Open Access

Cognitive Functional Therapy

Research

Below are a collection of research papers about Cognitive Functional Therapy.

Click the down arrow (  ) to access the summary and link to the full open access paper. 

Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain
Peter O'Sullivan, JP Caneiro, Mary O'Keefe, Anne Smith, Wim Dankaerts, Kjartan Fersum, Kieran O'SullivanPhysical Therapy & Rehabilitation Journal, Volume 98, Issue 5, 1 May 2018, Pages 408-423, https://doi.org/10.1093/ptj/pzy022

Summary

This paper was written for clinicians to help them understand Cognitive Functional Therapy.

Cognitive Functional Therapy is an approach to help individuals make sense of their pain within their own context and to develop an individualised management plan aligned with their personally relevant goals. The approach differs from traditional treatment approaches because it holistically addresses the wide range of individual factors that can lead to ongoing pain and disability, such as negative beliefs about back pain, emotional distress, and unhelpful behavioural responses to pain such as movement and activity avoidance. 

Cognitive Functional Therapy places the ‘person’ at the centre of their care, where their individual concerns, worries, ways that they move, and their functional limitations and goals, become the focus of treatment. The clinician works as a coach rather than a ‘fixer’. Cognitive Functional Therapy uses a multi-dimensional clinical reasoning framework to identify and target the factors important for each individual.

Section 1 - "Multidimensional Factors Associated with Disabling LBP" 

This section explores the relevance of pain characteristics, relevant pathoanatomical factors, physical factors, psycholoogical factors, social factors and general health factors. Table 1 provides 3 case examples of relevant multidimensional factors. Table 2 provides examples for how a clinician can ask questions about relevant psychological factors.

Section 2 - "Cognitive Functional Therapy: Assessment and Treatment" 

This section explores therapeutic alliance, highlights the need for a triage process for people with low back pain (Figure 2), describes a multidimensional clinical reasoning framework to identify key modifiable targets for management and outlines how to conduct a functional behavioural assessment for painful, fear or avoided movements. The Cognitive Functional Therapy intervention is then described which includes three key components:

Section 3 - "Skills Required to Implement CFT" 

There are specific skills required for successful implementation of Cognitive Functional Therapy in practice which include:
  • Communication skills to sensitively explore how people think and feel about their problem, build strong therapeutic alliance, enhance self-efficacy and promote behaviour change.
  • Strong clinical reasoning skills to triage and synthesise multidimensional information.
  • Observation skills are required to analyse functional and safety behaviours.
  • Hands-on feedback and movement facilitation skills are needed to guide behavioural experiments and teach new behaviours.
  • Clinicians need to have confidence to discourage safety behaviours, and to intrinsically recognise that pain is more strongly related to multidimensional factors, rather than damage, that the spine is strong and movement is helpful.

From Fear to Safety: A Roadmap to Recovery From Musculoskeletal Pain 
JP Caneiro, Anne Smith, Samantha Bunzli, & Steven J. Linton
Physical Therapy & Rehabilitation Journal, Volume 102, Issue 2, 23 December 2021, https://doi.org/10.1093/ptj/pzab271

Summary

This paper is written for clinicians exploring how people can recover from musculoskeletal pain. Within this paper a pain-related fear and safety-learning are explored and a framework using Cognitive Functional Therapy is proposed to promote safety learning for people with musculoskeletal pain through a common-sense lens.

Fear learning

Fear learning is often related to unhelpful 'common-sense' societal beliefs about the body and pain such as 'if there are symptoms, the body must be broken requiring protection until it can be fixed'. Therefore, people develop pain-related fear as a result of perceived threats to their body which result in common-sense protective behaviours, such as avoidance or modification of activities. Avoidance can help in the short term, but can also be a driver of ongoing pain in the long term, because for those who do not recover, avoidance behavours prevent safety learning. Qualitative studies indicate that diagnostic uncertainty, radiological reports that include threatening language, unhelpful advice 
received from clinicians, conflicting advice, and societal beliefs about the fragility of the spine, reinforce pain-related fear. These unhelpful factors can result in people adopting protective movement strategies including restricting movement and muscular guarding to 'protect' their back, despite these strategies often leading to increased pain. Over time, protective strategies develop across activities and contexts, further driving pain-related fear.

The common-sense model is a model of fear avoidance and a recovery pathway that has been investigated. Sense-making at the heart of this model goes beyond catastrophising, and includes the 'cognitive representation' of an individual's pain condition informed by memory of their past 'normal' self, pain experiences, treatments, lifestyle and social activities.
Five key dimensions for the cognitive representation:
The key principles include
  1. Identity (what is this pain? e.g. structure)
  2. Cause (what caused this pain? e.g. bending)
  3. Consequences (what are the consequences of this pain? e.g. disability)
  4. Timeline (for how long will this pain last?)
  5. Cure/controllability (can this pain be cured or controlled?)

Safety-learning

The primary mechanism in fear reduction is learning a new experience of safety to form new memories. Extinction of fear occurs via inhibitory learning through cognitive restructuring and fear habituation (exposure until fear reduces). It is recommended that clinicians download the article and print out Figure 1 which provides an extensive list of key principles to promote safety learning. 
The key principles include
  1. Screen
  2. Interview
  3. Examine
  4. Expose with Control
  5. Make Sense of Pain
  6. Integrate into daily life
  7. Provide an flare-up plan
  8. Refer if co-care is required
Expectancy violation is the cornerstone of inhibitory learning and provides an opportunity for the patient to undergo cognitive restructuring towards a new common-sense model of their condition. Expectancy violation is an intentional clinical process where safe memories (e.g. bending is safe) are developed that directly compete with an original fear memory (e.g. bending is painful).

