CARROLL UNIVERSITY

Doctor of Physical Therapy Program

Critically Appraised Topic

EFFICACY OF COGNITIVE FUNCTIONAL THERAPY IN THE MANAGEMENT IN

CHRONIC LOW BACK PAIN
Clinical Scenario:
Patient is a 50 yo male with low back pain for the previous 9 months, especially during lifting or bending activities. Squatting and
crawling on the floor are especially painful. He is a grandfather of an 8 month old girl and a 2 year old boy. He continues to try to
play with his grandkids whenever he gets a chance, but the pain is making it more and more difficult. He has been diagnosed with
chronic low back pain, one physician considered it related to disc degeneration while another did not. The patient would like to go
back to playing with his grandkids on the floor and picking them up without intense pain as soon as possible.

Clinical Question:
In a 50 y/o male with chronic low back pain lasting the last 9 months, does Cognitive Functional Therapy (CFT) reduce functional
disability as measured by the Oswestry Disability Index?

Clinical Bottom Line:

Yes, in the current research, it is indicated that CFT is an effective treatment in reducing functional disability in patients with CLBP.
CFT also has been shown to maintain these improvements long-term (at 12 months). CFT is a comprehensive intervention that
involves a biopsychosocial approach to the management of pain as well as movement re-education.

Refresh Date: 6/29/2019

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated:
Search Methodology: (This section should include enough detail to make the search repeatable)
Search Resources Search Terms Limits # of Articles
PubMed (CFT or "cognitive functional None 8
1 therapy") and (disability or "oswestry
disability index") and (low back)
CINAHL (CFT OR cognitive functional therapy) None 7
AND (disability OR oswestry
2
disability index) NOT compassion
AND low back
MEDLINE (CFT OR cognitive functional None 8
therapy) AND (disability OR
3
oswestry disability index) NOT
compassion AND low back
PsycINFO (CFT OR (Cognitive functional None 18
therapy)) AND (disability OR
4
(oswestry disability index )) AND
(low back )

Search Results Summary:

Results Reasons for Inclusion Reasons for Exclusion # of Articles
Included
-Case Series (1) -None -Study Protocol 5
-Case Report (3) -Adolescent
-Cross Sectional Qualitative (1) -Lower Limb Impairment
1
-Study Protocol for RCT (1)
-Multiple Case Cohort (1)
-RCT (1)
-Case Series (1) -None -Previously Cited 0
-Case Report (3) -Adolescent
2 -Cross Sectional Qualitative (1) -Lower Limb Impairment
-Multiple Case Cohort (1)
-RCT (1)
-Case Series (1) -None -Previously Cited 0
3 -Case Report (3) -Study Protocol
-Cross Sectional Qualitative (1) -Adolescent
Author(s): Andrew Johnson Date Created: 6/29/2018
Reviewer(s): Date Updated:
 -Study Protocol for RCT (1) -Lower Limb Impairment
-Multiple Case Cohort (1)
-RCT (1)
-Review (1) -None -Previously Cited 0
-Clinical Trial (2) -Correlational Study
-Handbook (2) -Cognitive Behavioral Therapy
-Cross Sectional Qualitative (1) -Functional Restoration
-Study Protocol (1) -Sleep
-Editorial (1) -Operant Behavioral Therapy
-RCT (5) -TENS
4
-Correlational Survey (2) -Chiropractic Intervention
-Empirical (3) -Integrated Care Program
-Review
-Handbook
-Editorial
-Mindfulness Based Functional
Therapy

Research Participant and Study Characteristics:

Reference Participant Key Clinical Control Intervention Experimental Level of
Characteristics (frequency/duration) Intervention/Interview Evidence
(frequency/duration)
Bunzli et al., 2016 -CLBP (6-456 months) -No control was used -CFT from trained PT Level 4
-Undergone CFT -Purposive sampling of -Interviews were conducted 3-
-Adult (22-61 y/o) patients who underwent CFT 6 months post-CFT
-6 M and 8 F -Qualitative design to assess -Semi-structured questions
-ODI outcomes post CFT feelings towards CFT were used to assess impact of
(no improve, large improve, intervention
small improve) -Questions were open-ended
and allowed participant to
respond freely
Meziat, 2016 -CLBP (4 months) -No control -CFT Level 4
-Adult (32 y/o) -12 sessions in 40 days

