Joe Laurence, a firefighter in Western Australia, was pulling a hose over a fence when he felt a sharp pain shoot down his back.
“It was pretty horrific at the time,” said Laurence, then 27. “From there, I probably spent a week in bed not being able to move.”
Laurence said his back hurt “every minute of every day” after the injury. He tried Pilates and worked with a physical therapist and a chiropractor, but he found little long-term relief.
A doctor told Laurence he had the spine of a person twice his age. Laurence gave up all his outdoor hobbies and started looking for a new career because he thought his back would never recover.
Two years later, Laurence met Peter O’Sullivan, a professor of musculoskeletal physiotherapy at Curtin University in Perth, Australia. O’Sullivan and his colleagues were working on a personalized physical therapy program called cognitive functional therapy. They published their first trial testing the intervention in 2013.
Cognitive functional therapy is an individualized approach to managing chronic pain in which a physical therapist coaches a person through the physical and psychological challenges of their pain and disability.
Laurence said that in just one session with O’Sullivan, he did things that he hadn’t done since his back pain began.
A few years ago, O’Sullivan and a team of researchers in Australia recruited close to 500 adults (median age 47) with persistent low back pain to conduct the largest clinical trial of cognitive functional therapy.
“We teach them ways to move, to get back to doing the stuff they love, in a normal, relaxed way,” O’Sullivan said.
Over 12 weeks, two groups of participants attended up to seven sessions of cognitive functional therapy at one of 20 clinics in Australia. In one of the two groups, therapists also gave “biofeedback,” guidance based on data provided by a movement sensor participants wore. The other volunteers in the study continued with usual care for their low back pain — acupuncture, injections, medications, physical therapy, and other treatments.
Participants self-reported how much their back pain limited their everyday activity, and their answers were scored on a scale of 0 to 24. On average, the cognitive functional therapy groups reported greater improvements in their chronic pain compared with the control group. O’Sullivan said they also were less fearful and more confident to engage in activities they wanted to return to.
And in August, the researchers published a three-year follow-up that showed that people who received cognitive functional therapy continued to be in less pain and were more active than they were before the study.
“We can help people with long-term, disabling back pain. There’s really strong evidence for that now,” said Mark Hancock, the lead author of the follow-up published in Lancet Rheumatology and a professor of physiotherapy at Macquarie University. “Not cure every bit of pain they have. But, hopefully, give them a much, much better life.”
The results are group averages, and some people benefited more than others, Hancock said. But some of those with the most debilitating chronic back pain improved the most with cognitive functional therapy, he said.
“I’d hate it to come across as a quick fix because it’s not,” O’Sullivan said. “It’s a journey to recovery, and the journey is often linked to flare-ups and setbacks and disappointments.”
Only 63% of the participants in the clinical trial responded to the follow-up questionnaire three years later, so it’s not clear how everyone fared. And it wasn’t possible to blind the participants from the intervention so they knew the therapy they received.
Laurence was not part of the trial, but he said that because of cognitive functional therapy, he’s able to do things now at 38 that he couldn’t do when he was 27 and had chronic back pain.
“I run, I cycle, I surf,” he said. “And I don’t even think about my back.”
Chronic low back pain is a leading cause of disability. About 1 in 4 American adults deal with it. The pain often starts with a strain from an awkward or unexpected movement, O’Sullivan said.
Most people recover in a few weeks, but for some, the pain “becomes persistent and disabling,” O’Sullivan said.
Available treatments such as nonsteroidal anti-inflammatory drugs (NSAIDs) or spinal manipulation only offer small benefits and short-term relief, O’Sullivan said. Treatments such as cognitive functional therapy aim to address the psychological aspects of persistent low back pain.
People often believe back pain means the spine is damaged, fragile, and needs to be protected, O’Sullivan said. They tense their muscles or stiffen their back to guard against any movement that may exacerbate the pain. But “it’s a bit like walking around with a clenched fist when you’ve got a sore wrist,” he said. “It makes things worse.”
Backs are designed for movement, O’Sullivan said. The goal is to help someone work through their anxiety or fear of the pain so they can return to bending and twisting as they normally would.
Laurence said: “All those beliefs that I had — I need to protect my back, my back is fragile, I can’t bend, I can’t twist” — O’Sullivan “just challenged those things and tried to undo them.”
Sitting, standing, or bending a certain way may be painful, but “there is no perfect posture,” O’Sullivan said. In fact, Hancock said, contracting your back muscles to sit “bolt upright” could lead to more back pain.
Cognitive functional therapy consists of three broad steps.
1. Make sense of what contributes to a person’s pain and how it affects their daily life.
First, your healthcare practitioner should rule out underlying problems that might respond to other treatments, O’Sullivan said. An MRI exam will detect tumors, fractures, and infections that could cause the low back pain.
Then, the therapy starts with the patient’s story “to get the whole picture” of the back pain, O’Sullivan said. The therapist would ask: How did the pain start? What’s the pattern of the pain? And how do you respond to it?
2. Gradually have the person practice activities, exercises, and movements they tend to avoid because of their back pain.
Laurence said O’Sullivan asked him to bring a list of hobbies he stopped doing because of the back pain, and they started training for each movement “one by one.”
Learning to relax your body and move normally again is the pathway to recovery, O’Sullivan said. The key is to gradually return to the sports and activities you enjoy.
“It’s actually amazing how many patients have stopped doing the thing they love because of their back pain,” Hancock said.
3. Have the person adopt healthy routines such as a consistent sleep schedule and regular exercise.
Flare-ups of low back pain can be related to a lack of sleep and to stress, O’Sullivan said.
“Pain doesn’t mean I’m damaged,” he said. “It usually means that I’m a bit tense or a bit stressed. I haven’t slept as well. I’ve not been exercising as much.”
“It’s pretty impressive,” said Stuart Warden, a professor of physical therapy at Indiana University Indianapolis who wasn’t involved in the study.
Cognitive functional therapy isn’t a cure-all for back pain, and some people are going to respond better than others, Warden said. But the results are encouraging because they show a clear long-term benefit. Now, researchers need to better understand why some patients improve more than others, he said.
Pain is complex; it’s not just a sensation. It’s a signal that’s coupled to cognitive, emotional, and motivational circuitry in the brain, said Steve Davidson, the associate director of the NYU Pain Research Center.
Cognitive functional therapy is “labor intensive” for the practitioner and the patient, Davidson said, but it gets results.
“It’s not a reversal or a cure. It doesn’t address what causes a patient’s back pain,” Davidson said. “What it does is it gives people the tools to deal with their situation in more powerful ways.”
Cognitive functional therapy isn’t common in the United States, but this type of psychologically informed care is becoming more popular because of studies like this one, said Steven George, a distinguished professor of orthopedic surgery at Duke University who reviewed the study before publication. He’s been researching this approach to treatment as well.
You can ask your physical therapist whether they use cognitive functional therapy or a similar treatment in their care, George said. It’s helpful to know whether they’re even aware of the approach, he said.
“They may run into someone who is using those same principles,” George said. “And, the reason for that is: We think it offers them a chance of a better outcome.”