Cognitive-functional therapy compared to manual therapy combined with motor control exercise for patients with chronic nonspecific low back pain: randomized controlled trial

Abstract

Introduction: Chronic low back pain is a public health problem, and there is strong evidence that it is associated with a complex interaction of biopsychosocial factors. Cognitive Functional Therapy (CFT) is an intervention that deals with multidimensional aspects of pain that are potentially modifiable. There is evidence (from a single randomized controlled trial) that CFT is better than manual therapy combined with motor control exercises (MTEX). However, this study presented significant methodological shortcomings, including failure to perform an intent-to-treat analysis and considerable loss of follow-up of the participants. It is important to replicate this study in another domain by means of a randomized clinical trial but correcting these methodological shortcomings.
Objective: To investigate the efficacy of CFT in comparison with manual therapy combined with motor control exercises in relation to pain and functional disability after 3 months of randomization in patients with chronic nonspecific low back pain. The secondary outcomes were the global perception of improvement and patient satisfaction. Methods: A randomized clinical trial with two arms and blind assessors was performed. 148 participants with chronic low back pain (which persisted for more than 3 months) and without specific spine pathology were recruited in the school clinic of the Augusto Motta University Center and through the social media in the Internet. Intervention A: from 4 to 10 CFT sessions. Intervention B: from 4 to 10 sessions of manual therapy combined with motor control exercises. An intention-to-treat analysis was performed using linear mixed models to compare the differences in mean intensity of pain, incapacity between intervention arms. A statistical significance level of 5% was used in the analysis. All analyses were performed using RStudio. Results: We attended 148 patients with nonspecific chronic lumbar pain. The follow up 3
months after randomization was performed with 143 patients (loss of only 2,8%). After treatment, we found that both groups promoted improvement on pain and disability, with no difference between groups for the primary outcome pain intensity at 3 months (mean difference (DM) = 0.01; CI 95%-1.07 up to 1.1), but there was a difference between groups in favor of the TCF Group for primary outcome disability at 3 months (DM-5.5; IC 95%-11.09 up to-0.01). There was no difference regarding global perception of improvement and satisfaction between groups. Conclusion: Cognitive Functional Therapy was more efficacious than combined manual therapy and motor control exercises in reducing disability 3 months after randomization, however CFT was not more efficacious in reducing pain intensity. No significant differences were observed between groups for global perception of improvement and patient satisfaction.