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated:
 -Female
-Flexion Pattern of
Movement
O’Sullivan et al., -CLBP (2-43 yr)
2018 -Adult (26-64 y/o)
-Had tried multiple
interventions prior to CFT
-No relief from prev.
interventions
• Exercise,
acupuncture,
chiropractic manip,
etc.
-2 Men and 1 Female
O’Sullivan et al., -CLBP of > 6 months
2015 -Low back was primary
location
-Reduced activity as result
of CLBP
-Adult (18-65 y/o)
-No evidence of spinal
pathology
-Pain was aggravated with
motion/posture
Fersum et al., 2013 -CLBP > 3 months
-Pain present from
T12Gluteal Folds
-ODI > 14%
-Pain > 2/10
Author(s): Andrew Johnson
Reviewer(s):
-Study was a case report of
one individual receiving CFT
-Study was a review of CFT -CFT Level 4
as well as a case series -28 y/o M (8 sessions in 3
-The case series included 3 months)
participants and their -64 y/o M (5 sessions in 3
outcomes associated with CFT months)
-26 y/o F (3 sessions in 3
months)
-Study was a case cohort -CFT Level 3
design -Phase B
-Control was used to attain -Minimum duration of 6
baseline measurements weeks
-Phase A1 -7.7 Average # Sessions
-Lasted 3 months at onset of -Outcomes were measured at
study conclusion of phase
-3 baseline interviews were -Phase A2
performed 6 weeks apart -Expectation of performing
therapy on their own over 12
months
-Follow ups at 3, 6, 12 months
-Manual Therapy and -CFT Level 1
Exercise -1x/week for 3 weeks
-8 session on average -Every 2 weeks for next 9
-MT was at the discretion of weeks
PT
Date Created: 6/29/2018
Date Updated:
 -Pain provoked with -Motor control therapy was
posture, movement and targeted around the abdominal
activities muscles

Outcomes:
Reference Event/Outcome Time to Mean (SD) ES &/or
(may have more than one per Event Control Group Experimental Group NNT
reference)
Meziat, 2016 Pain (VAS) 0 wks N/A 4/10 -Unable to
12 wks N/A 1-2/10 calculate with
Functional Disability (ODI) 0 wks N/A 42% a sample size
12 wks N/A 14% of 1
PT Observation/Subjective 0 wks N/A -Fear of lifting, bending, -This is due to
sitting the study
-Palpable co-contraction being a case
of Erector Spinae and Abs report
-Flexion movement
pattern
2 wks N/A -Bend normally (no co-
contraction)
-30 minute walks daily
-Sit for 20 minutes
6 wks N/A N/A
12 wks N/A -Return to Work
-1 Hr walking daily
Fersum et al., Functional Disability (ODI) 0 wks 24, (16-32) 21.3, (13.8-28.8) -ES: d = .92
2013 Measured in % 3 months 18.5, (10.4-26.6) 7.6, (.9-14.3) -This
95% CI Provided 12 months 19.7, (8-31.4) 9.9, (.1-19.7) represents a
large effect
size at 12 mo.
Pain (VAS) 0 wks 5.3, (3.4-7.2) 4.9, (2.9-6.9) -ES: d = .73
95% CI Provided 3 months 3.8, (1.9-5.7) 1.7, (0-3.4)
Author(s): Andrew Johnson Date Created: 6/29/2018
Reviewer(s): Date Updated:
 12 months 3.8, (1.7-5.9) 2.3, (.3-4.3) -This
represents a
medium effect
size at 12 mo.
O’Sullivan et al., Functional Disability (ODI) A1 0 weeks 42, (26-51) -ES: d = .85
2015 Measured in % A1 6 weeks 42, (26-53) -This is a
A1 12 weeks 42, (22-51) larger effect
B 0 weeks 19, (8-35) size
A2 3 month 17, (8-38)
A2 6 month 17, (8-37)
A2 12 month 16, (10-41)
Pain (numerical rating scale) A1 0 weeks 5, (3-7) -ES: d = .65
A1 6 weeks 5.5, (3.5-7.5) -This is a
A1 12 weeks 5, (3-7) medium effect
B 0 weeks 3.5, (1-6) size
A2 3 month 3.6, (1-6.2)
A2 6 month 3.6, (.8-6.5)
A2 12 month 3.5, (.7-6)
Themes Time of Subthemes Demographic
Interview Information
Bunzli et al., -Changing Pain Beliefs 3-6 months -Pain Beliefs -57% Female
2016 • Strong biomedical post-CFT • Therapeutic Alliance-building a trusting -Mean Age:
belief as source of pain relationship b/t PT and pt. 42
• Acceptance of o Decreased disability and pain -Mean CLBP
biopsychosocial model was linked to a stronger alliance Duration: 9
improved pain • Body Awareness-new perspective of yrs
-Achieving Independence self both physically and mentally
• Experiencing Pain Control-whether or
not control was felt reaffirmed their
beliefs on CFT
-Achieving Independence

