Core stability is being challenged by Prof Peter O’Sullivan and his team. Cognitive functional therapy (CFT) is a relatively new approach to athletes with lower back pain. It has also been called the “confidence cure.”
One of this issues with core stability training is that it feeds into the belief that the spine is vulnerable and requires this special “core activation” that no other body part requires before training.
What would happen if the “core stability industry” was wrong and it just perpetuated the low back belief that the spine is vulnerable and needs special training?
CFT is a patient centred approach to management that targets the beliefs, fears and associated behaviours (both movement and lifestyle) of each individual with back pain.
It leads the person to be mindful that pain is not a reflection of damage – but rather a process where the person is trapped in a vicious cycle of pain and disability.
This is fuelled by a nervous system that is stressed and sensitized due to negative beliefs, fear, lost hope, anxiety and avoidance, linked to mal-adaptive (provocative) movement and lifestyle behaviours.
It is integrated using a motivational interviewing approach to communication where it identifies discrepancies between beliefs and behaviours and acknowledges that the solutions that ‘stick’ are usually found by the person themselves.
It is strongly behaviourally orientated and explores different movement options using visual feedback in order for people to re-establish their body schema and relearn the basic building blocks of relaxed normal movement. It empowers the person to do the very things they fear and / or avoid, but in a graduated relaxed and normal manner.
It conditions them if they are weak. It motivates them to engage with exercise and active living based on their preferences and goals.
Results from a CFT approach can be excellent with the use of 4 proposed stages:
1. Cognitive re-education
– patients often tend to respond better to treatment if they understand what is going on. In this stage, the vicious cycle of pain is explained and the patient and physiotherapist will collaborate to set goals and problem solve. This helps to change the beliefs of the patient and helps their recovery.
2. Specific movement training
– by targeting faulty movement patterns and pain provocative functional tasks, the patient can develop enhanced body awareness and begin to move in a more pain free-way. By understanding the sequences of movement, they can be linked to the patient’s goals and again help recovery.
3. Functional integration
– these new movement skills can no be integrated into daily life in order to meet the goals and expectations of the patient. This helps to build confidence which gives a more positive outlook which is key to moving forward.
4. Physical activity and lifestyle advice
– this stage is patient directed. The patient sets goals and an exercise plan is devised to meet these. Lifestyle factors are also taken into consideration which can include support groups and tips for mindfulness or relaxation.
So what did the patients say?
“Now I know there can be pain without physical or structural problems”
Whilst most participants entered the intervention with strong biomedical beliefs about the cause of their pain, the acceptance of a biopsychosocial model of pain was a key ‘ingredient’ that differentiated improvers from non-improvers. A trusting relationship with the therapist facilitated effective communication and set the scene to challenge existing beliefs with a new explanatory model of pain. Participants described a new ‘body awareness’, an understanding of how physical and psychosocial stressors influenced their behaviour and pain. They were encouraged to challenge this new information and body awareness through behavioural experimentation and the experience of control over pain was key to the consolidation of a new belief system.
“When I get the pain now, I’m able to check myself. I can unravel it myself”
The second key ingredient to successful outcome was achieving independent self-management of their pain. This was built on the foundation of solid problem solving skills and improvement in pain self-efficacy that enabled improvers to confront threatening or pain provoking activities. Pain self-efficacy differentiated ‘large improvers’, those who reported a return to normality with renewed optimism for the future, and ‘small improvers’, who reported residual concerns about their ability to cope with a relapse in pain, particularly when faced with contextual life stressors.
Well, this adds debate this week to the theme of lower back pain in athletes. As usual, the truth will lie somewhere in the middle.
References
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: A qualitative study. Physical Therapy 2016;Accepted 13.03.2016 Online First.
Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, & Kvåle A (2012). Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain PMID: 23208945
O’Sullivan K, Dankaerts W, O’Sullivan L, O’Sullivan P. Cognitive Functional Therapy for disabling nonspecific chronic low back pain: Multiple case-cohort study. Physical Therapy 2015;30([Epub ahead of print]) Online First.
Video: https://www.youtube.com/user/bodylogicphysio