CFT to promote safety-learning

Write your awesome label here.
A) Person’s common-sense response to a pain experience interpreted as threatening (fear schema).

B) Core elements of Cognitive Functional Therapy as a vehicle to promote safety learning. The experience may confirm or violate the original schema. Confirmation of pain as a threatening experience (i.e. learning does not occur) leads to the reinforcement of the person’s fear response. Violation of pain as a threatening experience (i.e. learning of safety occurs) can powerfully disconfirm fear-avoidance beliefs while reinforcing that valued activities can be safely confronted when performed without safety behaviors and reduced pain vigilance. This leads to an update of the person’s response that promotes generalisation of safety.

C) Person’s common-sense response to an experience interpreted as safe (Safety schema).
D) Response to a pain flare, which may reinforce fear or safety learning. This is a crucial learning opportunity that influences a person’s process to recovery.

Patient-centered consultations for persons with musculoskeletal conditions
Joletta Belton, Hollie Birkinshaw & Tamar Pincus
Chiropractic & Manual Therapies, Volume 30, Issue 53, 2022, https://doi.org/10.1186/s12998-022-00466-w

Summary

This paper  was written by a person with a lived experience of persistent pain and academics. It discusses how healthcare professionals can better support patients with long-term musculoskeletal pain by focusing on patient-centered consultations. It highlights the importance of truly listening to patients, validating their experiences, and providing clear, meaningful reassurance.

The perspective is based on the personal story of Joletta Belton, a former firefighter-paramedic who experienced persistent pain. She describes how, after years of conflicting diagnoses and unsuccessful treatments, she felt lost, confused, and invalidated. Through her experience, the authors emphasise key aspects of effective consultations:

Listening to the Full Story – Patients want to be heard, not just assessed with checklists. Allowing them to share their experiences fully helps them feel valued and understood.

Building a Relationship – Empathy and trust between the clinician and patient can make a big difference in how patients engage with treatment and manage their pain.
Avoiding Empty Reassurance – Telling someone “everything will be fine” without providing real solutions can make them feel dismissed. Instead, reassurance should come from honest discussions about their condition and what they can do to manage it.

Validating the Patient’s Experience – Many patients feel they must “prove” their pain to clinicians. Simply acknowledging that their pain is real and distressing can provide emotional relief and help them move forward.

Providing Useful Information and Shared Decision-making – Rather than giving generic explanations, clinicians should work with patients to create a personal understanding of their pain, its causes, and management strategies.

The paper suggests that when patients feel heard, validated, and involved in their care, they are better able to manage their pain and lead fulfilling lives. This approach shifts the focus from "fixing" pain to helping patients regain control and improve their quality of life.

Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain
Samantha Bunzli, Sarah McEvoy, Wim Dankaerts, Peter O'Sullivan, Kieran O'Sullivan
Physical Therapy, Volume 96, Issue 9, 1 September 2016, Pages 1397–1407, https://doi.org/10.2522/ptj.20140570

Summary

This qualitative research paper is written for clinicians and researchers to help them understand the perspectives of patients' experience of Cognitive Functional Therapy.

Methods

This qualitative study used semi-structured interviews across 14 participants in Ireland and Australia. Interviews were conducted at 3-6 months post-intervention. Initially, a range of participants were selected based on their disability outcome measure (Oswestry Disability Index), including:
  • 4 participants who achieved a large improvement (>60%)
  • 3 participants who did not change (<30% improvement)
  • 2 participants who improved a little (~50%)
After specific themes began to emerge about a 'change in pain beliefs', an additional 5 participants were recruited based their response on the Tampa Scale of Kinesiophobia, a questionnaire that measures pain-related fear.
  • 2 participants were recruited who experienced significant reductions in pain-related fear resulting in them no longer meeting the criteria for 'high fear' after CFT
  • 3 participants were recruited who experienced improvements in pain-related fear but still met the criteria for 'high fear' after CFT

Two themes emerged from the interviews:

Theme 1 - Changing Pain Beliefs

  • Participant entered the study with biomedical beliefs.
  • Acceptance of a biopsychosocial model differentiated large improvers from small improvers.
  • Therapeutic alliance seemed to differentiate large improvers from non-improvers and be an attribute that was associated with successfully changing pre-existing beliefs.
  • Body awareness was shifted in people who improved, affecting their perception of themselves both physically and mentally, while those who did not improve were not empowered by this experience.
  • Experiencing pain control resulted from improved body awareness in people who improved, in contrast, those who did not improve did not experience pain control through improved body awareness.

Theme 2 - Achieving Independence

  • Problem solving and self-efficacy facilitated patients perceptions of control of their problem and future pain experiences, and large improvements in either disability and pain self-efficacy
  • Concerns about the cause of pain, and their ability to cope, remained in those who improved a little and those who did not improve at all.
  • Fear about new pain episodes reduced substantially in large improvers due to an understanding about the cause of their pain and ability to self manage symptoms, while those who improved a little or did not improve at all remained fearful about movement, pain intensity and their ability to control flareups.
  • Stress coping improved significantly in large improvers where they acknowledged the effect of lifestyle and stress on the pain experience. Those who improved a little or did not improve at all found it challenging to manage stress or did not acknowledge stress as being related to their pain experience.
  • Normality was described by large improvers where they were no longer defined by their pain experience and returned to normal activities. In small improvers, although they were coping better, their pain relapses reminded them they were not 'normal'.
Overall, acceptance of a biopsychosocial perspective of the low back pain experience differentiated those who did and did not improve. Improvement seemed to be related to the relationship with the clinician and the participant's ability to establish control of their symptoms through body awareness. Those who improved were able to achieve self-management had positive perspectives on their future ability to cope and control their symptoms through management strategies consistent with a biopsychosocial model of care. 

Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study
Aoife Synnott, Mary O’Keeffe, Samantha Bunzli, Wim Dankaerts, Peter O'Sullivan, Katie Robinson, Kieran O'Sullivan.
Journal of Physiotherapy, Volume 62, Issue 4, October 2016, Pages 215-221, https://doi.org/10.1016/j.jphys.2016.08.002

Summary

This qualitative research paper is written for clinicians and researchers to help them understand physiotherapists’ perceptions of the identification and treatment of the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training.

Methods

This was a qualitative study that used semi-structured interviews to explore the perceptions of 13 physiotherapists from 4 countries who had received specific CFT training. That training had involved supervised implementation of CFT in clinical practice with patients. Interviews were audio-recorded, transcribed verbatim, and an interpretive descriptive analysis was performed.

Four themes emerged from the interviews:

Theme 1

Changed understanding and attitudes due to an increased understanding of the nature of pain, the role of the patient’s beliefs and a new appreciation of the therapeutic alliance.

Theme 2

Changes in professional practice due to the use of new assessments, changes in communication and adoption of a functional approach.

Theme 3

Altered scope of practice due to a greater awareness of their scope of practice since undertaking CFT training.

Theme 4

Increased confidence and satisfaction due to better addressing cognitive, psychological and social factors.

Participants clearly articulated a perception that cognitive factors were modifiable by physiotherapy intervention. However, participants acknowledged that addressing cognitive factors could sometimes be challenging or difficult. Nevertheless, participants explicitly described feeling equipped to challenge patients’ belief systems after participating in CFT training.
Also, within this study there was no evidence of a negative characterisation of patients based on their attitudes or beliefs.
Participants described being motivated to systematically incorporate exploration of biopsychosocial factors in all interactions with chronic low back pain patients. And participants described using a more functional behavioural examination and management approach and changes in their interaction style in keeping with the ethos of CFT.

Physiotherapists’ validating and invalidating communication before and after participating in brief Cognitive Functional Therapy training. Test of concept study
Riikka Holopainen, Mikko Lausmaa, Sara Edlund, Johan Carstens-Söderstrand, Jaro Karppinen, Peter O’Sullivan & Steven J. Linton
European Journal of Physiotherapy, Volume 25, Issue 2, 23 September 2021, Pages 73-79, https://doi.org/10.1080/21679169.2021.1967446

Summary

This observational research paper investigated how communication during consultations changed after a brief Cognitive Functional Therapy intervention.

Methods

In ‘this test of concept’ study, 18 physiotherapists who treat patients with low back pain participated. The study had a within-group design in which the validating and invalidating aspects of their patient consultations were rated before and after 4-6 days of CFT training, using a reliable observational scale. The researchers also collected data on interview length and the percentage of physiotherapists’ and patients’ speech within the consultation.

Results

After CFT training, that included a focus on validating communication, the physiotherapists showed more validating and less invalidating communication behaviours in their filmed physiotherapy sessions.

Overall, the interviews were longer after training compared to before training but this appeared to be unrelated to the pre- and post-training level of validation/ invalidation. When the percentage of speaking time for physiotherapists and patients was explored, physiotherapists talked less, and patients talked more, after training compared to before. Interestingly, the length of the interview was not related to validating and invalidating communication indicating that it does not take more time to validate patients.
A practical implication of this study is that clinicians may engage in validating communication without fear of prolonging the length of the interview. This is of importance because time and effectiveness are a constant struggle in the clinic.
To further disentangle the specific effects of validating communication as well as other aspects of communication, future studies should include a larger sample and control groups, as well as measurements of other aspects of communication.

Cognitive Functional Therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial
Peter Kent, Terry Haines, Peter O'Sullivan, Anne Smith, Amity Campbell, Robert Schutze, Stephanie Attwell, JP Caneiro, Robert Laird, Kieran O'Sullivan, Alison McGregor, Jan Hartvigsen, Den-Ching A Lee, Alistair Vickery, Mark Hancock. The Lancet, Volume 401, Issue 10391, 3 June 2023, Pages 1866-1877, https://doi.org/10.1016/S0140-6736(23)00441-5

Summary

This was the largest clinical trial of Cognitive Functional Therapy so far, the first trial in Australia, and the first trial to measure health economic outcomes alongside clinical outcomes.

Methods

First, we trained a group of 18 physiotherapists across Perth and Sydney who had at least 2 years' experience in treating people with chronic low back pain and minimal previous exposure to Cognitive Functional Therapy. Competency standards had to be met before the physiotherapists could enter the trial and not all achieved competency at 6 months. Training was conducted by physiotherapists who had developed Cognitive Functional Therapy and had extensive experience using and teaching it. Towards the end of the training, the groups were randomly split into two where one group was also trained in the use of movement biofeedback.
492 people with persistent and disabling low back pain were recruited into the trial on the basis that they had sought care for their low back pain at least 6 weeks previously. The people recruited were more disabled than people in previous large clinical trials for chronic low back pain. There were 3 treatment groups:
Usual Care
  • People were able to seek care as usual with no restrictions.
Cognitive Functional Therapy only
  • Sensors were placed on the participant to assist blinding and provide movement information for the trial.
  • The sensor data was not accessible by either the patient or physiotherapist.
Cognitive Functional Therapy + movement biofeedback sensors
  • Sensors were placed on the participant to provide personalised feedback on movement and posture, as directed by their physiotherapist.
  • Data was accessible by the patient and physiotherapist.

