This transcript has been lightly edited for length and clarity.

Jason Beneciuk: Hi everybody and welcome to another podcast for PTJ. My name is Jason Beneciuk. I'm an associate editor for the journal and tonight we're really excited because we have two authors from a recent study in the journal that had to do with cognitive functional therapy. We have Lena Thiveos, a physical therapist.

Lena is a musculoskeletal physical therapist who recently completed a Master of Research in the Department of Health Science at Macquarie University in Sydney, Australia.

And then we have another author from the study, Dr. Mark Hancock. Mark's a professor of physiotherapy in the Department of Health Science at Macquarie University in Sydney, Australia as well.

Thank you, Lena and Mark, for being with us for this podcast. We're really looking forward to it.

Hancock: Thanks, Jason. Thanks for having us.

Beneciuk: I think one of the main questions I think the audience would be interested in, Lena, can you give us just a brief background, a brief description of cognitive functional therapy. What it is, I guess maybe an operational definition?

Thiveos: Yeah, of course. So cognitive functional therapy or CFT is a physiotherapist-led biopsychosocial intervention. It aims to individualize treatment and essentially teach people and coach people on how to self-manage their condition. So, it does that through three components and one of those is making sense of pain, which is almost an individualized pain education based on the person who comes in and their story.

And the second is called exposure with control, which is kind of a behavioral learning. It's graded exercise and exposure to painful or feared stimuli or activities or movements. And it's about the individual's goals and making them more confident in their daily life.

And the third is lifestyle change and lifestyle coaching.

So three components and very individualized type of care.

Beneciuk: Okay, thanks. Mark, do you have anything to add to that?

Hancock: No, I think that's a nice summary of what it is. I guess a key, Lena talked a lot about the three elements of the treatment, which I think are fundamental. The assessment's really critical to CFT as well. And I suppose one thing you could mention is that it takes longer than we typically do in normal physical therapy session.

You know, in most of the trials, the baseline assessments were probably like an hour. So to really do a thorough enough assessment to actually understand the drivers that really matter for individual people, that takes time and it takes skill as well.

Beneciuk: Yeah, I think that's a good point. So thank you for acknowledging that. So this study in particular was titled “Cognitive Functional Therapy for Chronic Low Back Pain.” It was a systematic review and meta-analysis.

The team actually included seven trials. And I think one of the important things here is, and a question I will ask both of you, is people that are familiar with some of the literature on cognitive functional therapy are aware of some other review papers that have been published. And your study included several trials. Can you talk briefly about how this review paper really differs from those prior papers?

Thiveos: Yes, certainly. And I might jump in first if that's okay, Mark. So I think that what we realized was that there were existing reviews out there on this topic.

However, we noticed that there were some limitations in those. And one of the main things that makes our paper a little different is that we were able to include three recent trials from 2023. So quite a lot of studies that came out quite recently that weren't included in some of the earlier reviews.

We also chose to exclude a couple of the papers that were included in earlier reviews. Because when we really looked at the intervention that was given, we deemed it not cognitive functional therapy based on it being group intervention or group classes. So we found that some of them were a bit contrary to the individual nature of CFT.

Beneciuk: That's a good description. Mark, was it difficult for you and your team to really make that decision? Because I know it is a challenge sometimes when we use terms, umbrella terms, if you will. And in reality, when you look at the methods and how the authors describe what they did in that study, experts in this area might, as a team, come to the conclusion that this wasn't really cognitive functional therapy. So was that a challenge for you and your team?

Hancock: Yeah, look, to be honest, it wasn't too hard. There were one or two that required a little bit of decision and primarily the one that Lena's talking about. But yeah, in the protocol, we pretty clearly set out what we were defining as CFT.

And I think that's always the key. It's just been clear and transparent about what we considered it to be. And very much it was around those three elements of the intervention that Lena described and around that individualized nature.

So it was pretty clear, to be honest, yeah.

Beneciuk: Okay, good. Yeah, I was really interested in the results.

And another component of what this study actually looked at was how other factors might be related to or improve the understanding of other factors that might impact the effectiveness of CFT. And we'll talk about that in a few minutes. But as a follow-up question to that, I guess, difficulty in operationally defining cognitive functional therapy, I'm interested to get both of your perspectives on just the term that we see out there a lot in the rehabilitation literature, physical therapy in particular, psychologically informed practice.

And I just wanted both of your opinions. Do you think something like CFT fits under the PIP umbrella, if you will?

