Physiotherapy professor Mark Hancock has co-written a pioneering paper that calls for more clinicians to be trained in delivering an approach known as cognitive functional therapy (CFT).

Professor Hancock was the first author of a research paper that was published online by a sister publication of The Lancet – one of the most highly-rated medical journals in the world – earlier this month (5 August).

Based at Macquarie University’s Faculty of Medicine and Health Science in Sydney, Australia, the professor of physiotherapy has more than 20 years’ clinical experience as a musculoskeletal (MSK) physiotherapist in primary care settings under his belt.

Professor Hancock now concentrates on his academic role and research work, which focuses on the diagnosis and management of back pain. He completed his PhD at the University of Sydney in 2007. 

Professor Hancock and his 11 co-authors conclude that the person-centred approach known as CFT is the first treatment for chronic disabling low back pain. The authors define CFT as ‘an individualised, person-centred approach that guides individuals to self-manage their own condition by targeting biopsychosocial barriers to recovery’.

According to the results of their randomised controlled trial (RCT), which were published in The Lancet Rheumatology journal on 5 August, there is sound evidence that CFT can reduce disability due to the pain for more than a year,

Previous findings

A previous study – published in The Lancet in 2023 – found that CFT was more effective than ‘usual care’ at improving self-reported physical activity participation in those with low back pain up to one year.

Usual care was defined as any treatment that the health provider recommended, or that the patient chose. It may have included painkillers, physical therapy and/or massage therapy. 

Peter Kent – the first author of that article and a co-author of the current one – is also a physiotherapist by background. Dr Kent is an adjunct associate professor at Curtin School of Allied Health at Curtin University in Perth, Australia. To access the earlier article, see: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00441-5/fulltext

The current trial

‘CFT produces clinically important effects for activity limitation at 3-year follow-up. These long-term effects are novel and provide the opportunity to markedly reduce the effect of chronic back pain if the intervention can be widely implemented [Mark Hancock et al]

The current trial is the first to show that these effects are sustained up to three years. The RESTORE RCT included 492 patients with chronic low back pain in Australia, who were randomly assigned to receive eight treatment sessions of usual care, CFT, or CFT plus biofeedback (a technique using sensors to measure body functions such as heart rate and enable the patient to modify them).

While those who received CFT and CFT plus biofeedback saw improvements in their physical activity participation over usual care, the difference between those receiving CFT-only and CFT plus biofeedback at three years were small and not significant, which is also consistent with the three-month and one-year results. 
 
Professor Hancock and his colleagues – who include other prominent physiotherapists, such as Australia-based professors Anne Smith and Peter O’Sullivan, and Ireland-based professor Kieran O’Sullivan – are confident that the current trial demonstrates that CFT has long-term benefits for physical activity among those with low back pain.

The approach provides an opportunity to markedly reduce the impact of low back pain if the intervention can be widely implemented.

The authors note that attempting to implement CFT would depend on successfully scaling up clinicians’ training to increase accessibility, and in order to replicate studies in diverse healthcare systems.

Conclusion

‘CFT produces clinically important effects for activity limitation at 3-year follow-up. These long-term effects are novel and provide the opportunity to markedly reduce the effect of chronic back pain if the intervention can be widely implemented,’ Professor Hancock and his colleagues state.

They add: ‘Implementation requires scaling up of clinician training to increase accessibility, and replication studies in diverse health-care systems.’

Fact file

CFT helps the patient change their mindset about the pain and self-manage via movement pattern changes and lifestyle changes. 

Low back pain is a long-term health condition for many people marked by unpredictable recurrences or pain flare ups. Interventions for low back pain have previously typically produced only small and short-term effects. 

To access the full version of the article – which is titled Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): 3-year follow-up of a randomised, controlled trial – see: https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(25)00135-3/fulltext

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