Core stability is being
challenged by Prof Peter O’Sullivan and his team. Cognitive functional therapy (CFT)
is a relatively new approach to athletes with lower back pain. It has also been
called the “confidence cure.”
One of this issues with core stability training
is that it feeds into the belief that the spine is vulnerable and requires this
special “core activation” that no other body part requires before training.
What would happen if
the “core stability industry” was wrong and it just perpetuated the low back
belief that the spine is vulnerable and needs special training?
CFT is a patient
centred approach to management that targets the beliefs, fears and associated
behaviours (both movement and lifestyle) of each individual with back pain.
It leads the person to
be mindful that pain is not a reflection of damage – but rather a process where
the person is trapped in a vicious cycle of pain and disability.
This is fuelled by a
nervous system that is stressed and sensitized due to negative beliefs, fear,
lost hope, anxiety and avoidance, linked to mal-adaptive (provocative) movement
and lifestyle behaviours.
It is integrated using
a motivational interviewing approach to communication where it identifies
discrepancies between beliefs and behaviours and acknowledges that the
solutions that ‘stick’ are usually found by the person themselves.
It is strongly
behaviourally orientated and explores different movement options using visual
feedback in order for people to re-establish their body schema and relearn the
basic building blocks of relaxed normal movement. It empowers the person to do
the very things they fear and / or avoid, but in a graduated relaxed and normal
manner.
It conditions them if
they are weak. It motivates them to engage with exercise and active living
based on their preferences and goals.
Results from a CFT approach can be
excellent with the use of 4 proposed stages:
1.
Cognitive re-education
- patients often tend to respond
better to treatment if they understand what is going on. In this stage, the
vicious cycle of pain is explained and the patient and physiotherapist will
collaborate to set goals and problem solve. This helps to change the beliefs of
the patient and helps their recovery.
2.
Specific movement training
- by targeting faulty movement patterns and
pain provocative functional tasks, the patient can develop enhanced body
awareness and begin to move in a more pain free-way. By understanding the
sequences of movement, they can be linked to the patient's goals and again help
recovery.
3.
Functional integration
- these new movement skills can no be
integrated into daily life in order to meet the goals and expectations of the
patient. This helps to build confidence which gives a more positive outlook
which is key to moving forward.
4.
Physical activity and lifestyle
advice
- this stage is patient directed. The patient
sets goals and an exercise plan is devised to meet these. Lifestyle factors are
also taken into consideration which can include support groups and tips for
mindfulness or relaxation.
So what did the
patients say?
“Now I know there can
be pain without physical or structural problems”
Whilst most participants entered the
intervention with strong biomedical beliefs about the cause of their pain, the
acceptance of a biopsychosocial model of pain was a key ‘ingredient’ that
differentiated improvers from non-improvers.
A trusting relationship with the therapist facilitated effective
communication and set the scene to challenge existing beliefs with a new
explanatory model of pain. Participants
described a new ‘body awareness’, an understanding of how physical and
psychosocial stressors influenced their behaviour and pain. They were
encouraged to challenge this new information and body awareness through
behavioural experimentation and the experience of control over pain was key to
the consolidation of a new belief system.
“When I get the pain
now, I’m able to check myself. I can unravel it myself”
The second key ingredient to
successful outcome was achieving independent self-management of their
pain. This was built on the foundation
of solid problem solving skills and improvement in pain self-efficacy that
enabled improvers to confront threatening or pain provoking activities. Pain
self-efficacy differentiated ‘large improvers’, those who reported a return to
normality with renewed optimism for the future, and ‘small improvers’, who
reported residual concerns about their ability to cope with a relapse in pain,
particularly when faced with contextual life stressors.
Well, this adds debate this week to
the theme of lower back pain in athletes. As usual, the truth will lie
somewhere in the middle.
References
Bunzli S, McEvoy S, Dankaerts W,
O’Sullivan P, O’Sullivan K. Patient perspectives on participation in Cognitive
Functional Therapy for chronic low back pain: A qualitative study. Physical
Therapy 2016;Accepted 13.03.2016 Online First.
Vibe Fersum K, O’Sullivan P, Skouen
JS, Smith A, & Kvåle A (2012). Efficacy of classification-based cognitive
functional therapy in patients with non-specific chronic low back pain: A
randomized controlled trial. Eur J Pain PMID: 23208945
O’Sullivan K, Dankaerts W, O’Sullivan
L, O’Sullivan P. Cognitive Functional Therapy for disabling nonspecific chronic
low back pain: Multiple case-cohort study. Physical Therapy 2015;30([Epub ahead
of print]) Online First.
Video: https://www.youtube.com/user/bodylogicphysio
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