Hancock: Yeah, absolutely. I'll take that one.

Absolutely is the answer. It's clearly a psychologically informed physical therapy. It's been developed by physical therapists over a long period of time. And it clearly taps into the importance of the biopsychosocial framework, and there's really important cognitive and psychological elements. So, it's definitely one of the interventions that falls under that umbrella.

Beneciuk: But as a clinician, still, that treats patients, do you have anything that you'd like to add to that?

Thiveos: Yeah, I think it's a really interesting issue defining these interventions. But I think that from my perspective, a lot of therapists try to practice physiotherapy within a biopsychosocial space anyway. And I think that we still need to differentiate them from interventions that are structured and you know, have their own definition and plan.

But in saying that, we all try to, or we all should try in my opinion, to be informed psychologically and keep all of those—yeah keep our scope much bigger than the individual person and their injury that comes in. So I think that's really important too.

Beneciuk: Thank you for that perspective. I think in looking at this paper, I thought one of the things that I was really impressed by is, and I agree with the authors on this, is this was probably the most comprehensive review of cognitive functional therapy to date. And the results did show promise in terms of using cognitive functional therapy as an intervention for a variety of different outcomes.

I will throw this question back to Lena in turn, and then Mark will obviously get your perspective on this too. But, I guess as a team of reviewers on this paper, you also talked about the extensive variability in the clinician training methods and how the treatment was really delivered. Can you speak a little bit about that, how that might have influenced the results of the study and also any challenges that you and your team experienced along the way in terms of making some of these decisions?

Thiveos: Yeah, I think that's such an important question and something that we were struck with as soon as we kind of piled up the evidence that we saw in front of us. So, really important to acknowledge that our review in no way could make decisions on which elements affected the results. But rather we chose to explore and describe the differences in the papers that we looked at.

So rather than making any inferences into the conclusion about this thing made a difference or that thing made a difference, we were really interested in just noting the differences and putting them all on a page, and letting clinicians and readers decide for themselves what they deem to be, you know, what they think will be important and also to inform future research.

So I think it was really great that we chose to do that. And we definitely found some variability. We found difference in the dosage of CFT. So certain studies gave more CFT sessions over a bigger period of time than others. We also noticed big differences in the way that—what the experience of the trainers actually had, we noticed that difference as well.

On that note, there were some differences in the dosage. There were some other differences in the training and the way the training was shown. And we also noticed, you know, some of the trials that were a little smaller had clinicians treating both the intervention group and the alternate group. So the same clinician delivering CFT as well as usual care or manual therapy or whatever the alternate intervention was.

So we thought that was quite interesting what, you know, biases might have come over. And, yeah, definitely not to make inferences, but just interesting to understand how the research world is choosing to, you know, teach and deliver this intervention.

Beneciuk: Yeah. Thank you. Thank you for that. There's a lot of great points that were brought up there.

Mark, I'm going to throw this one back to you based on your clinical experience, but then also, and related to this question, your experience with clinical trials. And this is a real interest for me in particular. I'm really fascinated with these studies that really involve a critical element of clinician training. And I wonder what your thoughts are related to, you know, the differences between, let's say, training for a clinician in everyday practice, as opposed to training a clinician who's participating in the trial. Challenges, differences. What are your overall thoughts about that in terms of, you know, the differences between that?

Hancock: Yeah. Wow. Jason, that's a big question. I might just go back and focus first on the trial, if that's okay. And then we can kind of expand that into clinical practice.

So, you know, Lena gave a nice description of what we did, but maybe there's a couple of things I'll just pick up that kind of take us in the direction you're talking about. So we'd all love to say, this trial had a big effect because of reason X, and this one had a smaller effect, and we'd love to be able to do that.

But ultimately, we can't do that, you know, in a review like we did. You know, there's seven trials, there's 100 differences between every trial, but we were just trying to highlight some of the ones that could be important. You and I are both interested in trials. And I think as a trialist, one of the things that's really obvious is some of these trials only have one or two clinicians. So ultimately, there's a real risk of are you testing the intervention or are you testing that trial? You know, nobody would probably be too happy if there was a trial that had one clinician, and it was Peter O’Sullivan, for example. They'd go, maybe that's not representative, you know, of these trials.

So we have to think about that thing. And, you know, we all know how hard these trials are to do. But that was something that really jumped out to me. There were trials with one clinician, two clinicians, 18 clinicians, these kinds of things.

