Research Lumbar/SIJ October 14, 2024
Hancock et al. (2024)

Who can Benefit from Cognitive Functional Therapy

Benefit from cognitive functional therapy

Introduction

Individualized treatment is advocated but how do you tailor your intervention to the specific needs of someone? The current study wanted to find who might benefit from cognitive functional therapy (CFT). The paper by Kent et al. (2023) which studied CFT has been analyzed in one of our earlier research reviews. CFT was more effective than usual care for activity limitations at 13 weeks. The effect sizes for this chronic back pain treatment were retained one year post treatment. However, the intervention was a huge success for two-thirds of participants, nearly one third remained with no or only small improvements. For that reason, the current study wanted to investigate which baseline factors could moderate CFT treatment effects. If we understand who will likely improve from CFT, then we can better tailor interventions.

 

Methods

Data from the original study by Kent et al. (2023) was used in this secondary analysis. Details about this study can be found summarized format in our earlier research review.

In brief: 492 patients with CLBP were randomized into three groups: usual care, CFT, and CFT plus biofeedback. In the current secondary analyses, the two CFT groups were combined. Adults with chronic (>3 months) low back pain (CLBP) and at least moderate pain-related activity limitations as documented by item 8 of the 36-item Short-Form Health Survey.

The primary outcome of the original study was pain-related physical activity limitation as measured by the 0-24 Roland Morris Disability Questionnaire (RMDQ) at 13 weeks. Higher scores represent higher levels of pain-related disability. The Minimal Clinically Important Difference is reported to be a 30% reduction in baseline score.

The authors selected 5 potential moderator variables:

  • Baseline activity limitations were measured using the Roland Morris Disability Questionnaire (RMDQ). High scores represent more disability
  • Cognitive flexibility was assessed using the Cognitive Flexibility Scale. Higher scores indicate that the participant is more flexible.
  • Baseline pain intensity was documented using a 0-10 numeric rating scale with higher scores indicating more pain.
  • Self-efficacy was determined by the score on the Pain Self-Efficacy Questionnaire (PSEQ), with higher scores pointing to better self-efficacy
  • Catastrophizing was registered by scoring the Pain Catastrophizing Scale. Higher scores indicate more levels of catastrophization

The table lists the authors’ rationale for selecting those 5 potential variables. These variables were chosen either because these variables are specific treatment targets for CFT (self-efficacy and catastrophizing) or since the authors assumed that people open to CFT and behavioral change would have more chance of improvement from the intervention (high cognitive flexibility), or people with high pain and disability levels might most need a complex intervention such as CFT.

Benefit from Cognitive Functional Therapy
From: Hancock et al., J Physiother. (2024)

 

Results

In the original RCT, 492 participants were recruited and randomized, 165 to usual care, 164 to CFT only, and 163 to CFT with biofeedback. In this study, both CFT groups were combined. At baseline, the median pain duration was 260 weeks (5 years), and the mean RMDQ was 13.5.

Benefit from Cognitive Functional Therapy
From: Hancock et al., J Physiother. (2024)

 

Who might benefit from Cognitive Functional Therapy?

The analysis of the moderators found that patients with greater baseline disability levels experienced larger benefits from CFT at 13 weeks and 52 weeks. Patients with less disability at baseline also improved but to a smaller extent.

For every point on the RMDQ at baseline (more points = more disability), the treatment effect of CFT increased by 0.18 points at 13 weeks (95% CI: 0.01 to 0.34). At 52 weeks, every RMDQ point led to an increase of the CFT effect by 0.23 (95% CI: 0.04 to 0.42).

Benefit from Cognitive Functional Therapy
From: Hancock et al., J Physiother. (2024)

 

The authors have tried to explain this by providing the following example, considering the RMDQ scale is a 0-24 scale and how the participants scored.

