Have a question or not sure which appointment to book? Book a free 15min call with us here.



Cognitive Functional Therapy – myths & reality of persistent low back pain

Cognitive Functional Therapy (CFT) is among the psychologically informed approaches that show promise in reducing pain, disability, and psychological outcomes in individuals with persistent or chronic low back pain (LBP).

The mechanisms for change appear to be rooted in the patient-centred, behavioural approach of this intervention, but the evidence informing the mechanism of these changes is still evolving. Today I take a closer look at the therapeutic framework and what may be the reason CFT shows good results.

Have a look first at Prof Peter O’Sullivan discussing and demonstrating some of the myths about back pain.

Peter O’Sullivan describes CFT as a flexible mind-body intervention that reflects the variability of people’s life and pain experience. It targets individualised interventions at pain and disability-related beliefs in order to reframe cognition / understanding and behaviours. Its three core components are (1) making sense of pain, (2) exposure with control and (3) lifestyle change. They are delivered in an integrated way, reflecting the inter-connectedness of factors driving the pain mechanism: pathoanatomical, physical, psychological (cognitive & emotional), social, lifestyle, and general health.

If any hands-on contact is used by the practitioner, it is to assist with movement experiments and relaxation.

An Randomised Control Trial  (RCT) carried out in 2013, with a 3-year follow up published in 2019 reported both statistically and clinically significant superior outcomes in pain, disability, anxiety, depression, fear-avoidance beliefs, total lumbar spine range of motion, patient satisfaction, sick-leave days, and care-seeking at 3 and 12 months of classification-based CFT when compared to traditional manual therapy and exercise. All outcomes in favour of CFT were maintained at 3-year follow up, except pain. The mechanisms for the change were unclear, likely multifactorial and hypothesised to be mediated by pain controllability, fear, emotional distress, and sleep.

While RCTs are the accepted method for analysing mediators of a treatment’s effect, methodological and cost constraints can be a limitation when it comes to the multifactorial and individual experiences of cLBP. Their clinical applicability is also limited, as they examine group effects and report on a common pathway to change as opposed to person-specific experience and outcomes.

“The reasons people got better were probably completely different reasons to what I thought. Why a human being changes has probably got a lot more to do with fundamental beliefs and their perception of threat, and probably what we were doing was reframing in a way that de-threatened them.”

Why beliefs

The Common-Sense Model (CSM) helps understand how musculoskeletal pain beliefs dictate coping responses. It suggests that pain beliefs are formed early in life and are shaped by parent / carer behaviours and beliefs, direct and / or witnessed experiences, encounters with clinicians, exposure to media… Their role is to make sense of pain symptoms (create a ‘representation’) and inform problem solving behaviours. For people with cLBP, there is a lack of useful representation to inform problem-solving behaviour, to predict and therefore exert control over the pain. The result is a self-perpetuating cycle of pain and distress, which reinforces unhelpful beliefs and fear-learning – a pathway explained by the Fear Avoidance Model.

CFT considers unhelpful beliefs a key modifiable aspect of chronic pain management. “Making sense” is one of the core components of its clinical framework as it creates opportunities to understand, reflectively challenge and reframe a person’s original cognitive representation of pain. Unhelpful behaviours are replaced with experiences of safety via movement experiments, or “exposure with control”, which teach reproducible movement strategies and relaxation techniques that modify the intensity or impact of pain. Specifically targeting the pain experience aims to create a “mismatch” between expectation and experience of pain. In turn, creating an experience of safety for the patient updates their cognitive representation and enables helpful, self-sustaining behavioural and emotional responses to future pain flare-up.

Building strong therapeutic alliance by use of a reflective, empathetic, validating style of communication is fundamental to CFT – it facilitates the unfolding of the patient’s “story”, triggering disclosures and reflections about their explicit and implicit beliefs.  This poses questions about the potential impact of cultural competency, language barriers and health literacy skills in the ‘making sense’ process of this clinical framework.

Process of change

Research underpinning the clinical reasoning frameworks of CFT is evolving and brings insights on the processes of change from the fields of behavioural psychology, pain neuroscience and, crucially, from the lived experiences of people recovering from chronic pain. A 2019 replicated single case experimental design study assesses the process of therapeutic change for four people with cLBP and high pain-related fear. The authors propose that experiential, de-threatening learning may be the core mechanism of change in disability in people with cLBP and high pain-related fear. Crucial to this process is forming of a strong therapeutic alliance needed to co-construct a patient’s story and inform the individualised care journey towards returning to valued functional activities and building of sustainable self-efficacy. Qualitative research confirms that a strong therapeutic alliance is a key element to enhancing treatment interaction, adherence and predictive of positive outcomes in CFT.

