Cognitive functional therapy compared with core exercise and manual therapy in patients with chronic low back pain: randomised controlled trial

Key points

1. 01CFT reduced disability scores by a mean of 4.75 points more than CORE-MT at 8 weeks, but this fell short of the clinically important threshold
2. 02No difference in pain intensity was found between the two treatments at any time point
3. 03The short-term disability advantage of CFT was not maintained at 6 or 12 months
4. 04Patient satisfaction and global perceived effect were similar between groups throughout follow-up
5. 05Both treatments were delivered in only 4-5 sessions over 8 weeks, which may have limited the effect of CFT

How it was conducted

Design

Parallel-group randomised controlled trial, single centre, Brazil

Participants

148 adults aged 18-65 with chronic low back pain (duration at least 12 weeks, ODI greater than 14%)

Groups

CFT (n=74): 5 individualised one-hour sessions over 8 weeks addressing pain reconceptualisation, graded exposure, and lifestyle change; CORE-MT (n=74): McGill-based core strengthening plus manual therapy, same session schedule

Primary outcomes

Pain intensity (0-10 numeric rating scale) and disability (Oswestry Disability Index, 0-100) at 8 weeks

Follow-up

Pre-intervention, 8 weeks, 6 months, and 12 months

Analysis

Intention-to-treat with multiple imputation; repeated-measures linear mixed models

What they found

• Disability at 8 weeks: CFT mean 17.48 vs CORE-MT mean 20.25; adjusted MD -4.75 (95% CI -8.38 to -1.11); P=0.011; effect size (Cohen d) 0.55
• Pain intensity at 8 weeks: CFT mean 3.57 vs CORE-MT mean 3.51; adjusted MD -0.04 (95% CI -0.79 to 0.71); P=0.916; effect size 0.07
• Disability at 6 months: adjusted MD -2.98 (95% CI -6.45 to 0.48); P=0.091; effect size 0.43
• Disability at 12 months: adjusted MD -1.43 (95% CI -5.45 to 2.58); P=0.484; effect size 0.22
• Pain intensity at 6 months: adjusted MD -0.25 (95% CI -1.12 to 0.62); P=0.576
• Pain intensity at 12 months: adjusted MD 0.29 (95% CI -0.54 to 1.11); P=0.494
• Global perceived effect at 8 weeks: MD 0.34 (95% CI -0.33 to 1.01); P=0.32; no significant difference at any time point
• Patient satisfaction: no significant difference at 2 months (P=0.550), 6 months (P=0.494), or 12 months (P=0.374)
• Trial completion: 97.3% in each group at 8 weeks; 95.9% CFT and 89.2% CORE-MT at 12 months

Limitations

• Single clinic in Brazil limits generalisability to other settings and populations
• Assessors and participants could not be blinded because outcomes were self-reported
• The CFT therapist was newly graduated with only 1 year of experience, and fewer total sessions were delivered compared with earlier CFT trials, potentially underestimating CFT's effect
• Slight baseline imbalance in disability scores between groups despite block randomisation

Why it matters

For patients

Patients with chronic low back pain can expect modest short-term improvements in daily function from CFT, but the benefit over a standard core exercise and manual therapy programme is small and fades within months.

For clinicians

CFT offers no clear advantage over core training plus manual therapy when delivered in 4-5 sessions; longer courses or booster sessions may be needed to sustain any functional gains.

For readers

This well-conducted RCT with low attrition tempers earlier enthusiasm for CFT by showing that its disability benefit at 8 weeks, while statistically significant, does not reach clinical importance and is not maintained at 1 year.