-reported outcomes.
• Follow-up was incomplete, with only 72 percent assessed at 6 months and 69 percent at 12 months.
• Cost-effectiveness of the more individualised CFT approach was not evaluated, so the value to health systems is unknown.
• A single trial in one country, so results may not generalise to all settings.

Why it matters

For patients

If your back pain is limiting what you can do, a tailored one-to-one program may help you move and function better than a generic group class, even if your pain level changes about the same.

For clinicians

Consider delivering individualised CFT over group exercise and education when the main goal is reducing disability in chronic low back pain.

For readers

Tailoring care to the individual produced a meaningful disability advantage over a standardised group program, though it did not translate into greater pain relief.