Hva er CFT (Cognitive functional therapy) for uspesifikke rygger? Hvorfor lovende? Jan Sture Skouen Professor dr. med. AFMR, Haukeland universitetssykehus Universitetet i Bergen

Risk factors for abscence from work Long-term sickness absence is associated with disability pension Gjesdal S et al Fear-avoidance predict long-term sickness absence Iles RA et al Less support from leaders, less control and decision latitude at work are related to more days sick-listed Berthge M. 2010, Verkerk K et al. 2012

Current evidence for management of NSCLBP Spinal manipulative therapy Rubinstein et al 2011 Cochrane review Exercise therapy Hayden et al 2005 Cochrane review – Stabilisation – Directional preference – Conditioning Cognitive behavioural treatment Henschke et al 2010 Cochrane review No intervention is superior Minimal change in pain Moderate change in disability

What is biopsychosocial treatment? Multidisciplinary examination and treatment, usually by a medical specialist doctor, a physical therapist and a nurse /occupational therapist, and if necessary, sometimes by a psychologist

Quebeck task force low back pain Persistent back pain Specific low back pain Non specific low back pain ? 1-2% 5-10% 85-90% Specific LBP Spondylolisthesis Disc prolapse + radicular pain Degenerative disc + modic change Foraminal and central stenosis Red Flags Cancer Infection Inflammatory conditions Fractures

What underlies CLBP? Patho- anatomical Psychological Social Neuro- physiological Lifestyle Physicall Genetics Different cluster of factors contribute to each pain disorder Target the modifiable factors that drive pain and disability

Non Specific Chronic LBP Mechanical Pain BehaviourNon Mechanical Pain Behaviour Pain related movement behaviours Adaptive versus maladaptive Body Schema considerations 3 Mixed Cognitive and psychological factors Cognitive, emotional, behaviou ral Social factors Socioeconomic factors, education, relationships (home, work, peers), work satisfaction, lifestress+/- events, cultural factors Lifestyle factors Life stress, smoking, activity levels, sedentary levels, diet, BMI, sleep, ergonomic considerations, work structure Genetic/familial factors Whole-person considerations Health and pain comorbidities, vitality, perceived general health, health literacy, goals, values, readiness for change, expectations (O’Sullivan, 2012)

Cronic back pain disorders Red flagg disorders Canser Infection Inflamatory disorder Fracture Spesific back pain disordersNon-spesific back pain disorders Level 1 spondylolistesis disc herniation + redicular pain degenrative disc + modic foraminal and central stenosis Centrally mediated back painPeripherally mediated back pain Level 2 AdaptiveMal-adaptiv Dominant psycho-sosial factor Pelvic girdle pain Low back pain Level 3 Reduced force closure Excessive force closure Directional subgroups Movement impairment Controle impairment Level 4 Directional subgroups +/ - central pain modulation based on contribution of psycho-social factors Level 5 P. B. O`Sullivan, 2003

Kontroll imp. fleksjon kjennetegn: Anamnestiske kjennetegn: Gradvis smerteøkning. Smertene provoseres av aktiviteter, bevegelser eller statiske stillinger som for eksempel: sittende stilling sittende stilling sideleie sideleie foroverbøy foroverbøy løft løft sykle sykle gå i oppoverbakke. gå i oppoverbakke. Kliniske kjennetegn: Lokale segmentelle smerter Lokale segmentelle smerter Smerter ved ventral fleksjon Smerter ved ventral fleksjon Tar ut mer fleksjons bevegelse i det dysfunksjonelle bevegelses segmentet enn i tilgrensende segmenter Tar ut mer fleksjons bevegelse i det dysfunksjonelle bevegelses segmentet enn i tilgrensende segmenter Redusert evne til å kontrollere en nøytral segmentell lordose Redusert evne til å kontrollere en nøytral segmentell lordose

