Cognitive Functional Therapy Relieved Chronic Disabling Low Back Pain for 3 Years

New research published in Lancet Rheumatology has found that cognitive functional therapy (CFT) relieved chronic disabling low back pain and related activity limitations for 3 years, with similar results seen with or without movement sensor biofeedback.1,2

“Most treatments for people with chronic low back pain produce small-to-moderate effects that are not sustained. This outcome is not surprising given that treatments typically target symptom relief and do not address underlying factors known to contribute to the condition or provide patients with skills and confidence to self-manage their condition.However, there is growing evidence that individualized interventions that target a person’s physical and psychosocial barriers to recovery, and provide them with self-management skills, produce larger and more sustained effects. A few studies have shown sustained long-term effects at 1 year, but very few studies have explored longer-term outcomes,” lead investigator Mark Hancock, PhD, Professor, Spinal Pain Research Center, Department of Health Sciences, Macquarie University, Sydney, Australia, and colleagues wrote.1

Hancock and colleagues investigated the long-term effects of CFT compared with usual care in this 3-year follow-up study to the randomized, controlled, 3-arm parallel group, phase 3 RESTORE clinical trial. The trial included 20 primary care physiotherapy clinics in Australia that delivered treatment to adult participants with low back pain lasting more than 3 months with at least moderate pain-related physical activity limitation and average back pain of at least 4 on a 0–10 scale. Notably, people with lived experience of chronic low back pain were involved in the study design and conduct.

Participants were randomly assigned (1:1:1) via a centralized adaptive schedule to usual care, CFT only, or CFT plus biofeedback. Participants in both CFT groups received up to 7 treatment sessions over 12 weeks plus a booster session at 26 weeks. Physiotherapists and patients were not masked.

Participants were invited to be included in the 3-year follow-up at the 1-year follow-up visit. At 3 years, the follow-up study primarily evaluated pain-related physical activity limitation, self-reported via the Roland Morris Disability Questionnaire (0–24 scale). The secondary outcome was pain intensity at 3 years, assessed using the numeric pain rating scale. The follow-up study did not collect adverse event data at 3 years.

RESTORE included 492 participants assigned to 164 (33%) to CFT only, 163 (33%) to CFT plus biofeedback, and 165 (34%) to usual care. At the 1-year follow-up, 359 (73%) participants provided consent to be contacted to complete the 3-year questionnaire, 312 (87%) of which were successfully followed up at 3 years. At 3 years, the analysis included 104 (63%) of the original 164 in the CFT only group, 106 (65%) of 163 in the CFT plus biofeedback group, and 102 (62%) of 165 in the usual care group. Of these 312, 188 (60%) were female, 124 (40%) were male, and they had a mean age of 48,1 years (SD, 14.6).

At 3-year follow-up, Hancock and colleagues found that CFT only (mean difference [MD], –3.5 [95% CI, –4.9 to –2.0]) and CFT plus biofeedback (MD, –4.1 [95% CI, –5.6 to –2.6]) were both more effective than usual care in reducing activity limitation at 3 years. They did not observe significant differences between CFT only and CFT plus biofeedback (MD, –0.6 [95% CI, –2.2 to 0.9]). Similarly, CFT only (MD, –1.0 [95% CI, –1.6 to –0.5]) and CFT plus biofeedback (MD, –1.5 [95% CI, –2.1 to –0.9]) were also more effective than usual care at reducing pain intensity at 3 years, with minimal differences between the 2 CFT groups (MD, –0.5 [95% CI, –1.1 to 0.1]).1

“In conclusion, CFT produces clinically important effects for activity limitation at 3-year follow-up. These long-term effects are novel and provide the opportunity to markedly reduce the effect of chronic back pain if the intervention can be widely implemented.Implementation requires scaling up of clinician training to increase accessibility, and replication studies in diverse health-care systems,” Hancock and colleagues concluded.1

The investigators also noted that future research should assess how CFT may be accepted in different contexts, cultures, and health-care systems. CFT is also highly variable between delivering clinicians so different models of training should also be investigated.

REFERENCES

1. Hancock M, Smith A, O’Sullivan R, et al. Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): 3-year follow-up of a randomised, controlled trial. Lancet Rheumatol. Published online August 5, 2025. Doi: 10.1016/ S2665-9913(25)00135-3

2. The Lancet Rheumatology: Course of psychotherapy for low back pain remains effective for at least three years, finds trial. News release. The Lancet. August 5, 2025. https://www.eurekalert.org/news-releases/1093516?