Results

Disability and Pain
Both Cognitive Functional Therapy groups demonstrated large and sustained (at 12-months) reductions in pain-related activity limitation (disability) and pain intensity compared to usual care. At the end of the 3-month treatment period, the proportion of people with a within-person clinically important reduction in activity limitation (5 points on the Roland Morris Disability Questionnaire) was 19% in the Usual Care group and was 61% in the CFT groups. At 12-months, the proportion was 24% in the Usual Care group and was 67% in the CFT groups.

On the outcome of pain intensity, at the end of the 3-month treatment period, the proportion of people with a within-person clinically important reduction in pain (2 points on a 10-point scale) was 16% in the Usual Care group and was 48% in the CFT groups. At 12-months, the proportion was 25% in the Usual Care group and was 51% in the CFT groups.
These large, sustained effects are particularly novel. We had a low drop-out rate from the trial (15% at the primary time point) giving us confidence in these results.

There were also large and sustained effects for all other measures: people had more positive pain beliefs (reduced pain catastrophising), they were more confident to engage in movement and activity (higher self-efficacy), and they were less fearful of movement, both immediately after the Cognitive Functional Therapy intervention and at 12-months follow-up. 82% of people receiving Cognitive Functional Therapy were satisfied with the treatment compared to 19% receiving usual care.
There was no additional clinical benefit of sensor biofeedback. Cognitive Functional Therapy was safe.

Economic
In addition to being much more effective, Cognitive Functional Therapy was also much less costly than usual care. There were large quality adjusted life year improvements in the Cognitive Functional Therapy groups. Reductions in health-related costs and improvements in productivity valued (combined) produced more than AU$5000 in societal saving per person over a year, beyond the cost of the care. These cost savings were mainly driven by work productivity gains.

How do the results compare to previous research?
At the end of the treatment period the clinical effectiveness of Cognitive Functional Therapy for improvement in activity limitation and pain was larger than most interventions for chronic low back pain. The sustained and large effects at 52 weeks are unusual in the low back pain field. These clinical effectiveness findings are noteworthy in the context of a recent case-control study that showed CFT was more effective, and was only 7% of the cost, compared to multi-disciplinary pain management for people with severe low back pain [Vaegter et al. Pain Rep 2020; 5(1): e802].

What do the results mean?

For Clinicians
Clinicians with a range of years of clinical experience treating people with disabling chronic low back pain can be trained to competently deliver Cognitive Functional Therapy in primary care. However, we have also found in a previous study that learning to become competent to deliver Cognitive Functional Therapy is not just about doing a workshop [Holopainen et al. Physiother Theory Pract 2022; 38(2): 309-26]. It takes dedication, time and training under skilled mentoring to develop the specific skills to meet the competency standard. A central component in this training is direct mentoring from skilled trainers, while treating people with low back pain.

The results provide hope to patients and clinicians. Most people with persistent and disabling low back pain can be effectively treated with Cognitive Functional Therapy. Person-centred care puts the patient in charge of their health. It identifies and targets the patient’s individual biopsychosocial barriers to recovery. The role of the clinician is a ‘coach’ rather than a ‘treater’, taking patients on the journey to learn to self-manage their condition in line with their goals. The clinicians in the trial found the training challenging and rewarding. They found the new way of working both liberating and empowering, helping them bridge the evidence-practice gap in delivering person centred care [Simpson et al. Phys Ther 2021; 101(10)].
For Healthcare Services
Cognitive Functional Therapy represents a high-value care option for many people with disabling chronic low back pain. To deliver this care in health systems, there is a need to invest in competency-based training of clinicians. Furthermore, a lack of time is a massive barrier for clinicians to the deliver high value care. So, in addition to clinician training, we need to invest in remunerating clinicians for the time they spend performing a suitable length consultation.

For Governments/Insurers
There is an urgent need to provide access and funding to support high-value care like Cognitive Functional Therapy, for people suffering from chronic low back pain. Continuing the way health systems are currently organised and funded will result in wasted resources, harm to patients and increasing disease burden. Sadly, it is often easier and cheaper for people to get low-value care such as a scan, injection, surgery and opioids, than to get documented high-value care such as Cognitive Functional Therapy.

For the Public
There is an urgent need to educate the public about low back pain and build a more positive narrative. Low back pain can be really scary and disabling, and chronic low back pain is real. People suffering from chronic low back pain need to feel heard, understood and validated. Their pain is felt in the body and influenced by the body-mind interactions. Effective care that provides sustained reductions in pain, distress and disability is possible. The role of the clinician is to coach the person with low back pain to be in charge of their own care. The journey is different for everyone. For some this is a tough and long journey full of setbacks, while for others is relatively quick and straight forward. Importantly, there will be setbacks (flare-ups) along the way for most people, and the key is to help and support people navigate these setbacks to stay on track.

It's time for a change with the management of non-specific chronic low back pain.
Peter O'Sullivan. British Journal of Sports Medicine, Volume 46, Issue 4, 1 March 2012, Pages 224-227, https://doi.org/10.1136/bjsm.2010.081638

Summary

This paper by Professor Peter O’Sullivan challenges the traditional approach to managing chronic low back pain (LBP). For years, back pain has been managed as a purely physical problem, focusing on spinal abnormalities, posture, and muscle weakness. However, despite increasing medical treatments like surgeries, injections, and painkillers, disability from back pain continues to rise.

Chronic back pain is influenced by many factors, including stress, emotions, movement habits, and lifestyle choices. Research shows that the way people think and feel about their pain can impact their recovery more than structural issues seen on scans.