  • People in the 10th percentile, who had low RMDQ disability at baseline scored 3.6 points better when receiving CFT compared to usual care (95% CI: 2.6 to 4.6).
  • If someone in the 90th percentile with a high baseline RMDQ score received CFT, they improved 6.1 points more than those receiving usual care (95% CI: 4.8 to 7.4).

No moderating effect was found for baseline scores of cognitive flexibility, pain intensity, self-efficacy, or catastrophizing.

Benefit from Cognitive Functional Therapy
From: Hancock et al., J Physiother. (2024)

 

Questions and thoughts

What is CFT? Cognitive functional therapy (CFT) seeks to help patients self-manage their persistent lower back pain by addressing specific psychological pain-related cognitions, emotions, and behaviors that contribute to their pain and disability. These include fear avoidance, seeing pain as a threat, protective muscle guarding, etc.

What is cognitive flexibility? Cognitive flexibility refers to being open to new ways of thinking. It was described as a person’s awareness of other alternatives and options being available, willingness to be flexible and adapt to the situation, and self-efficacy in being flexible. (Martin et al. 1995) It means using dynamic strategies that allow us to adapt our thinking and behavior to changing contextual demands. (Hohl et al. 2024)

 

Talk nerdy to me

If a patient with high activity limitations receives CFT, we can expect larger benefits than we could in someone with low activity limitations. However, even people with good functional levels may expect treatment benefits of CFT since still clinically meaningful benefits were shown. This is in contrast to Hayden et al. (2020) where baseline activity limitations were not moderating the effect of exercise interventions. Therefore the current authors assume that the larger benefits of CFT in those with more pronounced activity limitations at baseline are specifically attributed to the CFT intervention itself. However, regression to the mean could still have led to those larger effects in people having high baseline activity limitations.

The authors also proposed potential moderation effects of cognitive flexibility at 13 weeks, but not at 52 weeks. However, the confidence interval spanned zero at 13 weeks so I don’t know why they proposed this. The state: “The moderating effects of cognitive flexibility were smaller and not statistically significant but may be important for short-term effects.” I can understand their reasons for raising cognitive flexibility as a necessary condition for cognitive functional therapy to succeed. Indeed, “CFT aims to change unhelpful beliefs about low back pain and dispel common myths, so flexible thinking should facilitate this.” Yet, before any confirmation is given for the moderating effect of cognitive flexibility, I’d stick to the moderating factor of activity limitation (RMDQ) since that one reached the threshold of significance in the confidence interval.

Positive points from this study include the use of continuous variables instead of dichotomized ones. Very often, in such studies, dichotomous variables are used. They categorize for example high versus low activity limitations using an arbitrary threshold of above or below … points. Here the whole spectrum of scores in a specific variable was used. Although this makes interpreting the effects much more difficult, the authors found a way to clearly indicate the effects using the percentiles in table 4 (see above).

Benefit from Cognitive Functional Therapy
From: Hancock et al., J Physiother. (2024)

 

Take home messages

More effects from CFT can be expected in people with higher levels of activity limitations. This means that those people have greater benefit from cognitive functional therapy compared to people with lower activity limitations. Therefore, CFT should be strongly considered for patients with chronic low back pain who present with significant activity limitations. The absence of moderating effects for pain intensity, catastrophizing, and self-efficacy shows that CFT may still be useful across a wide variety of psychological profiles, contrary to original predictions (that it would be more useful in people having high negative psychological contributors).

 

Reference

Hancock M, Smith A, O’Sullivan P, Schütze R, Caneiro JP, Hartvigsen J, O’Sullivan K, McGregor A, Haines T, Vickery A, Campbell A, Kent P. Patients with worse disability respond best to cognitive functional therapy for chronic low back pain: a pre-planned secondary analysis of a randomised trial. J Physiother. 2024 Sep 25:S1836-9553(24)00081-X. doi: 10.1016/j.jphys.2024.08.005. Epub ahead of print. PMID: 39327170. 

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