Deconstructing: Cognitive Functional Therapy

If you have had the pleasure of working alongside a clinician who has previously attended a Cognitive Functional Therapy (CFT) workshop, you will understand very well when I say that Cognitive Functional Fever may well be a more appropriate working title for this approach.

I think there is a genuine and palpable sense of zeal surrounding CFT, that we simply don’t witness with respect to ‘Combined Movements of the Lumbar Spine’ courses, for example.

A close colleague of mine had attended Peter O’Sullivan’s CFT workshops many times over the years, so I had experience of hearing the deafening thump, thump, thump of deconditioned souls hopping on the spot, often accompanied by laughter through the clinic wall, not to mention the mirrors and the boxes of tissues.

When talk turned to CFT I found some of the concepts familiar but the bigger picture – what it was exactly that was different about CFT – I found elusive. What was crystal clear though was her enthusiasm and passion for the approach and yes, she had facilitated some great recoveries with people.

So, I booked on Peter O’Sullivan’s London Course (Summer, 2017) and – having listened to the podcasts (e.g. here), seen the YouTube videos (e.g. here) and even read about being on the receiving end of CFT (here) – I was really keen to hear the theory behind the therapy first hand and more so, I was looking forward to seeing CFT in action, as two days were set aside for ‘patient demos.’

The Workshop Manual London June 2nd-4th 2017

I was particularly interested in finding the nub of CFT, to see for myself if this was a synthesis of approaches – essentially a contemporary evidence based physiotherapy or was there something genuinely new behind the rather awkward moniker ‘Cognitive Functional Therapy’?

So it was with these experiences and expectations in the back of my mind that I took my seat at the back of the conference venue at the London Royal Free Hospital along with 300 or so other clinicians (60% of whom were returning to the course having attended in the past).

Here are my eight take-home messages from the three days…

Lesson One: CFT covers an enormous evidence base. Enormous.

Day One was an intense day of theory and Powerpoint – a free-form heading-free whistle-stop tour of the CFT approach. Prof O’Sullivan took us through his childhood influences (falling out of trees / other dangerous pursuits and basically ‘getting on with it’) and his early academic and teaching background including his nocturnal foray into the Land of Lumbar Stability and Transversus Abdominis.

An enormous amount of literature was presented and I think it would be helpful to put it all in one place. In a nutshell, CFT appears to acknowledge the following factors:

  • Cognitive factors:
    • fear avoidance
    • the meaning of pain / beliefs
    • health care professionals nocebic language
    • catastrophisation
    • self-efficacy
  • Emotional factors:
    • pain-related fear
    • depression / anxiety / worry
  • Social
    • compensation / work / family / stress load
  • Physical
    • poor relationship between posture and LBP
    • little evidence for biomechanical diagnoses for LBP e.g. core stability / asymmetry
    • triggers of acute LBP involve physical activity whilst tired or fatigued
  • Lifestyle
    • sleep / obesity / sedentary behaviour
  • Co-morbidities
    • irritable bowel / migraine / fibromyalgia
  • Motor / Behavioural / Physiological responses
    • adaptive & helpful versus maladaptive & unhelpful movement
    • loss of flexion relaxation at end range lumbar flexion
    • avoidance / protective muscle guarding
    • safety behaviours
    • physiological ‘fight – flight’ response
  • Widespread sensory hypersensitivity
Modifiable influences on pain & disability behaviours

In the literature, CFT is also referred to as a ‘multidimensional clinical reasoning framework’ and you can certainly see why! I don’t know about you, but when people start talking in terms of ‘multidimensional clinical reasoning frameworks’, I start looking for the emergency exit.

So what’s under the hood of CFT?

Lesson Two: you may be familiar with some aspects of CFT, but not all

Well I think the bottom line is that there is little that is completely new here and for all intents and purposes this ‘approach’ to my eye is, very simply put – an evidence based physiotherapy approach that has been given another name i.e. ‘CFT’.

My feeling is that giving a therapy a new name automatically suggests that something new is being offered, when it could be argued here that perhaps it is not; CFT is probably best viewed as a practical synthesis of the evidence base.

It is certainly not Prof O’Sullivan’s fault that, for example the cognitive, emotional and social factors – having been discussed since the 1990’s with reference to Louis Gifford, Mick Thacker and the Physiotherapy Pain Association here in the UK – are certainly taking their time becoming central to our day-to-day work.

Interacting factors & the pain experience

Other aspects of this clinical reasoning framework are varyingly old and new e.g. work questioning the role of posture and biomechanics has been steadily building over the last twenty years but material such as ‘lifestyle factors’ (sleep and exercise), co-morbidities and Martin Rabey’s work on directional preferences (ref, ref), sensitisation and sub-grouping are clearly welcome additions to the evidence base.