Key Takeaways:
Back Pain Is More Than Just a "Back Problem"
  • Only a small percentage of back pain cases are due to a clear structural issue.
  • Factors like stress, fear of movement, and negative beliefs about pain can make symptoms worse.
Traditional Treatments Often Don’t Work Well
  • Many common treatments, such as muscle strengthening exercises and spinal injections, don’t offer better results than general exercise or lifestyle changes.
  • Over-focusing on "stability" and "perfect posture" can actually make pain worse by increasing fear and tension.

A New Approach: Treating the Whole Person
  • Successful treatment focuses on helping people move confidently rather than just strengthening muscles.
  • Cognitive-behavioral approaches that address fear, stress, and lifestyle habits show better results in reducing pain and disability.
  • Patients need reassurance that movement is safe and that their pain is manageable.

Encouraging Self-Management and Active Lifestyles
  • Rather than avoiding activities, patients should gradually return to normal movement and exercise.
  • Addressing emotional and psychological factors—like reducing fear and stress—can improve pain management.
  • A personalised, multidimensional approach is more effective than one-size-fits-all treatments.

What This Means for Patients:
If you have chronic back pain, it’s important to know that your pain does not necessarily mean damage. Instead of focusing only on scans and diagnoses, working on stress management, movement confidence, and daily activity can help reduce pain and improve quality of life. By taking an active role in your recovery, you can regain control and live well despite having pain.

From protection to non-protection: A mixed methods study investigating movement, posture and recovery from disabling low back pain
Kevin Wernli, Anne Smith, Fiona Coll, Amity Campbell, Peter Kent, Peter O'Sullivan. British Journal of Sports Medicine, Volume 26, 12 August 2022, Pages 2097-2119, https://doi.org/10.1002/ejp.2022

Summary

Chronic low back pain is one of the most disabling health conditions worldwide, yet the relationship between movement, posture, and pain is not well understood. Many people with back pain adopt protective movement habits, but it is unclear how these habits change as pain improves. This study aimed to:

  • Understand how people with persistent low back pain think about their movement and posture before and after treatment.
  • Measure how changes in movement, posture, and psychological factors relate to pain recovery.

Research Methodology
Who Participated?
12 adults with disabling low back pain lasting more than three months.
Participants had no specific spinal injury (e.g., fractures or nerve damage).
Most had tried multiple treatments before without lasting success.
What Was the Treatment?
Participants underwent Cognitive Functional Therapy (CFT)—a 12-week physiotherapy program designed to:
  • Help them understand their pain and reduce fear of movement.
  • Guide them in gradually moving more freely and confidently.
  • Address psychological and lifestyle factors contributing to their pain.

How Was Recovery Measured?
Researchers collected both qualitative and quantitative data:
  • Interviews before and after treatment – to understand how participants thought and felt about their pain and movement.
  • Movement and posture analysis – using wearable sensors to track spinal movement, muscle activity, and posture.
  • Questionnaires – measuring pain levels, activity limitations, and psychological factors such as fear of movement.

Key Findings
1. Before Treatment: Fear and Protection
Before starting CFT, participants described their backs as feeling:
  • Stiff, tense, or locked up
  • Fragile or at risk of further injury
  • In constant need of protection through careful movement and posture
  • Many avoided certain movements or held their muscles tight, believing this would prevent further pain. Some reported that healthcare advice and societal messages reinforced these fears.

2. During Recovery: Learning to Move Differently
  • As participants progressed through therapy, they gradually became less protective. Their recovery followed three different pathways:
  • Some still needed to focus on moving differently ("Conscious Non-Protection")
  • These participants had to actively remind themselves to relax and move more freely.
  • Some began to move naturally and without fear ("Nonconscious Non-Protection")
  • These individuals forgot about their pain and returned to normal movement without effort.
  • A few remained protective despite treatment.
  • One participant continued to brace and avoid movement, suggesting that some people need more time or a different approach.

3. Improved Movement and Less Pain
Most participants who reduced their protective behaviors experienced:
  • Less pain and stiffness
  • Increased spinal movement and flexibility
  • More confidence in daily activities
  • Reduced fear of movement

Movement sensors showed that as pain improved, people:
  • Moved more quickly and smoothly
  • Stopped bracing their muscles unnecessarily
  • Adopted more relaxed postures

What Does This Mean for People with Back Pain?
  • The main takeaway from this study is that over-protecting the back can sometimes make pain worse. Rather than focusing on rigid posture and avoiding movement, people with chronic low back pain may benefit from:
  • Gradually moving more freely and confidently
  • Challenging their fear of movement
  • Recognising that their back is not as fragile as they may think
  • Working with a physiotherapist trained in Cognitive Functional Therapy (CFT) can help people shift from fearful, protective movement to more natural, relaxed movement—leading to pain relief and improved function.

A Prospective Qualitative Inquiry of Patient Experiences of Cognitive Functional Therapy for Chronic Low Back Pain During the RESTORE Trial
Nardia-Rose Klem, Peter O’Sullivan, Anne Smith, and Robert Schütze. Qualitative Health Research, 9 September 2024, https://doi.org/10.1177/10497323241268777

Summary

This research paper delves into the lived experiences of patients with chronic low back pain (CLBP) undergoing Cognitive Functional Therapy (CFT), providing a detailed narrative of their journeys over 12 months as part of the RESTORE trial. CFT, a biopsychosocial intervention, focuses on understanding pain, graded exposure to feared movements, and lifestyle changes, aiming to empower individuals to self-manage their condition.

