Cognitive functional therapy for chronic low back pain: a systematic review and meta-analysis

Key points

1. 01CFT is an individualized biopsychosocial approach that coaches people to make sense of their pain, move with control, and change lifestyle factors to self-manage.
2. 02CFT reduced disability at all time points (low to moderate certainty) versus usual care or other treatments.
3. 03CFT improved pain self-efficacy with high certainty evidence in the medium and long term.
4. 04Larger benefits tracked with more clinicians trained, more prior clinician experience, competency checks and lower contamination risk.
5. 05One trial (RESTORE) found CFT was both more effective and less costly than usual care.

How it was conducted

Design

Systematic review and meta-analysis of randomized controlled trials, GRADE certainty

Search

MEDLINE, EMBASE, CINAHL and CENTRAL from inception to October 2023; 7 RCTs (8 manuscripts) included

Participants

1011 adults with chronic nonspecific low back pain across 7 trials; 6 of 7 in chronic LBP populations

Intervention

Cognitive functional therapy vs usual care, manual therapy plus exercise, group exercise and education, or MSI-based treatment

Outcomes

Pain, disability and pain self-efficacy at short (under 3 months), medium (3 to 12) and long term (12 months or more), all on a 0 to 100 scale

Analysis

Random effects meta-analysis (Comprehensive Meta-Analysis), Cochrane RoB 2 tool, GRADE certainty; descriptive synthesis of trial factors

What they found

• Disability vs all controls: short term MD 10.8 (95% CI 6.6 to 14.9, low); medium term MD 10.6 (95% CI 6.6 to 14.6, moderate); long term MD 8.8 (95% CI 1.8 to 15.9, low).
• Pain vs all controls: short term MD 13.8 (95% CI 5.5 to 22.2, low); medium term MD 13.7 (95% CI 9.3 to 18.2, moderate); long term MD 7.8 (95% CI -0.2 to 15.8, low).
• Pain self-efficacy vs all controls: medium term MD 12.3 (95% CI 8.4 to 16.2) and long term MD 12.5 (95% CI 8.6 to 16.5), both high certainty.
• RESTORE trial: CFT gained 0.12 QALYs per participant (95% CI 0.08 to 0.16) at a lower cost of AUD -5276 (95% CI -10,529 to -24).
• Effect sizes ranged from the smallest (Castro, 1 newly graduated unchecked clinician) to the largest (RESTORE, 18 experienced competency-checked clinicians).

Limitations

• Clinical heterogeneity in CFT training, dosage, comparators and populations across the 7 trials.
• Some long-term confidence intervals (e.g. disability 1.8 to 15.9) span values patients may consider both worthwhile and not.
• All trials used heavily trained clinicians (over 80 hours), so generalizability to less-trained clinicians is uncertain.
• Cost-effectiveness rests on a single trial.

Why it matters

For patients

CFT, a coaching approach that helps you understand and confidently move with your back pain, can meaningfully improve disability and confidence and the gains tend to last.

For clinicians

Consider CFT for chronic low back pain, but invest in proper training and competency checking, since effectiveness depends on delivery quality.

For readers

CFT is a promising, possibly cost-effective intervention for chronic low back pain, with effects on self-efficacy especially robust.