Cognitive Functional Therapy

May 4, 2011 by   Print
Filed under Physiotherapy Blog

In today’s post I want to feedback on a three-day workshop I just completed with Prof. Peter O’Sullivan, Physiotherapist from Curtin University, Western Australia. Most of you will be aware of Peter’s published work in many of the prestigious scientific journals and he’s been a great advocate of the role of physiotherapy in the management both of musculoskeletal pain and more specifically spinal pain. Peter is well-known for his earlier work on classifying movement impairment patterns and applying specifically targeted treatment strategies relative to the movement dysfunction. Readers will be aware of the increasing numbers of movement impairment based systems now popular (Shirley Sahrmann, Grey Cook, Gary Gray, Bobath, Klein-Vogelbach, Carr & Sheppard as well as all the bodywork systems).

Due to the complexity and multi-factorial issues involved in low back pain Peter and his research team have now evolved a system of approach known as Cognitive Functional Therapy. This system integrates not only movement pattern analysis but  incorporates a much broader holistic approach into the multitude of factors which we know influence the patient’s pain experience.

The concept of psychosocial profiling has been a discussion we have had several times on this blog . with so much conflicting evidence regarding the role of the physical findings and their contribution to low back pain. A practical clinical system has been developed to incorporate assessment of the most useful psychosocial variables which we know influence the pain experience. We know from the vast amount of research undertaken regarding the management of low back pain that there are a large number of variables which ultimately contribute to the pain experience. Prof. O’Sullivan and his team have formulated the treatment approach of cognitive functional therapy to incorporate these findings into a practical system of patient management that can be delivered by physiotherapists.

Factors influencing low back pain


Social factors

Psychological factors

Genetic factors

Pain/ neuro-physiological factors

Patho- anatomical factors

Physical factors

Prof. O’Sullivan spent a considerable amount of time on clinical case histories and highlighting the need for careful attention to detail in the subject of questioning. We’ve talked about the role of subjective questioning previously  and the critical importance of this aspect of patient / therapist interaction was one of the major take-home messages from this three-day workshop.

Peter demonstration strategies of subjective questioning and patient interview using a technique known as Reflective Questioning in order to enhance the patient’s analysis of their own  situation and the information they have received(for better or worse!). As physiotherapist’s we can frequently feel overwhelmed by the volume of information available particularly in the field of psychosocial issues. The framework was provided whereby clinicians can pick up on appropriate verbal cues and follow specific lines of inquiry in order to elucidate the role / relevance of specific psychosocial factors. Some of these well-known factors include:

Psychosocial Factors

Personality type

Beliefs and attitudes


Coping strategies




Since the introduction of the psychosocial model for management of low back pain there’s been much debate regarding the appropriateness /willingness of physiotherapists to address psychological issues. I would go so far as to say that many have hidden behind the professional boundaries excuse for not exploring or challenging distorted beliefs and behaviors which patients may present with. Of course we also need to challenge our own beliefs particularly in the light of treatment tools me choose to use.

The overriding message from this Cognitive Functional Therapy workshop was that physiotherapists not only should get involved with exploring psychosocial issues but in reality have a duty of care in order to deliver the best possible treatment to the patient.

This places a great onus on appropriate training which is typically not incorporated into undergraduate programs. It also places an emphasis on personal development and interpersonal skills in order to recognize psychosocial risk factors and to determine which elements are modifiable and which are not- don’t go there if you can’t deal with it (you can’t handle the truth).

We have discussed the issue of therapist burnout in previous discussions and this is relevant again here because recognizing which factors are modifiable and which are not has profound implications on  therapist management strategy and ultimately on prognosis. Failure to recognize the confounding factors which may negatively influence prognosis frequently leads to a breakdown in the patient therapist relationship, distorts or sabotages patient compliance, and can seriously undermine physiotherapist credibility.

In reality approaching many of the psychosocial issues require physiotherapists to have a good knowledge of their own belief systems, their values and attitudes, variation in cultural perspectives on pain / disability and of course some practical recommendations or alternative strategies to improve patient’s specific functional deficits.

Some of these issues involve evaluating lifestyle changes and devising strategies which encourage habitual change – not just talk glibly about it!. We know from much of the research that resistance to change is one of the fundamental reasons why humans keep doing things which they know are bad and ultimately detrimental to the health. This is also ties in with readiness to change, the patient’s goals and objectives regarding benefits of  potential improvement in function (to use a marketing phrase “what’s in it for me”) and also the need in some cases to challenge distorted belief systems based on the evaluation of symptom behavior, radiological findings, provoking an easing factors and disability trajectory.

For too long physiotherapists have been comfortable identifying risk factors using validated questionnaires but failing to take the next step of dismantling psychosocial issues which are perpetuating physical impairment. In fact the clinical guidelines which indicate a lack of evidence for specific manual therapy in these patients suggest that group therapy, general exercise or advice being the interventions of choice.

One of the cornerstones of the Cognitive Functional Therapy-based approach to rehabilitation is that we as physiotherapists are well placed to administer this type of multi-factorial approach to management because our repertoire of skills involves movement analysis, strength and conditioning, localized musculoskeletal techniques, communication and a significant period of one-to-one contact time in which to engage with the patient.

Lookout for Prof. O’Sullivan’s regular published work and of course workshops conducted either by himself or Prof. Wim Dankaerts.

Cognitive Functional Therapy, the future of low back pain management delivered by physiotherapists. A patient centered approach incorporating evidence with the best practice to achieve patient focused goals. Making simplicity out of complexity – how exciting.


Enjoy the clinical challenge





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One Response to “Cognitive Functional Therapy”
  1. Nicolas says:

    Dear David,

    In the workshop, did you use profesor O’Sullivan’s movement classification (flexion, extension, multidirectional) at the physical assessment of the patient? (can you give a specific reference). Did he always taught abdominal relaxation and pelvic dissociation? How did he picked which patients should do which strategies?
    How do you recognize when a psychosocial issue is not within the bounderies of physiotherapy?
    Did he use any specific scale or self-assessment? Roland-Morris, FABQ or ohter…
    Thank you

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