Low back pain is the leading cause of disability worldwide. There is strong evidence that in the absence of serious pathology (such as nerve compression, malignancy, fracture, infection affecting 1-5% of people), low back pain is associated with a combination of biopsychosocial factors than can result in sensitisation of spinal structures.
While findings on MRI (such as disc degeneration) may be associated with a person’s low back pain, they are poor predictors of their levels of pain, disability and future trajectory. Stronger predictors of pain chronicity include negative back pain beliefs, pain-related fear and distress, leading to over-protection and avoidance of movement and activity.
Care for people with low back pain in Australia is often discordant with the evidence-based guidelines. Few treatments offer lasting benefits, while the costs of treatments for people with low back pain escalate.
In response to this, the Australian Commission for Safety and Quality in Health Care released a Clinical Care Standard for low back pain
in 2022.
The standard is aligned to best care guidelines for people presenting with low back pain. It was developed and endorsed by all key professional groups who treat people with low back pain, in conjunction with patient advocacy groups. The standard has implications for all clinicians who treat people with low back pain, with a challenge for better inter-professional collaboration.
Key elements of the standard include:
- Screening for serious pathology
- Psychosocial assessment to identify potential barriers to recovery
- Reserve imaging for suspected serious pathology
- Patient education and advice
- Encourage self-management and physical activity
- Provide interventions that target physical and psychological barriers to recovery
- Judicious use of pain medicines
- Review and referral.
Cognitive Functional Therapy for people with disabling low back pain
Cognitive Functional Therapy (CFT) is a physiotherapist led person-centred intervention for people with disabling low back pain, once serious pathology is excluded. It identifies and targets both the physical and psychosocial barriers to recovery in people with disabling low back pain and coaches them to self-manage their pain. The intervention takes up to eight sessions over six months, and the sessions are longer than traditional physiotherapy sessions.
The key elements of CFT include:
- Making sense of pain: helping people make sense of their pain from a biopsychosocial perspective and build a positive mindset towards their condition and recovery.
- Exposure with control: guiding people to build confidence in their back to re-engage in valued activities that are painful, feared or avoided, without over protection, and in a graduated manner.
- Healthy lifestyle: coaching engagement in physical activity based on their preference, healthy sleep and eating habits, and stress management skills.
A multi-centre clinical trial of CFT (RESTORE) was published in the LANCET in 2023. The trial included 492 people (over 18 years) with disabling low back pain, many who had previously failed numerous interventions.
CFT resulted in large and long-lasting reductions in pain and disability, compared to usual care for people with disabling low back pain. People reported a more positive mindset toward their condition, less fear of movement and great confidence to engage in valued activities. It resulted in over $5000 cost savings due to people getting back to work. It was safe and people liked it.
CFT is broadly in line with the recommendations of the Low Back Pain Clinical Care Standard and provides hope to people with disabling low back pain that recovery (even after numerous failed interventions) is possible.
Call to action
The adoption of the standard and treatments such as CFT require a different approach for clinicians, once serious pathology has been excluded. This involves a focus away from only treating the ‘symptom’ of back pain, towards a whole person empowerment model that involves guiding people towards effective self-management skills.
This is in line with best practice approaches for other chronic health conditions such as depression, asthma, diabetes and heart disease. This approach involves the upskilling of clinicians to competently deliver the intervention, as well as greater interdisciplinary collaboration to better support people living with disabling low back pain.
Key messages
- Low back pain is the leading cause of disability
- Low Back Pain Clinical Care Standard provides a roadmap for best care
- Coaching people to self-manage their pain has long term benefits.
– References available on request
Author competing interests – Member of the working party that developed the Low Back Pain Clinical Care Standard and Developer of Cognitive Functional Therapy intervention, lead trainer of physiotherapists in the RESTORE trial and author on the LANCET publication.