Cognitive Functional Therapy

Cognitive Functional Therapy was developed by physiotherapists at Body Logic Physiotherapy as a mind-body approach to managing pain problems when they become disabling and distressing. In contrast to more traditional physiotherapy where the therapist performs hands-on treatment, with Cognitive Functional Therapy the aim is to place the patient in charge of their pain condition and to coach the person to understand it and effectively self-manage it.

What’s going on with persistent and disabling pain?

Persistent and disabling musculoskeletal pain problems are the leading cause of disability in the world. These include pain problems such as back and neck pain, as well as shoulder, nerve pain, joint pain and arthritis, and chronic widespread pain.

There is strong evidence supporting that persistent and disabling pain problems are complex and involve multiple factors making these problems really hard to treat. While there is a common belief that the intensity of pain is reflected in the degree of tissue damage (i.e. pain = damage) – we now know this is often not the case. For example:

  • a person can experience severe back, neck and head pain without any evidence of injury or tissue damage;
  • a person’s pain may persist after an injury when tissue has healed (6-8 weeks);
  • or where two people have the same degree of arthritis on a scan – but one is active and relatively pain-free, the other has severe and disabling pain. How does this happen?

Our amazing nervous system can sometimes let us down

The nervous system is amazingly complex and it can work to help us or hinder us. It is a bit like an orchestra – the same instruments can either produce amazingly beautiful music or dreadful, ear jarring noise. It’s a feature of how the different parts work and integrate.

In the same way the nervous system can protect the body from pain or it can leave us vulnerable to persistent pain. When this happens, our nervous system (which is normally designed to warn us of danger), and the way we control our body (which is designed to protect us), can end up working against us. This can become scary and distressing.

There is evidence that persistent pain is associated with complex changes in the nervous system, where networks in the nervous system can undergo change, resulting in sensitivity of the body’s structures to touch, movement, load and activity or even create pain from doing nothing. The wonderful thing about our nervous system is that it is highly adaptable and can be re-trained!

Who is at risk of persistent and disabling pain?

There is a lot of research that tells us a person’s vulnerability to persistent and disabling pain is influenced by multiple factors.

Here is a check list of factors that are known to increase a person’s chance of persistent and disabling pain:

Genetics: pain can cluster and be linked to families. Certain genes increase susceptibility to pain.

Early life stress experiences such as physical and emotional trauma and ongoing stress or threat.

Early life pain experiences can leave a person more susceptible to pain, and can also influence how a person responds to it.

Negative thoughts: If a person feels helpless, lacks control over their pain, focusses on their pain a lot, and views their pain as a threat, these thoughts will eventually limit their ability to engage in the things in life that they value.

Negative emotions: When pain that is severe, poorly controlled and unpredictable it can be very scary, distressing and worrying. When pain limits a person’s ability to engage in activities they value, this can negatively impact on their mood and lead to a sense of loss, grief, frustration and anger. These emotions in themselves are quite normal but can be a powerful driver for pain, which is why we often feel more pain when we are stressed, sad and worried. There is also strong evidence that people who suffer from depression and anxiety are at greater risk for developing pain. Chemicals in our nervous system that influence our mood can also influence how we process body sensations.

Avoidance of activity, movement and living, and over protecting the painful body part. It is normal and helpful to guard, protect and avoid moving a broken bone until it heals. However, with persistent pain in the absence of ongoing tissue damage and injury, movement and activity avoidance, and muscle guarding usually leaves the person more disabled and in more pain. This can often lead to avoidance of important things in life such as work, socialisation and physical activity, which in turn leads to greater emotional distress.

Lifestyle factors

Physical activity levels and sedentary behaviours: Being sedentary is a risk factor for pain, and physical activity is protective of pain.

Sleep: There is strong evidence that broken sleep or insufficient sleep increases our susceptibility to pain. Sleep can influence the chemistry of our body, impacting on many things like our ability to relax, our mood, our levels of sensitivity and our immune system.

Abdominal (belly) fat: there is strong evidence that increased fat around our belly results in increased inflammatory chemicals in our blood that can result in inflammation of our joints and tendons.

Together the combination of these factors can set up a complex and vicious cycle of pain, disability and distress, that may feel impossible to get out of.
The great news is that many of these factors are modifiable, and with the right support you can break this cycle.

Traditional physiotherapy

Traditionally physiotherapy has focussed on symptom relief through hands-on techniques such as massage, mobilisation, manipulation and needling, or exercises which focus on postural control or core strengthening. Given the complexity of pain, while these treatment approaches can result in short-term pain relief – they often don’t have a long-term positive impact on a person’s disabling pain problem. A different physiotherapy approach is needed to effectively address the problem.

How does Cognitive functional therapy work?

Your story is the key. Most of the critical information about your condition is in your story. It’s a bit like a person who brings in a jigsaw puzzle with all the pieces present, but they don’t know what the picture looks like. Our job is to work with you to find the place for all the pieces of your puzzle, to help you make sense of it (make the picture clear).

