Effectiveness of cognitive-functional therapy for chronic low back pain: a systematic literature review

Abstract

Introduction: Low back pain is the most prevalent and the health condition that causes the most disability and has the greatest socioeconomic impact worldwide in the last three decades. In 90% of cases, low back pain is not associated with anatomical causes or specific diseases and is therefore classified as non-specific. It is known that biopsychosocial factors, such as emotional aspects, cognitive aspects, social aspects, behavioral aspects and lifestyle are related, for each individual in different proportions, to the emergence and persistence of pain. Functional Cognitive Therapy (FCT) is an approach that focuses on managing pain and its consequences. It is a behavioral intervention that consists of three main components: a cognitive component (generally called making sense of pain); controlled exposure; and lifestyle change. Objective: To investigate the effectiveness of Cognitive-Functional Therapy to improve pain, disability or specific function in individuals with chronic low back pain. Methods: Systematic review of randomized clinical trials. The systematic search was conducted in the main databases PubMed, CINAHL (via EBSCOhost), EMBASE, PEDro and Cochrane Central Register of Controlled Trials (CENTRAL), and were included studies that investigated the effectiveness of Cognitive-Functional Therapy for chronic low back pain compared to active interventions, passive interventions, minimal interventions or no intervention. The PEDro tool (Physiotherapy Evidence Database) was used to analyze the risk of bias of each included study and the GRADE (Grading, Assessment, Development and Evaluations) scale was used to interpret the level of certainty of the meta-analysis evidence. Results: Eight trials involving 1322 participants were included informing low to high certainty of evidence. When compared with active interventions including exercise, moderate certainty of evidence showed that CFT has a moderate effect in reducing disability in the short term (MD -8.58, 95% CI -10.67 to -6.49), low certainty evidence showed that CFT has a moderate effect in reducing disability in the moderate term (MD -8.28, 95% CI -13.04 to -3.52), and high certainty evidence showed that CFT has a small effect in the long term (MD -4.00, 95% CI - 7.42 to -0.58). For pain intensity, very low certainty of evidence indicated CFT has a moderate effect in the short term (MD -13.93, 95% CI -21.76 to -6.10), low certainty of evidence indicated that CFT has a moderate effect in the moderate term (MD -13.25, -19.44 to -7.05), and moderate certainty of evidence that CFT has a small effect in the long-term (MD -6.55, 95% CI -13.30 to 0.20). Low certainty evidence suggests that CFT has a large effect compared with minimal intervention for disability in the short term (MD -18.40, 95% CI -23.74 to -13.07). Conclusion: Compared with active interventions including exercise, CFT probably reduces disability in the short term, may reduce disability in the moderate term and slightly reduces disability in the long term. For pain intensity, the evidence is very uncertain about the effect in the short term, but CFT may reduce pain intensity in the moderate term and probably has a small effect in pain reduction in the long term. Compared with minimal interventions, CFT may result in large reduction of disability and pain intensity sustained in the long term. Current evidence supports the use of CFT in patients with chronic low back pain.