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated:
 • Problem Solving/Self-Efficacy-
understanding of pain and ability to
control in the future
• Fear-less fear was reported when they
understood their pain and felt control
• Stress Coping-coping mechanisms
helped diminish stress which led to
decreased pain
• Normality-increased confidence in
control of pain allowed participants to
feel “normal” again

Subjective Reports Post-CFT Time of Biopsychosocial Factors of CLBP Primary

Interview Average Change Post-CFT Aims of CFT
O’Sullivan et al., -“I don’t fear my back/pain” -Conclusion -Reductions indicate improvements in each area -Make sense
2018 -“I have control over my pain” of final associated with perception, acceptance or of pain
-Not seeking care anymore for session coping ability with their pain -Develop
pain -Scores were graded by researcher on their positive
-Increased self-efficacy and impact they had on CLBP coping
positive coping strategies -Scores were out of 10 strategies for
-Increased activity level -Cognitive: -7 pain
-Emotional: -6 -Adopt
-Physical: -7 healthy
-Pathoanatomy: -2 lifestyle
-Lifestyle: -4.7 behaviors
-Social: -2
-Sensory: -5
-Health: -1.7

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated:
Key Findings

➢ Breadth: There is a lack of evidence examining the efficacy of CFT in the management of CLBP.
o The evidence available is of lower quality due to lack of randomization and control consisting of levels 3, 4.
o The primary designs are case series and cohort studies. However, with the preliminary effectiveness of CFT, the utilization of a large-
scale RCT is not far off.
➢ Flaws: The main concern is the lack of participants included in all of the studies. Another limitation is a lack of true control group in order to
compare CFT against.
➢ CFT has been shown to significantly reduce functional disability post-intervention.
o CFT also has the potential to maintain these improvements long-term.
➢ Limitations of CFT: Require extra PT training, requires strong PT-patient alliance in order for long-term behavioral change.

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated:
References:

Bunzli S, Mcevoy S, Dankaerts W, Osullivan P, Osullivan K. Patient perspectives on participation in cognitive functional therapy for
chronic low back pain. Physical Therapy. 2016;96(9):1397-1407. doi:10.2522/ptj.20140570.

Meziat Filho N. Changing beliefs for changing movement and pain: Classification-based cognitive functional therapy (CB–CFT) for
chronic non-specific low back pain. Man Ther. 2016;21:303-306.

O’Sullivan PB, Caneiro JP, O’Keeffe M, et al. Cognitive functional therapy: An integrated behavioral approach for the targeted
management of disabling low back pain. Physical Therapy. 2018;98(5):408-423. doi:10.1093/ptj/pzy022.

O'Sullivan K, Dankaerts W, O'Sullivan L, O'Sullivan PB. Cognitive functional therapy for disabling nonspecific chronic low back
pain: Multiple case-cohort study. Phys Ther. 2015;95(11):1478-1488.