All this material was covered in one long theoretical day and I was certainly a little apprehensive about how this was going to play out clinically.

Lesson Three: Peter O’Sullivan is a truly incredible clinician

There were four individuals with back pain assessed over the remaining two days of the course. Prof O’Sullivan sat back – almost supine in fact, in his chair – and revealed a clinician at the height of his powers. Three of the individuals were profoundly disabled by fear of pain and movement, but Prof O’Sullivan connected, laughed and followed through with a virtuoso performance of evidence based physiotherapy.

Over the two clinical days of watching Prof O’Sullivan work, we witnessed the most jaw dropping and at times moving sights. This was deeply emotionally engaging material.

‘Always slump’ – Prof O’Sullivan’s summary

What is more, the individual cases returned the following day to reveal that their remarkable improvements from ‘day one’ had indeed carried over.

Lesson Four: …but prepare to be mistaken for a psychologist

And here’s the rub. Prof O’Sullivan’s reflective, person-centred interviewing style has so much more in common with psychological, why even psychotherapuetic approaches than physiotherapy. I am reminded of my other brush with CFT, one that was more tangential than working next door to a CFT convert, but no less interesting.

I took my eldest son to a guitar exam in the middle of deepest darkest Kent, UK, a couple of years ago and a woman walked in, talking about how her daughter had been to see a ‘leading back pain specialist’ the day before, in London – ‘an NLP expert’, she added…’Peter O’Sullivan.’ Small world….but what an interesting interpretation!

Blending the physical & the psychological

The problem of course is that in our day to day work, people who consult with us are expecting physical treatment. Applying the ‘CFT approach’ with individuals with persistent, highly disabling pain may well be less problematic than working with individuals with less bothersome problems. The former will be willing to ‘try anything’ while the latter may not easily see the links between the body and the mind. This leads me to wonder: wouldn’t it be great to see Prof O’Sullivan working with someone experiencing their first episode of acute back pain?

Lesson Five: it may feel like it’s getting out of hand at times

And yes at times the similarities to stage hypnosis were almost too uncomfortable to bear: from the deeply relaxed state (achieved prior to the fear exposure work), to the adoption of unfamiliar postures: viz. a person who has not flexed for 15 years standing in full end range lumbar flexion, for minutes at a time, microphone thrust in their face, proclaiming, ‘I don’t believe i’m doing this!’

I was reminded of Television evangelists from the 90’s, as I found myself literally swept stage-ward on a rising tide of applause as the family of one of the individuals took to the stage to declare ‘she uses a wheelchair when she’s out of the house’, ‘the patient’ skipping Disney-like around with Prof O’Sullivan in the background! Wonderful stuff indeed! (And much more fun than a combined movements course…).

Lesson Six: you will be challenged, you will learn, but be prepared to do some homework

But to dismiss this as ‘smoke and mirrors’ and as some sort of ‘stage effect’ would be to seriously miss the point: what was demonstrated was an utterly brilliant clinician stepping up to the plate and expertly blending an individuals narrative with cognitive behavioural therapy (CBT) with motivational interviewing (MI) with exposure to feared activities, through in vivo behavioural experiments.

CFT, however does not wear its influences on its sleeve, so be prepared to do some homework and digging around to find the source of some of the material. For example, Jeroen De Jong’s work didn’t get a mention (and of course the parallels are striking. See his superb presentation here) nor the fact that fear exposure – really a large component of the approach presented – has its origins in 1950’s behavioural psychology (see here).

Lesson Seven: it’s like a fast-track postgraduate module

On my way out, on the last day, I bumped into a student I had met previously on a Musculoskeletal Masters module. He said ‘you know, this is not a million miles away from what we learnt….’ And yes, in a nutshell the workshop was essentially a fast-track postgraduate musculoskeletal workshop on the contemporary management of low back pain, demonstrated by a superb clinician and – boy! – how we need to see people working successfully in our field, to model their behaviour and to move forward as clinicians.

Yeah – we need more Gurus!

Lesson Eight: for emotionally compelling, spiritually inspiring CPD – look no further

What greater accolade is there, that so many clinicians return year after year, to drink from the waters of CFT. I wonder if this phenomenon also reflects in part the dearth of high profile expert clinicians who are presenting their work ‘seeing patients’ on their courses? (How many of our Twitter experts would be happy to see patients in front of 300 people?)

Considering all the positives above, I could not recommend the CFT workshop highly enough. If you are a clinician you simply MUST see ‘CFT’ in action.

Who knows, you may even get ‘the fever’!

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