— Benefits lasted more than 3 years in randomized trial
by John Gever, Contributing Writer, MedPage Today
August 5, 2025
Key Takeaways
- Most therapies for low back pain provide only short-term relief; it’s unclear, however, whether benefits from cognitive functional therapy (CFT) may last longer.
- Investigators in this study performed 3-year follow-up with participants in a 6-month trial of CFT versus usual care.
- Compared with usual care, patients receiving CFT either with or without biofeedback for 6 months continued to show more improvement after 3 years.
Cognitive functional therapy (CFT) for chronic low back pain yielded benefits that far outlasted a 6-month program initially delivering it, researchers said.
When patients participating in a randomized trial were followed up after 3 years, mean self-reported function and pain scores in those assigned to CFT (with or without biofeedback) still showed significantly greater improvement relative to a usual-care control group, according to Mark Hancock, PhD, of Macquarie University in Sydney, Australia, and colleagues.
In the trial, the researchers explained in Lancet Rheumatology, CFT was tested with and without use of biofeedback movement sensors in separate arms, alongside usual care as mutually decided by patients and their customary providers. Primary results from the trial, reported in 2023 and covering outcomes at 1 year, indicated that self-reported disability (using the 24-point Roland Morris Disability Questionnaire) was improved by an average 4.6 points more with CFT (both with and without biofeedback) than was seen with usual care; patients’ pain ratings on an 11-point scale were reduced by 1.4-1.8 points more with CFT than usual care.
At the 3-year follow-up, differences between the CFT and usual-care groups in disability ratings shrank only slightly:
- CFT alone vs usual care: -3.5 points (95% CI -4.9 to -2.0)
- CFT with biofeedback vs usual care: -4.1 points (95% CI -5.6 to -2.6)
And for patients’ pain scoring:
- CFT alone vs usual care: -1.0 (95% CI -1.6 to -0.5)
- CFT with biofeedback vs usual care: -1.5 (95% CI -2.1 to -0.9)
Whether these differences in pain ratings are big enough to matter are a subject for debate, as studies to establish the minimal clinically important difference have yielded values in the range of 1.4-1.7.
Still, Hancock and colleagues called it a solid win for CFT. “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,” they wrote — noting, however, that wide implementation will require “scaling up of clinician training to increase accessibility, and replication studies in diverse healthcare systems.”
CFT began to draw attention for treating chronic back pain when clinicians realized both that the physiologic causes were highly variable and yet patients’ experiences shared many features suggesting that their own cognitive and emotional reactions were worsening the condition. Guidelines already recommend consideration of psychological factors in treating low back pain, but treatment modalities can take many forms.
CFT not only addresses patients’ thinking about the pain but also seeks to minimize “pain-provocative movement patterns” — e.g., muscle guarding and movement avoidance — that patients adopt in trying to relieve the pain but instead may add to it. That’s where the biofeedback comes in. One approach to this latter issue is to equip patients with movement sensors that alert them to postures and behaviors that they should avoid.
As Hancock and colleagues explained in the new paper, “Pain-related fear and movement and activity avoidance are targeted through guided exposure to painful, feared, and avoided movements and goal-oriented activities.” Other aspects of the therapy include coaching on physical activity, sleep habits, and social engagement. “By targeting these causal factors and changing the way individuals think about, and respond to, pain, CFT aims to produce lasting change,” the group wrote.
For the trial, 492 patients were randomized in equal numbers to CFT alone, CFT with biofeedback, and usual care, with 20 Australian clinics participating. Eligibility criteria included back pain of at least 3 months duration and self-reports of significant activity limitation. Roland Morris scores for disability after 1 year were the primary outcome measure; 11-point pain intensity ratings were the chief secondary outcome. The study was not blinded, except that movement sensors were worn in both CFT arms, although the data were masked for those assigned to CFT alone.
Mean patient age was about 48 and some 60% were women. Disability scores at baseline averaged about 13.5 and the mean pain rating was approximately 6.2.
Patients in the CFT groups received up to seven individualized training sessions over 12 weeks, plus a booster session at week 26. Therapy included a process to help patients make sense of their pain, then “exposure with control” in which behavioral changes and movement control strategies were introduced. General healthy behaviors, especially around sleep, were also taught.
About one-third of the enrolled sample didn’t make it to the 3-year follow-up. Hancock and colleagues looked at whether these patients differed significantly from those who were available at year 3: they tended to have more severe pain and disability at baseline and also less favorable outcomes at the 1-year evaluation. In sensitivity analyses aimed at adjusting for differences between these groups at baseline and at the primary 1-year evaluation, the effect sizes were slightly smaller but still consistent with the main findings.
His note of caution came from recognition that healthcare systems aren’t yet ready to deliver CFT en masse; few clinicians are adequately trained in it and their institutions aren’t prepared to give them that training.
Overall, Lytras wrote, the trial “sets a new benchmark that warrants replication and contextual adaptation across diverse healthcare systems and cultural settings.”