Vibe Fersum K, O'Sullivan P, Skouen J, Smith A, Kvåle A. Efficacy of classification‐based cognitive functional therapy in patients
with non‐specific chronic low back pain: A randomized controlled trial. European journal of pain. 2013;17(6):916-928.

Author(s): Andrew Johnson Date Created: 6/29/2018

Reviewer(s): Date Updated:
Article Appraisal Summary: Original Research

Article Title: Cognitive functional therapy: An integrated behavioral approach for the targeted management of disabling
low back pain.

Author(s): Peter O’Sullivan, J.P. Caneiro, Mary O’Keefe, Anne Smith, Wim Dankaerts, Kjartan Fersum, Kieran O’Sullivan

Journal, Year, Volume/Issue, Pages: Physical Therapy. 2018;98(5):408-423.

PICO Question: In a 50 y/o male with chronic low back pain lasting the last 9 months, does Cognitive Functional Therapy
(CFT) reduce functional disability as measured by the Oswestry Disability Index?

Study Clinical Traditional approaches in the management of chronic LBP have not yielded desirable
Problem/Background results as health care costs, disability and pain are all on the rise. LBP is also one of the
leading causes of disability.
Hypothesis/Purpose/Aims Help patients with chronic LBP understand pain in their own context and develop a
management plan. Observe the effects of CFT on function.
Intervention/Indicator Intervention of Interest

Independent variables CFT

Levels None

Dependent variables Fear, Disability, Pain (subjective data)

Levels None

Study design Review and Case Series

Subjects Adults with chronic LBP

Sample Size 3

Inclusion criteria Chronic LBP

Exclusion criteria None, case series

Subject selection Outpatient PT in Australia

Threats to Validity Hawthorne Effect

Statistical Analysis Pre-post subjective interview questions

 Results Case 1: loss of fear, RTW, physically active, sleep normalized, positive coping strategies
Case 2: no fear of pain, self-efficacy, confidence, physically active, minimal pain/disability
Case 3: decreased pain, no fear of pain, restoration of ADL

Study Author’s Conclusions: Do not copy-paste. Create a summary of the authors’ conclusions
CFT has been shown to be superior in the management of chronic LBP as compared to traditional medicines. CFT has
shown qualitative data to decrease pain, decrease fear, decrease disability and increase self-efficacy over pain.

Your interpretation: What conclusions did you draw from the results and conclusions?
A biopsychosocial approach is beneficial to those who experience chronic LBP. It provides them with positive strategies
to cope with the pain.

Study Quality: Describe factors about the study that would increase or decrease its quality and how confident you are in
its findings.
The study was very well performed in a qualitative sense. However, due to it being a case series its level of evidence is
low. That being said, there was very good information that showed the efficacy of CFT.

Applicability to PICO Question: How does the information in the study specifically apply to your PICO question? How can
you make a connection between the study results and the question you are trying to answer?
This article included males in the age group of my patient. It is also included the intervention but did not include the
outcome of utilization of the ODI.
Article Appraisal Summary: Original Research

Article Title: Cognitive functional therapy for disabling nonspecific chronic low back pain: Multiple case-cohort study.

Author(s): O'Sullivan K, Dankaerts W, O'Sullivan L, O'Sullivan PB

Journal, Year, Volume/Issue, Pages: Physical Therapy. 2015;95(11):1478-1488.

PICO Question: In a 50 y/o male with chronic low back pain lasting the last 9 months, does Cognitive Functional Therapy
(CFT) reduce functional disability as measured by the Oswestry Disability Index?