And then this idea of competency, which again, kind of touches into where you're going. And I've become really fascinated with this. I think as a trialist, what we start with is the model of trials that worked for drugs, for example. And we've just kind of taken that model, but parts of it don't work for us.

So if you give someone a drug, you probably don't need a whole lot of skill to do that. But when you start delivering these really complex interventions, the question is, how much does the clinician skill impact on the outcomes that we see? And obviously, if we have a thousand clinicians, we get a much more average effect, you know, of the effect of those clinicians. But that's really hard to do in a trial.

So the clinician training is really interesting. So one of the things that Lena and the team kind of extracted from these trials was, was there kind of a competency check. You know, was there some kind of measure at the end of whether people had met a level, you know, of performance that you would consider at least adequate. And I think that's really interesting. I know in the RESTORE trial that I was involved in, a lot of the questions we had, you know, as we talked to people about that was around the competency training.

And I think  as a field we're interested in that we understand that training, upskilling people. We can't just presume that people can do these kind of complex interventions.

So then without going on too long, sorry, when you kind of say, what does that mean in clinical practice? That's really interesting. Because I mean, in clinical practice, you know, we want people to know about these interventions. We try to publish enough in the trials that people can pick them up and hopefully read about it and go and do something better in clinical practice tomorrow. The question is, how well will they be delivering it based on reading a trial, for example. And, you know, the resources that are around that. And that's really complex.

And, you know, some of the people involved in the Restore trial, for example, and involved in this review, have started developing training to try to upskill clinicians. Because again, we know this is complex. And, you know, I think they see it as their responsibility to kind of create better resources to train clinicians. But that needs to be at scale. And that's really complex, because obviously, one thing that was consistent across most of these trials is that there was quite a bit of training. You know, I think it was in the range of 80 hours to 100 hours, was pretty consistent across all of these studies, not just one or two.

So trying to deliver training, that's not feasible for everybody. But I think there's core elements and the plan of that team, as I understand it, is develop elements that are online for everybody, and very accessible, and then kind of further training for people that would like to explore that. So, yeah, I think there's some of the things we need to think about.

And I guess just the final point is that, you know, I teach physiotherapy students. And so, we're trying to incorporate these types of skills, you know, you don't have to call it CFT, you've set that framework of psychologically informed care. I think we think would all be a problem if we're not doing that. But I think there's some kind of core skills that seem to be coming to the surface that CFT is a really good way, a good framework for packaging that. And we are personally trying to teach some of those skills at an undergraduate level. Sorry for the long answer.

Beneciuk: No, no, Mark, I really appreciate a lot of what you said. And I think it's a really important point to emphasize that. And I look at CFT, and I look at other psychologically informed approaches as treatment approaches, right? They're not single interventions. And like you said, Mark, they are very complex. And that in itself brings a challenge to not only the training, but also the delivery. And, you know, I would go one step further and even say the assessment of fidelity. It's very challenging to do that with a very complex multi-component intervention. So I think those are points, you know, well taken. And thanks for addressing a lot of things there. That was important.

And I do, I also agree with you on the point about the core components. I think a lot of these complex packages do have core components. And, you know, I like to say we need to start somewhere in terms of educating, you know, either entry-level students or even new graduates for these complex interventions. Especially if they're shown to be effective. So, thank you for that.

I have one more question, and then I'll let you both kind of provide some closing thoughts before we end this. And Mark, you kind of touched on this a little bit in terms of the authors that were on this study. You know, a lot of them, or not a lot of them, some of them might have actually been involved with the trials themselves that were actually included in the review.

And so, my question is, was that a dilemma for your team? I didn't really look at it as a negative aspect. You know, if we have a long discussion, I could say that could have potentially been a positive aspect, because you actually are the experts in this area. And in terms of things like the operational definition, and is this a true study that assessed CFT? I think that could have actually been a strength.

But do you have any thoughts about, you know, the dilemmas for the investigators being involved with a lot of the studies that made the review?

Hancock: Yeah, another great question. I think the key here is transparency, being really clear about, you know, who was, who wasn't. And obviously, as you said, some of the team have been involved in, you know, two or three of the included studies, and I think it's clear. I do genuinely think that on balance, there's more positives that you've actually got people that really understand this area, that understand the issues in the trials, et cetera. But again, you know, we need to be transparent, and people need to understand that, and we're completely comfortable that that's explained.