Informing practice

Successful application of CFT requires a broad skillset, further training and supervision, nuanced communication skills, understanding of behavioural psychology and neuroscience, clinical reasoning and observational skills, confidence around movement re-education coaching and competent handling skills.

Most of these attributes are compatible with contemporary understanding of the role of osteopathy in the management of cLBP. Above all, the onus seems to be on clinicians to monitor their own beliefs towards cLBP, boulster their knowledge and confidence in managing the BPS dimensions of pain and invite a wide range of research designs to inform their practice.

Biliana has embarked on the journey of CFT training, recently completing a workshop facilitated by Prof Kieran O’Sullivan – a co-researcher of Peter O’Sullivan. She incorporated the knowledge into her practice and would be happy to discuss any questions you may have about this approach.


  1. O’Keeffe M, Purtill H, Kennedy N, et al. Comparative Effectiveness of Conservative Interventions for Nonspecific Chronic Spinal Pain: Physical, Behavioral/Psychologically Informed, or Combined? A Systematic Review and Meta-Analysis. The Journal of Pain. 2016;17(7):755-774. doi:10.1016/j.jpain.2016.01.473
  2. Guerrero Silva VA, Maujean A, Campbell L, Sterling M. A Systematic Review and Meta-analysis of the Effectiveness of Psychological Interventions Delivered by Physiotherapists on Pain, Disability and Psychological Outcomes in Musculoskeletal Pain Conditions. The Clinical Journal of Pain. Published online March 2018:1. doi:10.1097/ajp.0000000000000601
  3. O’Sullivan PB, Caneiro JP, O’Keeffe M, et al. Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Physical Therapy. 2018;98(5):408-423. doi:10.1093/ptj/pzy022
  4. Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. European Journal of Pain. 2013;17(6):916-928. doi:10.1002/j.1532-2149.2012.00252.x
  5. Vibe Fersum K, Smith A, Kvåle A, Skouen JS, O’Sullivan P. Cognitive functional therapy in patients with non‐specific chronic low back pain—a randomized controlled trial 3‐year follow‐up. European Journal of Pain. 2019;23(8):1416-1424. doi:10.1002/ejp.1399
  6. Hill JC, Fritz JM. Psychosocial Influences on Low Back Pain, Disability, and Response to Treatment. Physical Therapy. 2011;91(5):712-721. doi:10.2522/ptj.20100280
  7. Powell J. Episode 17: Peter O’Sullivan. http://www.youtube.com. Published December 2, 2021. Accessed March 8, 2022. https://www.youtube.com/watch?v=e13gSp1lFe8
  8. Caneiro JP, Bunzli S, O’Sullivan P. Beliefs about the body and pain: the critical role in musculoskeletal pain management. Brazilian Journal of Physical Therapy. 2020;25(1):17-29. doi:10.1016/j.bjpt.2020.06.003
  9. Caneiro JP, Smith A, Bunzli S, Linton S, Moseley GL, O’Sullivan P. From Fear to Safety: A Roadmap to Recovery from Musculoskeletal Pain. Physical Therapy. 2021;102(2). doi:10.1093/ptj/pzab271
  10. Caneiro JP, Smith A, Linton SJ, Moseley GL, O’Sullivan P. How does change unfold? an evaluation of the process of change in four people with chronic low back pain and high pain-related fear managed with Cognitive Functional Therapy: A replicated single-case experimental design study. Behaviour Research and Therapy. 2019;117:28-39. doi:10.1016/j.brat.2019.02.007
  11. Caneiro JP, Smith A, Rabey M, Moseley GL, O’Sullivan P. Process of Change in Pain-Related Fear: Clinical Insights From a Single Case Report of Persistent Back Pain Managed With Cognitive Functional Therapy. Journal of Orthopaedic & Sports Physical Therapy. 2017;47(9):637-651. doi:10.2519/jospt.2017.7371
  12. Bunzli S, McEvoy S, Dankaerts W, O’Sullivan P, O’Sullivan K. Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain. Physical Therapy. 2016;96(9):1397-1407. doi:10.2522/ptj.20140570
  13. Macdonald RJD, Vaucher P, Esteves JE. The beliefs and attitudes of UK registered osteopaths towards chronic pain and the management of chronic pain sufferers – A cross-sectional questionnaire based survey. International Journal of Osteopathic Medicine. 2018;30:3-11. doi:10.1016/j.ijosm.2018.07.003