First, we take time (1 hour for the first consult) to hear your story. We are interested in:

  • how your pain journey began
  • the things that provoke and relieve your pain
  • how it impacts on all aspects of your life (physical, social, work, emotional etc)
  • your understanding of your pain problem and your thoughts about it
  • your previous experiences of pain and how you managed these episodes
  • what strategies you have developed to cope with your pain condition
  • whether you avoid things in life that are important to you
  • if you protect your painful body region how does this affect your levels of confidence to move and engage in activities you value.
  • your short and long-term goals.
  • your general health and emotional well being
  • we also screen for any serious health conditions, and will look at your scans if you have them.

Assessing your body and how it functions:

  • We know that when a person feels pain, the body’s response is often to tense up and over protect the painful body part. This can also change our perception of our body and alter the way we control it.
  • We are interested in the things that hurt you – and how your body functions during these activities.
  • We are interested in your perceptions and the way you control your body.
  • We will examine how you move, whether you can relax your body, and your confidence to move.
  • We will also examine your strength and conditioning.
    We may also conduct tests of your nerves and assess the sensitivity of your tissues.

Based on all this information we will develop a treatment plan:

1. Making sense of pain

First, we will sit down and help you understand why you have pain and all the factors that are contributing to it. We will help you come up with different ways of thinking and responding to pain that can put you in charge of the pain. We will develop a plan to reach your goals and get you back to living again.

We will also direct you to resources to help you better understand your pain condition.

2. Confidence in moving and living

We will develop an exercise program that is specific to you, your unique presentation, your functional capacity and pain levels, as well as your level of confidence and your goals. We will start slowly and build the program up to get you confident to move, load and strengthen your body. We will help you find ways of moving that reduce your pain and put you in charge. These exercises are functionally orientated and linked to your goals to help build your confidence to get back to living in the way you want. We will teach you ways that you can adapt and integrate to your every-day life.

For example, with back pain it is very common that people lose confidence in their ability to bend and lift, limiting their ability to dress, garden, and play with kids etc. Usually the muscles in the back and belly over-tense – a bit like clenching the fist. This makes movement both stiff and painful. We will first teach you to relax, and learn to move in ways that don’t hurt in order to slowly build your strength, confidence and capacity to bend and lift again. We will then help you integrate this into your activities of daily living.

3. Adopting a healthy lifestyle

Regular movement and physical activity is so important for our mental and physical health. Finding ways to move and engage in activities that you enjoy – participating in social activities are so helpful when dealing with pain. This can be anything from walking, riding a bike, dancing, yoga, swimming, Pilates, running or gym work. We will coach you to achieve your goals. All exercise is helpful, and the best exercise is whatever you find enjoyable and will keep doing. Exercise is like a drug – you need enough to get the benefits. For pain, at least 150 minutes per week is recommended.

Sleep is so important for the nervous system, immune system and mental health, and yet sleep disruption is a key problem when living with pain. We will explore with you regarding your sleep habits, your ability to relax, move and posture yourself in bed. Simple strategies can often be very effective.

Stress management is a key component of pain management. Stress can manifest itself in the body, making it more sensitive and tense. We can coach you on body relaxation, breathing and mindfulness techniques. There is strong evidence that these techniques provide relaxation, pain relief and a positive feeling of well-being.

Healthy eating is also important for managing many pain conditions. There is growing evidence of the negative impact that carrying excessive belly fat can have on the body’s tissues via increased inflammation. Reducing belly fat can reduce pain relating to arthritis and tendinopathy.

How long does it take to work?

For some people this journey may be short while for others it can take a longer time. Usually we expect to see you between 4-8 times over a period of 12 weeks depending on the level of complexity. We will space these times out as you develop more control over your pain and reach your goals. It’s really important that you tell us if you feel we are pushing you too hard or not hard enough. Some people may need ongoing support depending on their presentation.What if my pain flares-up?

During and after treatment pain flare-ups are very common. They often occur when people are tired, run down, unwell, stressed, not sleeping or when you are inactive or do unaccustomed activity. It’s very important to have an action plan to effectively manage flare-ups and to get on top of them fast to get back on track. We are here to support you in this process. They can be great opportunities to learn.

How about the other people in my health care team?

Working with other people in your health care team gives you the best outcome. It’s so important that everyone in your health team works together and have shared and common goals. If you give us permission we will work with your team ie. GP, psychologist, dietician, or personal trainer to support you.

What kind of pain conditions can Cognitive Functional Therapy help?

Most of our research to date has been conducted on people with chronic low back pain, however we have also adapted this approach for people with joint pain, nerve pain, tendon pain and widespread pain. We are currently doing research in these areas.

What is the evidence for pain conditions?

There are now a number of clinical studies demonstrating that Cognitive Functional Therapy can result in long term reductions in pain and disability compared to other interventions. Importantly it is not a cure for all – however many people who undergo the intervention report greater pain control, less need for medication, treatment and feel like they are able to get back to living again. There is also evidence for improved confidence and mental health.

The key to success is that we put you in charge of this journey. To find out more about Cognitive Functional Therapy contact us today!

Additional Resources

‘Cognitive Functional Therapy With Professor Peter O’Sullivan’ – Professor Peter O’Sullivan discusses Cognitive Functional Therapy.