Classification based cognitive functional therapy for back pain

This story of a 28 year old man with disabling low back pain illustrates the CB-CFT intervention trialled in the RCT in Bergen, Norway.

‘Eight years ago I had a lifting injury at work. It was terrible pain, I was worried so I went to the doctor who ordered a scan. The doctor said I had a back of a 70 year old. He said I couldn’t surf again and or do manual work.I was devastated.

I underwent lots of treatments to stabilise my spine with exercises, spine injections and medication. Over this time the pain just got worse. Before I started the CFT program I had stopped work, I was spending 6 hours a day lying down and had stopped socialising. My back pain had consumed my life, I felt desperate and had nearly lost hope.

Through the CFT program I have learnt that my back isn’t damaged – I now realise that my whole nervous system was really wound up. I have learnt to relax and move normally again, I don’t fear movement now – my mindset has changed. Best of all I can go out for dinner, I can exercise and am now back doing my job. I still flare up when I am stressed but I don’t worry about it so much – the pain doesn’t limit my life like it did.

Looking back I now realise that for 8 years I was living with fear, I had lost confidence in my body and I was continually protecting my back by tensing it because I thought it was damaged. I avoided things that hurt, I couldn’t relax – I was so stressed.’

This is not an isolated story. It’s a sad reflection of the potential negative consequences of communication and treating back pain as a damaged structure. It is also a story of hope that disabling back pain can change for the better with a different narrative and coping strategies.

This RCT was a collaboration between Bergen University, Norway and Curtin University, WA, Australia and was conducted by Dr Kjartan Vibe Fersum. It tested an approach to managing mechanically provoked ‘non-specific’ persistent low back pain – which we called ‘classification based – cognitive functional therapy – CB-CFT’. It’s a bit of a mouthful but we called it this as it represents a person centred, body/mind approach to understanding and managing this complex problem.

The multi-dimensional classification system that underpins it, guides the therapist in a clinical reasoning process that considers the contribution of: patho-anatomical factors where present, neurophysiological mechanisms, cognitive and psychosocial, lifestyle and physical factors, such as maladaptive movement behaviours, body schema distortions and muscle conditioning.  It acknowledges that for each individual there is a unique contribution of factors across these different domains that act to maintain a vicious cycle of pain and disability. It is not a subgrouping system.

Cognitive functional therapy (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 reestablish 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.

This approach ticks a lot of boxes for management of chronic disorders, as it aims to build self-efficacy, confidence, adaptability and provides hope and opportunity for change for the person with pain in a person centred manner.

The results of the trial suggest that CB-CFT worked a lot better than traditional manual therapy and exercise. There were greater reductions in pain, disability, fear of movement and work, improved mood, less need for ongoing treatment and less time off work. The patient satisfaction levels at 12 months were remarkably high (96%).

This approach isn’t rocket science, but it we think it requires a different perspective on back pain on the part of the treating therapist. It requires confidence that pain is to be respected but not feared. It also requires trust and engagement on the part of the person with pain.

The trial had limitations that are outlined in the paper and clearly needs replication in higher disability groups and this is ongoing in different parts of the world. Not all people responded – and we are looking at what the mediators of outcome were in this intervention.


The EJP paper is open access so the full paper and appendices can be uploaded for the readers.  Here they are in PDF form

About Peter O’Sullivan

Peter OSullivan Curtin UniPeter  is a Specialist Musculoskeletal Physiotherapist who works with people with persistent pain and  is a Professor of Musculoskeletal Physiotherapy at Curtin University where his research team conducts clinical research into the complexity of pain and its management.


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


  1. Michael Ingle says

    Peter’s approach gave me the skills to integrate the mass of information I had learnt in physiotherapy school. The physiotherapy profession seems fixated on core stability and approaching back pain from a biomedical approach. A new approach is clearly needed – I think CFT is pioneering the way here.

  2. This is what Dr John Sarno has been saying in his books for the past 30 years. Our backs are no damaged, it’s caused by the brain which is protecting us from emotional things that we don’t want to know about.

    John Quintner Reply:

    With respect, Dr Sarno’s myofascial tension theory cannot be tested. It is therefore in the same boat as Freudian psychoanalytic theory in so far as it purports to explain everything but succeeds in explaining nothing!

  3. douglas scown says

    We all excited about investigations into the complex experience of pain however it’s important to refer to a broad sample of the literature with regards to ‘spine’. There is robust information which supports the view that spine diagnosis is generally poor (across the professions) thus management ineffective in a large proportion of cases. Many studies (most in fact) approach ‘back pain’ as a condition forgetting that it is a symptom. Mr Smith presents with acute severe lower back pain. It is not approached the same way as abdominal pain. Back pain is common, considered non life threatening and at best is perceived as an economic burden. Wonderful. We still have no identifiable tissue in lesion. Mangement is most likely hit and miss, the patient loses hope, there is no explanation of the problem, thus no possible way to set realistic expectations regarding recovery; no time line. What happens? The increasing loss of control, fear, anxiety. What does this do? A hypervigilant midline neurology disinhibits nociception. We wind up. Will they respond to CBT or CFT? Likely yes. They have someones ear; an explanation, control, inhibition. Could it have been avoided to begin with? Diagnosis; educated professionals who are aware of the importance of making a specific tissue diagnosis, the spectrum of mechanisms involved in pain production and its management (and the fact that our knowledge base rapidly changes). I genuinely value these studies but I must be honest – if we begin with such ersatz ‘diagnoses’ as NS…etc we are often stuffed before we start and interpretation is problematic. Regards.

  4. Donna Conran says

    I am so thrilled that we, as primary care providers, are now disseminating what we have seen in clinic for many years – the “movers” do best. Thank you for your research, and commitment to patient “life” wellness, not just patient “physical” wellness.

  5. I think this type of approach will be the future of Physical Therapy. Looking forward to seeing this replicated in other populations and trials.

  6. 100% agree with David. Have workshop-shopped for many years now and have finally found what I was looking for in the form of Prof Peter O’Sullivan’s live demos during his courses. He is the only researcher I know that continues to work 3 days a week with real patients and also prepared to get up on the stage and treat patients with persistent back pain in front of literally 100s of patients. His patient centred motivational interviewing techniques are truly awe inspiring and his ability to adapt his approach within his CFT framework according to the patient is truly remarkable. It really has changed my whole approach and I look forward to his workshop every year in the UK now. It is like taking off my foggy spectacles and putting on a crystal clear new pair. Practice based (and research based) evidence at its best.

  7. Without doubt Peters approach is the most truly integrated approach I have seen in 25 years of practice.
    It is also free from commercial motives which dominate this arena.
    My best advice is to get to a workshop and see this in practice. We’ve had colored flags for nearly 2 decades – this approach integrates this information and actually uses it in a practical