Kontroll imp. ekstensjon Anamnestiske kjennetegn: Gradvis smerteøkning og +/- ”stikk-smerter”. Smertene provoseres av aktiviteter, bevegelser eller statiske stillinger som for eksempel: stående stilling stående stilling sittende stilling +/- sittende stilling +/- mageleie mageleie reise seg opp fra sittende reise seg opp fra sittende rette seg opp fra foroverbøy/ løft rette seg opp fra foroverbøy/ løft å gå, løpe ( nedoverbakke) å gå, løpe ( nedoverbakke) bryst svømming bryst svømming Kliniske kjennetegn: lokale segmentelle smerter lokale segmentelle smerter smerter ved dorsal ekstensjon smerter ved dorsal ekstensjon aksentuert lordose i det aktuelle bevegelses segmentet aksentuert lordose i det aktuelle bevegelses segmentet Initierer bevegelsen i det dysfunksjonelle bevegelses segmentet Initierer bevegelsen i det dysfunksjonelle bevegelses segmentet Tar ut mer ekstensjons bevegelse i det dysfunksjonelle bevegelses segmentet enn i tilgrensende segmenter Tar ut mer ekstensjons bevegelse i det dysfunksjonelle bevegelses segmentet enn i tilgrensende segmenter Redusert evne til å kontrollere en nøytral segmentell lordose Redusert evne til å kontrollere en nøytral segmentell lordose

Korrigert holdning Vanlig holdning

Movement impairment Anamnestiske kjennetegn: Fokus på smerter Overdrevet avverge respons Tror at smertene er tegn på skade Kliniske kjennetegn: lokaliserte smerter +/- refererte smerter og ofte sekundær generalisering bevegelsesnedsettelse i samme retning som smertene oppleves avverge mot bevegelse i smerteretning retningsspesifikk (fleksjon, ekstensjon, rotasjon, lateral skift, vektbæring eller multidiretionell)

Efficacy of classification based ‘cognitive functional physiotherapy’ in patients with Non Specific Chronic Low Back Pain (NSCLBP) – A randomised controlled trial Kjartan Vibe Fersum, Peter O’Sullivan, Jan Sture Skouen, Anne Smith and Alice Kvåle Eur Journ of Pain 2013

Inclusion criteria Patients with NSCLBP Male and female Age years Localised back pain: from Th12 to lower part of gluteal folds PNRS > 2/10 and Oswestry > 14% Pain provoked by postures, movements and daily activites

Physio clinis Medical centres Back and Neck clinic Haukeland University hospital Hospital at HagavikRecruitment / Referal /Inclusion Telephone screening Cognitive Functional Therapy Randomisation Manual Therapy/Exercise Flowchart RCT study Testing/classification Inclusion N=121 Exclusion N=48 Newspaper add Withdrawn N=9 Treatment N=112

Cognitive Functional Therapy 2 manual therapists and 1 physiotherapist Cognitive behavioural principles CFT individualized according to classification 1. Cognitive model 2. Specific movement based exercise 3. Functional integration 4. Cardiovascular fitness Treatments (mean-SD): 7.7 (2.7) Manual Therapy / Exercise 3 experienced manual therapists Cognitive behavioural principles Individualised treatment from the therapists clinical decision included: -Education -Manipulative therapy -Stabilising exercises Treatments (mean–SD): 7.7 (3.1) Interventions RCT

Cognitive Functional Therapy Old wayNew way Biopsychosocial understanding Lifestyle changes Cognitive restructuring O’Sullivan 2005,2012 Functional integration In the context of a strong therapeutic relationship

From Linton, Vlaeyen 2005 Vicious cycle of chronic pain -VE BELIEFS / STRESS / FEAR PROVOCATIVE MOVEMENT PATTERNS

Disability - Oswestry P=0.164P< months postPostPre Cognitive Functional Therapy Manual Therapy

Pain intensity P=0.417P < months postPostPre Cognitive Functional Therapy Manual Therapy

Cognitive Functional Therapy Manual Therapy 31% 63% Minimally Important Change – Disability at 15 months (> 10 point change in function - ODI) Ostelo et al 2008

Minimally Important Change – Pain at 15 months (> 1.5 on pain on VAS) Cognitive Functional Therapy Manual Therapy 74% 41% Ostelo et al 2008

Sick-leave days (mean & SD) 0 CFT 1-7> 70 MT 1-7> 7 Baseline15 (29.4)13 (25.5)23 (45.1)14 (32.6)9 (20.9)20 (46.5) 15 months32 (65.3)7 (14.3)10 (20.4)16 (40.0)7 (17.5)17 (42.5)Z=2.95** ** p< 0.01 Significant difference: CFT group fewer sick days

Summary and clinical implications Cognitive Functional Therapy (CFT) resulted in superior outcomes across several dimensions (pain, function, beliefs, work absenteeism) These changes were maintained at 15 months New non published data confirm same results This supports that classification based CFT is effective in the management of NSCLBP