Cognitive Functional Therapy: Treating Chronic Low Back Pain by Restoring Participation

I recently came across an ABC News story discussing a new, personalized therapy approach that could meaningfully reduce the prevalence of chronic low back pain (LBP) in America. That immediately caught my eye, not because it promised a miracle cure, but because it focused on long-term relief and self-management, two things our profession has been preaching for years.

The article featured work from Australian researchers, and I’ll say it plainly: Kevin O’Sullivan is the GOAT. His influence shows up again and again in the highest-quality low back pain research, and this story was no exception. The ABC piece sent me straight to the source, a large, high-quality randomized controlled trial published in The Lancet Rheumatology.

Outlining the Study

This study was a 3-year follow-up of the RESTORE randomized controlled trial, designed to test whether Cognitive Functional Therapy (CFT) with or without wearable movement sensor biofeedback could produce sustained benefits for people with chronic, disabling low back pain when compared to usual care.

This matters because most low back pain interventions show only small improvements that fade quickly. The authors weren’t asking whether CFT helped in the short term, they were asking whether a conservative, PT-led intervention could change outcomes years later.

The Research Question

The population included adults with chronic low back pain lasting longer than three months who also had meaningful limitations in daily activity. The intervention was Cognitive Functional Therapy, delivered either alone or paired with wearable movement sensor biofeedback. This was compared against usual care, meaning whatever treatment participants independently chose in the community. Outcomes focused on pain-related physical activity limitation as the primary outcome and pain intensity as a secondary outcome.

Outcome That Actually Matters

The primary outcome was not pain.

Instead, the researchers measured pain-related restriction in participation, using the Roland Morris Disability Questionnaire. This distinction is critical. Pain intensity alone does not determine quality of life. What limits people is whether pain prevents them from working, exercising, parenting, socializing, or trusting their body.

By prioritizing participation over pain, this study aligns far more closely with how patients actually experience chronic low back pain and how physical therapists should be defining success in practice.

Interventional Treatments and What Really Happened

Participants were randomized into one of three groups. The usual care group pursued any treatment they wanted in the community, with no attempt to standardize or control care. This reflects the real-world experience of many patients navigating chronic low back pain.

The two intervention groups received Cognitive Functional Therapy delivered by specially trained physiotherapists. Treatment consisted of up to seven sessions over twelve weeks, with an additional booster session at twenty-six weeks. Both CFT groups wore movement sensors, but only one group had access to the data.

In the CFT-only group, neither the patient nor the therapist could see the sensor output. In the CFT plus biofeedback group, therapists used real-time sensor data to guide assessment, movement retraining, and feedback during daily activities.

What is Cognitive Functional Training

CFT was not simply exercise paired with generic education. It was a highly individualized, behaviorally driven intervention built around three integrated components.

First, therapists helped patients make sense of pain. This involved reframing pain through a biopsychosocial lens, addressing fear-based beliefs, and using the patient’s own story and examination findings to reduce threat and catastrophizing.

Second, treatment emphasized movement with control. Patients were gradually exposed to feared or avoided movements in a structured way that rebuilt confidence and capability simultaneously. Movement retraining was always tied back to meaningful, functional goals.

Third, CFT addressed lifestyle behaviors. Therapists coached patients on physical activity preferences, sleep habits, stress management, and social engagement. This wasn’t delivered as a handout, it was active behavior change work.

Outcomes After Years of Good Education and Training

At the three-year follow-up, both CFT groups demonstrated significantly less activity limitation than the usual care group. Pain intensity was also lower in the CFT groups, although these effects were smaller than those seen for disability. Importantly, there was no meaningful difference between CFT delivered with biofeedback and CFT delivered without it.

More patients in the CFT groups achieved clinically meaningful improvements, and a substantial proportion maintained disability scores below a recovery threshold for years after treatment ended. Sustained results of this magnitude are rare in chronic pain research.

What Does This Mean for Patients?

These findings are not about shaving a single point off a pain scale. They reflect changes that matter at a life level: returning to valued activities, moving with confidence, managing flare-ups without fear, and avoiding the endless cycle of care-seeking.

This is the kind of outcome patients care about and exactly where physical therapy has the greatest opportunity to lead.

Strengths and Limitations

One of the biggest strengths of this study is the three-year follow-up, which is exceptionally rare in low back pain trials. The study was adequately powered, used a large pragmatic sample across multiple clinics, and included rigorous training and fidelity monitoring of physiotherapists. Most importantly, the benefits persisted long after formal treatment ended.

There are limitations worth acknowledging. Neither participants nor therapists were blinded, which can influence expectations and self-reported outcomes. The outcomes themselves were self-reported, which introduces potential bias, particularly in the absence of blinding. There was also loss to follow-up at three years, which is common in long-term trials but still limits generalizability. That said, multiple sensitivity analyses supported the main findings.

Parting Words

This study reinforces a message physical therapy already knows but does not always operationalize: conservative, PT-led care can protect both patient health and healthcare dollars.

Long-lasting improvements in participation reduce repeated care-seeking, unnecessary imaging, medication use, and invasive procedures. This is what high-value care looks like, and stories like the ABC News feature, backed by high-quality research, remind us that physical therapists are uniquely positioned to lead this shift.

References

1. Kent P, Haines T, O'Sullivan P, et al. Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. Lancet. 2023;401(10391):1866-1877. doi:10.1016/S0140-6736(23)00441-5

2. Lee M. New personalized therapy may provide long-term relief for chronic back pain, study finds. ABC News. August 5, 2025. Accessed December 14, 2025. https://abcnews.go.com/Health/new-personalized-therapy-provide-long-term-relief-chronic/story?id=124346657

Disclaimer

I am a current Doctor of Physical Therapy (DPT) student sharing information based on my formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While I strive to provide accurate and up-to-date information, my knowledge is based on my current academic and clinical rotations and ongoing learning, not extensive clinical practice.