Cognitive functional therapy may not beat manual therapy for back pain

Chronic low back pain is one of the most common and stubborn complaints in adults, and treatment fashions move faster than the evidence behind them. Cognitive functional therapy is a physiotherapy approach that has attracted considerable attention and enthusiasm as a way of addressing the beliefs, fears and movement habits that keep pain going. Before it displaces more familiar approaches, it needs to be tested against them head to head. This review asked whether the trial evidence yet justifies treating it as superior.

The authors searched four electronic databases and two clinical trial registers from inception to March 2022 for randomised controlled trials of cognitive functional therapy in adults with low back pain. Primary outcomes were pain intensity and disability; secondary outcomes included psychological status, patient satisfaction, global improvement and adverse events. Risk of bias was assessed with the Cochrane Risk of Bias 2 tool and certainty of evidence with GRADE. Random-effects meta-analysis with the Hartung-Knapp-Sidik-Jonkman adjustment was used to pool effects. Fifteen trials were identified, but 9 were ongoing and 1 terminated, leaving 5 with usable data (n = 507; 262 cognitive functional therapy, 245 control).

For the comparison against manual therapy plus core exercises, drawn from 2 studies with 265 participants, the pooled mean difference in pain intensity was -1.02 out of 10 with a confidence interval running from -14.75 to 12.70, and disability was -6.95 out of 100 with an interval from -58.58 to 44.68. Both intervals span benefit and harm, which is why certainty was graded very low. Narrative synthesis of the remaining evidence showed mixed results for pain intensity, disability and the secondary outcomes. No adverse events were reported, and every included study was judged to be at high risk of bias.

This tempers a genuinely popular idea rather than demolishing it: the conclusion is uncertainty, not proven ineffectiveness. The authors are explicit that the effectiveness of cognitive functional therapy will remain very uncertain until higher-quality studies are available, and 9 ongoing trials mean the picture could change. The review also shows how a treatment can accumulate reputation ahead of usable data, since two-thirds of the identified trials had not yet reported. Whether particular subgroups respond better, and how the approach compares with other active treatments, are still open.

If you have been told that cognitive functional therapy is clearly better than conventional physiotherapy for persistent back pain, this pooled evidence does not yet support that. It also gives no reason to avoid it: no adverse events were reported, and the imprecision cuts both ways. The practical reading is that several common active approaches to chronic low back pain currently look broadly comparable on the available trial data. Anyone weighing options may find that access, cost and personal preference are the more informative considerations until better trials land.