Key Findings:
Initial Experiences – "Left High and Dry": Before starting CFT, participants often felt stuck and unsupported, having experienced multiple failed medical interventions. They described living with fear, restricted activity, and a sense of loss in identity, with life "on hold." Many were informed by biomedical narratives emphasising structural damage, leading to protective behaviors like avoiding movement, which exacerbated their disability.

CFT Experiences and Trajectories: The study identified three distinct journeys during and after CFT:
"Plain, Smooth Sailing": A seamless experience characterised by rapid adoption of CFT principles. These participants quickly re-engaged in activities and reported significant reductions in pain and disability, demonstrating how some individuals can respond effectively to CFT with minimal obstacles.

"Learning the Ropes and Gaining Sea Legs": This group encountered a more iterative process of learning and adaptation. They initially grappled with their structural beliefs about pain but gradually built confidence through repeated practice and successful experiences. These participants reported steady progress, albeit with some setbacks.

"Sailing Through Headwinds": Patients in this group faced persistent challenges, such as difficulty integrating CFT principles, ongoing reliance on medications, or struggles with motivation. Despite partial improvements, these individuals felt less in control of their pain and required more support to achieve lasting change.

Mechanisms of Change: The study highlighted mechanisms underpinning successful CFT outcomes:

Sense-making: Patients benefited from understanding their pain as non-structural and related to factors like tension, movement habits, and psychosocial stressors.

Exposure with control: Gradual and guided reintroduction to feared movements helped reduce the threat associated with pain, fostering confidence and self-efficacy.

Therapeutic alliance: A strong relationship with the physiotherapist was critical, providing trust and reassurance during challenging moments.
Pain flares as learning opportunities: For some, managing flares built resilience and skills, while for others, flares hindered progress and highlighted the need for additional support.

Clinical Implications:
The findings emphasise the importance of tailoring CFT to individual needs.

Clinicians should:
  • Provide clear, personalised explanations to help patients make sense of their pain.
  • Offer graded exposure to feared movements, ensuring patients feel supported and confident.
  • Recognise that not all patients progress at the same pace; some may need extended or additional interventions to address persistent challenges.
  • Use pain flares as an opportunity for education and skill-building to enhance self-management.

For patients with CLBP, this study validates the diverse trajectories of recovery and offers hope through relatable narratives. It also underscores the role of clinicians in facilitating not only physical recovery but also psychological and social empowerment.

What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis
Mary O'Keeffe, Paul Cullinane, John Hurley, Irene Leahy, Samantha Bunzli, Peter B. O'Sullivan, Kieran O'Sullivan. Physical Therapy, 1 May 2016, Volume 96, Issue 5, Pages 609-622, https://doi.org/10.2522/ptj.20150240

Summary

This study looked at what makes the relationship between patients and physical therapists work well. When people go to physiotherapy for pain, the interaction between patient and clinician can influence how they feel and recover. 

What Was the Study About?
The researchers reviewed multiple studies where both patients and therapists shared their views on what helps or hinders a good interaction. They found four main themes that influence how well patients and therapists connect:

1. Communication and Personal Connection
Patients felt that their therapist should:
  • Listen actively and let them share their story.
  • Show empathy—understanding how pain affects their daily life.
  • Be friendly and approachable, making them feel comfortable.
  • Encourage and motivate them throughout treatment.
  • Communicate with confidence, so patients feel reassured.
  • Good communication helps build trust, making the patient more likely to stick with treatment and see better results.
2. Therapist’s Knowledge and Skills
Patients said they trusted their therapist more if they:
  • Had strong expertise and practical skills.
  • Explained things in simple terms (not complicated medical jargon).
  • Taught them about their condition so they could manage it better at home.
  • When patients understood what was happening in their body and why certain treatments were used, they felt more in control of their recovery.

3. Individualised and Patient-Centered Care
Patients felt more engaged in therapy when their treatment was:
  • Tailored to their specific needs, rather than a one-size-fits-all approach.
  • Based on their opinions and preferences, rather than just following a standard plan.
  • This made them feel valued and encouraged them to take an active role in their recovery.

4. The Therapy Setting and Appointment Structure
The environment and organisation of care also mattered. Patients appreciated when:
  • They were given enough time to discuss their issues and weren’t rushed.
  • Therapists were flexible with appointments and follow-ups.
  • On the other hand, long wait times and limited access to therapists made some patients feel frustrated and disengaged.

What This Means for Patients and Therapists
This study shows that good communication, trust, and personalised care can help patients feel more positive about their treatment and may even improve their recovery. If you’re seeing a physiotherapist, don’t hesitate to:
  • Ask questions and make sure you understand your treatment.
  • Share your concerns—a good therapist will listen and adjust care to suit you.
  • Look for a therapist who makes you feel heard, respected, and involved in your recovery.

For therapists, being clinically proficient is important, but how you connect with patients can be just as vital for successful treatment outcomes.

Patients with worse disability respond best to cognitive functional therapy for chronic low back pain: a pre-planned secondary analysis of a randomised trial
Mark Hancock , Anne Smith , Peter O’Sullivan , Robert Schütze , JP Caneiro, Jan Hartvigsen, Kieran O’Sullivan, Alison McGregor, Terry Haines, Alistair Vickery, Amity Campbell, Peter Kent. Journal of Physiotherapy, 16 October 2024, Volume 70, Issue 4, Pages 294-301, https://doi.org/10.1016/j.jphys.2024.08.005

Summary

This research paper reports a secondary analysis of the RESTORE trial, which examined moderators influencing the effectiveness of Cognitive Functional Therapy (CFT) for chronic low back pain (CLBP).

Study Design:
The RESTORE trial included 492 adults with CLBP for over three months, with moderate to severe pain-related activity limitation.

