What is Cognitive Functional Therapy in Physiotherapy and how may it help me?
What is CFT?
CFT is a pain management approach that focuses on the patient and targets their beliefs, fears and associated behaviours (both movement and lifestyle). This approach has been devised by Professor Peter O’Sullivan and his research team. Peter is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2005) and Professor of Musculoskeletal Physiotherapy at Curtin University. Internationally recognised as a leading clinician, researcher and educator in Physiotherapy, he has published more than 100 research papers, been keynote speaker at 60 national and international conferences and taught in 22 countries on the diagnosis and management of persistent pain disorders
What sort of problems is CFT most helpful for?
CFT is extremely useful in the management of chronic pain. Chronic pain is pain that has persisted for more than 6 months or pain that extends beyond the expected period of healing. Pain is an emotional and sensory experience doing whatever the person says it is doing at that time, often expressed in terms of tissue damage.
Over 80% of people will experience back pain during their lifetime and this can be a common area for chronic pain. It has been shown, however, that only 1% of back pain patients will have a serious disorder such as fracture, malignancy or inflammatory disorder; 5-10% will have a specific back diagnosis as the cause of their pain such as disc prolapse or nerve compression; and the other 90-95% of back pain disorders have no diagnosis based on MRI scan.
This suggests that pain is not always purely peripheral nociceptive pain (pain resulting from activity in neural pathways secondary to actual tissue damage or potentially tissue-damaging stimuli) or centrally mediated pain (neurological condition caused by damage or malfunction in the central nervous system (CNS) which causes a sensitisation of the pain system) but rather they are interlinked.
MRI scans on healthy, pain free individuals showed disk degeneration in 37% of those aged 20-30 rising to over 80% in those 50 and over. Disc bulge was found in 30% of patients aged 20-30 and in more than 60% of those over 50. And yet all these patients were pain free. Studies have shown that MRI scans for low back pain can actually result in poorer health outcomes, poor perceived prognosis and an increased likelihood of surgery.
What are the principles of CFT when used in physiotherapy?
When using CFT as part of the physiotherapy management, there are a number of key considerations. Following on from above, the physiotherapist will aim to identify the extent of the pain be it either primarily centrally or peripherally mediated. In order to achieve this, forming a relationship is required as it enables to physiotherapist to listen to the full story which will help them to understand the patient's beliefs, concerns, fears and motivations. This approach will help them to determine the appropriate course of treatment.
Furthermore, good communication is essential. Often in the case of chronic pain patients, the full history of their presenting condition may not be known. Thus as mentioned above, a physiotherapist will encourage the patient to tell their full story during the subjective examination. This requires excellent communication skills to listen to the patient, identify the problem areas and effectively convey the appropriate messages back to them.
As discussed, pain is caused by both centrally mediated and peripheral nociceptive factors. Centrally mediated factors will include stress, anxiety, depression, fear, physical inactivity, poor sleep, poor diet to name a few. Peripheral nociceptive factors include local inflammation, maladaptive postures and movement behaviours, muscle tension among others. Along with listening and communicating to identify the history of the pain and management to date both, the physiotherapist will perform on objective assessment to determine the source of pain.
This hands on approach is useful in analysing the relationship between movement and pain behaviour. The aim of the assessment is to identify factors that mediate pain. The physiotherapist will endeavour to make the assessment a positive experience for patients by taking their pain seriously, explaining what is being done, giving understandable information on the sources of pain, providing reassurance and discussing what can be done to help.
What sort of results could I expect from a CFT approach?
Results from a CFT approach can be excellent with the use of 4 proposed stages.
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.
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 amore pain free way. By understanding the sequences of movement, they can be linked to the patient's goals and again help recovery.
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.
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.
Is CFT used on it’s own or with other physiotherapy techniques?
At Mount Merrion Chartered Physiotherapy we use CFT in conjunction with other physiotherapy techniques such as manual therapy, medical acupuncture, laser therapy, ultrasound, massage and exercise. These forms of physiotherapy are still vital for total patient management and to ensure that the most effective treatment is provided. We find CFT is an approach to treatment that incorporates other modalities, when indicated, for best results.
CFT is a very useful method of assessing and treating chronic pain patients. It works on the principle that pain is real, and is a combination of both mechanical and nonmechanical factors. In order to determine all the contributing factors, physiotherapists need to allow the patient to give the full history of their condition. With this information and the information retrieved from the hands on assessment, the physiotherapist will help the patient to better understand their pain and move and function in a more positive way. This understanding of the pain and involvement of the patient in problem solving and goal setting, helps for better prognosis and healthier living.
By Graham Widger MISCP