Study Clinical Chronic LBP is a costly debilitating disease with effective treatments remaining hidden.
Problem/Background

Hypothesis/Purpose/Aims To provide information about the efficacy of CFT in a case cohort format in order to set a
basis for a RCT. .
Intervention/Indicator Intervention of Interest: CFT

Independent variables CFT

Levels None

Dependent variables Pain and Functional Disability

Levels VAS and Oswestry Disability Index

Study design Case Cohort

Subjects Adults with CLBP

Sample Size 26

Inclusion criteria Age 18-65, independently mobile, capable of performing exercise, LBP was exacerbated
by changes in motion,
Exclusion criteria Spinal pathology, pregnant, neurological issues, pain-relieving medical procedure in last 3
months.
Subject selection Medical Consultant Clinics in Ireland

Threats to Validity Maturation Effect

Lack of Blinding

Statistical Analysis Pre and Post Intervention using Paired T-Test and Wilcoxon Signed Rank
 Results Pain and Disability were significantly reduced at 12 month follow up. No difference was
found in activity or posture.

Study Author’s Conclusions: Do not copy-paste. Create a summary of the authors’ conclusions
Patients receiving CFT had significant reductions in both pain and functional disability at 12 months post intervention.
The efficacy for use in debilitating LBP should be assessed in a RCT.

Your interpretation: What conclusions did you draw from the results and conclusions?
CFT shows some good efficacy in the management of CLBP especially at 12 month follow up. It is an intervention to
consider in the management of CLBP. There was shown no side effects but CFT does require excess training in order to
perform.

Study Quality: Describe factors about the study that would increase or decrease its quality and how confident you are in
its findings.
Lack of blinding and a control limit the overall quality of the research. However, the study was well performed and the
information can be utilized clinically.

Applicability to PICO Question: How does the information in the study specifically apply to your PICO question? How can
you make a connection between the study results and the question you are trying to answer?
This study helps to answer the population, intervention and outcomes.
Article Appraisal Summary: Original Research

Article Title: Changing beliefs for changing movement and pain: Classification-based cognitive functional therapy (CB–
CFT) for chronic non-specific low back pain.

Author(s): Filho N. Meziat

Journal, Year, Volume/Issue, Pages: Manual Therapy, 2016, 21, 303-306

PICO Question: In a 50 y/o male with chronic low back pain lasting the last 9 months, does Cognitive Functional Therapy
(CFT) reduce functional disability as measured by the Oswestry Disability Index?

Study Clinical Low back pain is one of the most common causes of disability in the world. Most
Problem/Background interventions focus on anatomical and biomechanical issues while no intervention is
superior to another.
Hypothesis/Purpose/Aims Present the effect of CFT in a patient experiencing chronic LBP.

Intervention/Indicator Intervention of Interest (Case Report)

Independent variables CFT

Levels None

Dependent variables Pain and Function

Levels VAS for pain

ODI for Function

Study design Case Report

Subjects Adults with chronic LBP

Sample Size 1

Inclusion criteria Patient presented with chronic LBP

Exclusion criteria None, case report.

Subject selection Brazilian Outpatient Physical Therapy Clinic

Threats to Validity Hawthorne Effect

Multiple Treatment Interference

Statistical Analysis Pre/Post Interviews on pain and function. Qualitative data was also collected to verablize
the patient’s feelings.
 Results Initial: 4/10 pain. 42% on ODI. Flexion pattern of movement. Unable to sit more than 10
minutes. Fear of lifting/bending.
14 Days: Seated for 20 minutes. Normal movement observed when bending over.
40 Days: 1-2/10 pain. 14% ODI. Return to work.

Study Author’s Conclusions: Do not copy-paste. Create a summary of the authors’ conclusions
In this case report, CFT was utilized effectively to treat non-specific chronic LBP. It decreased pain levels, greatly reduced
functional disability and also helped to remediate the fear that future movement would increase the damage in the
intervertebral disc.

Your interpretation: What conclusions did you draw from the results and conclusions?
CFT can be a useful intervention when working with patients with chronic LBP. Through education about pain we can
help to lower the pain experienced. However, the most important aspect was the reduction in functional disability which
ultimately allowed the patient to return to work.

Study Quality: Describe factors about the study that would increase or decrease its quality and how confident you are in
its findings.
The study is a case report with 1 subject so it is fairly low evidence. However, the information was provided in a way that
explained the intervention clearly. It is a good starting point for the implementation of a larger RCT investigating CFT.