You know, me personally, I've done trials of probably 15 or 20 different interventions, and I've done one trial of CFT, you know. So I think, you know, if I did a review of manual therapy, well, you know, I've got the same issue I did, you know, one trial of manual therapy. So that's kind of my perspective. But I think it's important, you know, to be really clear about that issue.

Beneciuk: Yeah, Mark, and I think you and your team were transparent in that regard. I wasn't questioning that. I think you did a really good job, and you were transparent about it. And I asked the question, because I think it's an important point for everybody to understand is the team was very transparent in that.

Hancock: And Jason, sorry, if I can just pick up, you know, I got to sit through the RESTORE training. And that's not something as a researcher, you can do you kind of, you know, running the trial, doing whatever. But I sat through and watched the training of CFT. And I must say, it's an example of if you've actually seen something, you think about it differently. That completely changed the way I thought about this.

So I used to think, for example, as a clinician that I could do this before I saw that training, I thought I was doing this. And then I watched it. And I watched really experienced clinicians just struggle. And they will tell you to a T how hard it was for them. And then to watch that development over time, really has changed the way I look at everything, to be honest, at the moment. That these issues of training and competency, and you raised fidelity.

You know, if I hadn't sat through that, I don't think I would have ever appreciated how critical they were. So I guess that's where I think, being close to it, hopefully not too close to it, but really does inform the way you look at these things, you know. And I think it's important. And a quick reflection related to that is that—and it kind of relates to your question about training, if you're looking for a good news story in a lot of this, I think it's that we found that the more recently trained clinicians actually became competent way more quickly in that study. So, you know, I think if, you know, people growing up in a biopsychosocial world of training, you know, in their undergraduate training, et cetera, these kinds of interventions are going to be much, much easier for them to pick up is our sense.

Beneciuk: Yeah, thanks again for that, Mark. And I think any of the researchers that are listening to this podcast, I remember similar experiences where either clinicians would tell me about — because a lot of times I'm delivering the training. But to have a clinician tell me about their experiences, and then to actually sit on a course, it's a totally different perspective. And it was a great experience. And like you said, Mark, it kind of reshaped how I kind of think about these things. So, great point. And I think it's a good message for others.

Lena, do you want to go ahead and start sending us off with any final comments related to this paper or anything else you want to add?

Thiveos: Yeah, just on the note about having such a wide and kind of a team that really understands this topic as a young career researcher, and a relatively young clinician. You know, I found it quite invaluable to have everyone that has seen it from different perspectives. And on that note, I was lucky enough to actually sit into some training myself when I was a clinician in my first job, actually, out of physio. And for one of the trials. So, seeing it from the clinical perspective, and then the trial perspective, and now the review perspective has been, yeah, very shaping to my perspective on all of these issues.

But also about just delivering interventions across lots of different people, lots of different clinical specialists. It's definitely a challenge, but it's a great thing to study. And it's a really interesting space that we're going into in the future. I think that our trial was really comprehensive in that sense. And that our review shows a lot of the factors that probably play into trials and clinical implementation. And hopefully, we'll let future researchers really hone in on some of these issues and, yeah, give us more information.

Beneciuk: Yeah, Lana, that's again, a great experience, especially so young in your career to be working with this group. And I think just to be involved in the study itself, that's a great experience.

Mark, how about you? You want to send us off with any final thoughts? This has been a really great conversation, and we could probably go on for another hour if we had the time.

Hancock: Yeah, thanks, Jason. Oh, look, I like to finish on a positive note. You know, I feel so much more positive than I did five or 10 years ago with the results that are coming out. And this is just one example. But, you know, there's more and more evidence that these kinds of, and CFT is one example of, good biopsychosocial care for complex pain is starting to give us the results that we wanted. And I think, you know, you can get tied down into, you know, I like this, I don't like this about the trial or the review. But ultimately, I feel we should all be feeling really positive about these types of results coming out.

And particularly that we're starting to see sustained results, I think is really exciting to me so that, you know, these reviews show the results lasting out to 12 months, for example. And that's great. You know? So I think there's a lot to be done, a lot to still understand. Obviously, the implementation challenge is important. But, you know, there's people working really hard on that. So I think it's exciting times ahead.

Beneciuk: It is exciting times. So I'm excited as well. And I think your paper is just another great example of that. So I'd like to thank you again on behalf of the journal for this contribution. I'm sure this will be a highly impactful paper. And again, thanks for all the work that you do. And thanks for joining us for this podcast.

Hancock: Thanks, Jason. Enjoyed it.

Thiveos: Thanks, Jason.

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