Participants were randomised into groups receiving CFT (with or without biofeedback) or usual care.The primary outcome was activity limitation, measured using the Roland Morris Disability Questionnaire (RMDQ), assessed over 52 weeks.

Key Results:
Baseline Disability as a Moderator: Patients with higher baseline activity limitations showed the greatest improvement with CFT compared to usual care. For example, those in the 90th percentile of baseline disability experienced an average improvement of 6.1 RMDQ points at 13 weeks versus usual care. This effect was sustained at 52 weeks, supporting the value of CFT for individuals with severe baseline disability.

Other Factors: Cognitive flexibility may influence short-term benefits of CFT, but this effect was not sustained long-term. Pain intensity, self-efficacy, and catastrophising did not significantly affect the outcomes.

Overall Effectiveness: CFT demonstrated consistent benefits across the spectrum of disability, with the strongest effects in patients with the most severe baseline activity limitations.

Clinical Implications:
Targeting High-Need Patients: CFT is particularly effective for patients with severe disability, who often experience the greatest health burden and are the most challenging to treat.

Universal Benefit: While most effective in highly disabled individuals, CFT remains beneficial for patients with lower levels of disability.

Efficient Resource Use: If access to CFT is limited, prioritising patients with severe disability may maximise clinical impact.

Conclusion:
CFT provides a robust and effective treatment option for CLBP, especially in individuals with greater baseline disability. This study highlights the importance of tailoring interventions based on patient characteristics to optimise outcomes.

The "future" pain clinician: Competencies needed to provide psychologically informed care
Steven J Linton, Peter B O'Sullivan, Hedvig E Zetterberg, Johan W S Vlaeyen. Scandinavian Journal of Pain, 8 August 2024, Volume 24, Issue 1, Pages 294-301, https://doi.org/10.1515/sjpain-2024-0017

Summary

What is This Paper About?
This paper looks at how healthcare professionals can better help people with chronic pain by including psychological approaches in their care. Right now, many pain treatments don’t work as well as they should because they focus only on the physical side of pain, ignoring emotions, stress, and lifestyle factors.

The researchers argue that pain treatment should be more personalised—tailored to each patient’s needs, emotions, and daily challenges. To do this, clinicians need extra training to understand not just the body but also how the mind and behaviors affect pain.

Why Does Pain Treatment Often Fail?
Right now, many people with chronic pain go through a cycle of different treatments—scans, medications, physiotherapy, injections, or even surgery—but they often don’t find lasting relief. 
Why?
Pain is complex – It’s not just about damaged tissue or injuries. Stress, fear, and emotions can make pain worse.
One-size-fits-all treatments don’t work – Each person’s pain is different, but healthcare often follows standard treatment plans that don’t address individual needs.
Patients want clear guidance – Many people with chronic pain feel frustrated because they don’t fully understand their condition or what to do about it.
Healthcare providers aren’t always trained to address the psychological side of pain – Even though research shows that fear, stress, and beliefs about pain can make it worse, many clinicians don’t have the skills to help patients change how they think and behave.

What Needs to Change?
The study suggests that healthcare providers should focus on "psychologically informed care," which means:
  • Helping patients understand their pain in a way that makes sense to them.
  • Teaching strategies to manage pain better, including relaxation techniques, movement retraining, and mindset shifts.
  • Encouraging patients to gradually return to daily activities rather than avoiding movement out of fear.
  • Using a personalized approach—what works for one person may not work for another.

The authors argue that training clinicians in these areas could lead to much better results. Instead of just focusing on the physical side of pain, healthcare providers should also be skilled in coaching, communication, and behavioral therapy.

What Skills Should Pain Clinicians Have?
To provide this kind of care, clinicians need specific competencies (skills and knowledge areas), including:

Communication Skills
  • Listening to patients and validating their experiences.
  • Explaining pain in a way that makes sense without using confusing medical terms.
  • Helping patients feel understood and supported.

Understanding Pain Science
  • Knowing how pain works, including the role of the nervous system, emotions, and behaviors.
  • Understanding that pain isn’t always caused by tissue damage—it can be influenced by stress, fear, and past experiences.

Behavior Change Techniques
  • Helping patients gradually return to activities they have been avoiding due to fear of pain.
  • Teaching relaxation techniques to reduce muscle tension and stress-related pain.
  • Encouraging self-management, so patients feel more in control of their pain.


Individualised Treatment Planning
  • Creating a treatment plan based on each patient’s goals, fears, and daily challenges rather than using a one-size-fits-all approach.
  • Using psychological strategies (like Cognitive Behavioral Therapy) to help patients challenge negative thoughts about pain.

Cognitive Functional Therapy:

An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain

Peter O'Sullivan, JP Caneiro, Mary O'Keefe, Anne Smith, Wim Dankaerts, Kjartan Fersum, Kieran O'Sullivan
Physical Therapy & Rehabilitation Journal, Volume 98, Issue 5, 1 May 2018, Pages 408-423, https://doi.org/10.1093/ptj/pzy022

Summary

This paper was written for clinicians to help them understand Cognitive Functional Therapy.

Cognitive Functional Therapy is an approach to help individuals make sense of their pain within their own context and to develop an individualised management plan aligned with their personally relevant goals. The approach differs from traditional treatment approaches because it holistically addresses the wide range of individual factors that can lead to ongoing pain and disability, such as negative beliefs about back pain, emotional distress, and unhelpful behavioural responses to pain such as movement and activity avoidance. 

Cognitive Functional Therapy places the ‘person’ at the centre of their care, where their individual concerns, worries, ways that they move, and their functional limitations and goals, become the focus of treatment. The clinician works as a coach rather than a ‘fixer’. Cognitive Functional Therapy uses a multi-dimensional clinical reasoning framework to identify and target the factors important for each individual.

Section 1 - "Multidimensional Factors Associated with Disabling LBP" 

This section explores the relevance of pain characteristics, relevant pathoanatomical factors, physical factors, psycholoogical factors, social factors and general health factors. Table 1 provides 3 case examples of relevant multidimensional factors. Table 2 provides examples for how a clinician can ask questions about relevant psychological factors.

Section 2 - "Cognitive Functional Therapy: Assessment and Treatment" 

This section explores therapeutic alliance, highlights the need for a triage process for people with low back pain (Figure 2), describes a multidimensional clinical reasoning framework to identify key modifiable targets for management and outlines how to conduct a functional behavioural assessment for painful, fear or avoided movements. The Cognitive Functional Therapy intervention is then described which includes three key components:

Section 3 - "Skills Required to Implement CFT" 

There are specific skills required for successful implementation of Cognitive Functional Therapy in practice which include:
  • Communication skills to sensitively explore how people think and feel about their problem, build strong therapeutic alliance, enhance self-efficacy and promote behaviour change.
  • Strong clinical reasoning skills to triage and synthesize multidimensional information.
  • Observation skills are required to analyse functional and safety behaviours.
  • Hands-on feedback and movement facilitation skills are needed to guide behavioural experiments and teach new behaviours.
  • Clinicians need to have confidence to discourage safety behaviours, and to intrinsically recognise that pain is more strongly related to multidimensional factors, rather than damage, that the spine is strong and movement is helpful.

From Fear to Safety: A Roadmap to Recovery From Musculoskeletal Pain 

JP Caneiro, Anne Smith, Samantha Bunzli, & Steven J. Linton
Physical Therapy & Rehabilitation Journal, Volume 102, Issue 2, 23 December 2021, https://doi.org/10.1093/ptj/pzab271

Summary

This paper is written for clinicians exploring how people can recover from musculoskeletal pain. 
Within this paper a pain-related fear and safety-learning are explored and a framework using Cognitive Functional Therapy is proposed to promote safety learning for people with musculoskeletal pain through a common-sense lens.

Fear learning

Fear learning is often related to unhelpful 'common-sense' societal beliefs about the body and pain such as 'if there are symptoms, the body must be broken requiring protection until it can be fixed'. Therefore, people develop pain-related fear as a result of perceived threats to their body which result in common-sense protective behaviours, such as avoidance or modification of activities. Avoidance can help in the short term, but can also be a driver of ongoing pain in the long term, because for those who do not recover, avoidance behavours prevent safety learning. Qualitative studies indicate that diagnostic uncertainty, radiological reports that include threatening language, 
unhelpful advice received from clinicians, conflicting advice, and societal beliefs about the fragility of the spine, reinforce pain-related fear. These unhelpful factors can result in people adopting protective movement strategies including restricting movement and muscular guarding to 'protect' their back, despite these strategies often leading to increased pain. Over time, protective strategies develop across activities and contexts, further driving pain-related fear.
The common-sense model is a model of fear avoidance and a recovery pathway that has been investigated. Sense-making at the heart of this model goes beyond catastrophising, and includes the 'cognitive representation' of an individual's pain condition informed by memory of their past 'normal' self, pain experiences, treatments, lifestyle and social activities.
Five key dimensions for the cognitive representation:
The key principles include
  1. Identity (what is this pain? e.g. structure)
  2. Cause (what caused this pain? e.g. bending)
  3. Consequences (what are the consequences of this pain? e.g. disability)
  4. Timeline (for how long will this pain last?)
  5. Cure/controllability (can this pain be cured or controlled?)

Safety-learning

The primary mechanism in fear reduction is learning a new experience of safety to form new memories. Extinction of fear occurs via inhibitory learning through cognitive restructuring and fear habituation (exposure until fear reduces). It is recommended that clinicians download the article and print out Figure 1 which provides an extensive list of key principles to promote safety learning. 
The key principles include
  1. Screen
  2. Interview
  3. Examine
  4. Expose with Control
  5. Make Sense of Pain
  6. Integrate into daily life
  7. Provide an flare-up plan
  8. Refer if co-care is required
Expectancy violation is the cornerstone of inhibitory learning and provides an opportunity for the patient to undergo cognitive restructuring towards a new common-sense model of their condition. Expectancy violation is an intentional clinical process where safe memories (e.g. bending is safe) are developed that directly compete with an original fear memory (e.g. bending is painful).

CFT to promote safety-learning

Write your awesome label here.
A) Person’s common-sense response to a pain experience interpreted as threatening (fear schema).

B) Core elements of Cognitive Functional Therapy as a vehicle to promote safety learning. The experience may confirm or violate the original schema. Confirmation of pain as a threatening experience (i.e. learning does not occur) leads to the reinforcement of the person’s fear response. Violation of pain as a threatening experience (i.e. learning of safety occurs) can powerfully disconfirm fear-avoidance beliefs while reinforcing that valued activities can be safely confronted when performed without safety behaviors and reduced pain vigilance. This leads to an update of the person’s response that promotes generalisation of safety.

C) Person’s common-sense response to an experience interpreted as safe (Safety schema).
D) Response to a pain flare, which may reinforce fear or safety learning. This is a crucial learning opportunity that influences a person’s process to recovery.
A hybrid learning portal integrating cutting-edge research, clinical innovations, and resources for the treatment of musculoskeletal pain.

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The information provided is general information only.
Clinicians should make their own judgement about the best care for each patient.
People who have pain should discuss information presented here with their healthcare team.


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