Applicability to PICO Question: How does the information in the study specifically apply to your PICO question? How can
you make a connection between the study results and the question you are trying to answer?
It applies to the adult population, intervention and outcomes, however, the participant was female.
Article Appraisal Summary: Qualitative

Article Title: Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain.

Author(s): Samantha Bunzli, Sarah McEvoy, Wim Dankaerts, Peter O’Sullivan, Kieran O’Sullivan

Journal, Year, Volume/Issue, Pages: Physical Therapy, 2016, 96(9), 1397-1407

PICO Question: In a 50 y/o male with chronic low back pain lasting the last 9 months, does Cognitive Functional Therapy
(CFT) reduce functional disability as measured by the Oswestry Disability Index?

Study Clinical Chronic low back pain (CLBP) is a very common diagnosis that causes distress and
Problem/Background disabilities. Many factors including biological, psychosocial, behavioral and lifestyle factors
play a role in CLBP.
Objective(s) Investigate the patients’ experiences with CFT in order to yield information about the
implementation of this intervention.

Qualitative Design Non-Interventional Cross-Sectional Qualitative Design

Subjects Australian/Irish Adults with CLBP

Sample Size 14

Inclusion criteria Participated in a CFT intervention, CLBP, Oswestry Disability Outcomes

Exclusion criteria None listed. Purposive sampling was employed.

Subject selection Ireland and Australia

Data Collection One-on-one interviews were conducted. Semi-structured questions were asked including
(circumstance of CLBP, CLBP impact on life, and prior interventions). Follow up questions
were asked in regard to CFT.
Data Analysis Coding was performed by two authors and a process of constant comparative analysis was
employed. Participants were split into groups (large/small improvers and no change).

Major Themes Changing Pain Beliefs, Achieving Independence

Results/Interpretation Changing beliefs: therapeutic alliance, body awareness and pain control
Independence: problem solving/high self-efficacy, fear, stress coping and normality

Study Author’s Conclusions: Do not copy-paste. Create a summary of the authors’ conclusions
The success of CFT is highly dependent on the patient’s ability to adopt the biopsychosocial approach and to self-
manage their pain.

Your interpretation: What conclusions did you draw from the results and conclusions?
CFT is a useful treatment when looking at the changes in Oswestry Disability Index scores from pre and post
intervention. The themes identified in this study contribute much to the understanding of the mechanisms underlying
the improvements. A common theme amongst CFT is the ability of the patient to understand that the pain they are
feeling is not from damage, but rather, their system in another form. It is important to address independence and buy-in
to the biopsychosocial model if you want to see the most impact from CFT therapy.

Study Quality: Describe factors about the study as a whole that would increase or decrease its quality, how confident you
are in their results and how well those results would apply to the general population of interest.
Overall, the study was well conducted as was performed until no more themes were generated. However, the
participants included may not be wholly representative of the population in general. The study was of high quality and
addressed many limitations as well as providing insights for clinicians.

Applicability to PICO Question: How does the information in the study specifically apply to your PICO question? How can
you make a connection between the study results and the question you are trying to answer?
The article relates to my population, intervention and outcome. This makes this article a useful tool in treatment of the
patient.
Article Appraisal Summary: Original Research

Article Title: Efficacy of classification‐based cognitive functional therapy in patients with non‐specific chronic low back
pain: A randomized controlled trial

Author(s): Vibe Fersum K, O'Sullivan P, Skouen J, Smith A, Kvåle A

Journal, Year, Volume/Issue, Pages: European journal of pain. 2013;17(6):916-928.

PICO Question: In a 50 y/o male with chronic low back pain lasting the last 9 months, does Cognitive Functional Therapy
(CFT) reduce functional disability as measured by the Oswestry Disability Index?

Study Clinical CLBP is a common disabling diagnosis that has limited treatments for the effective long
Problem/Background term management.

Hypothesis/Purpose/Aims Aim: investigate the efficacy of CB-CFT compared with manual therapy and exercise (MT-
EX) for the management of NSCLBP.
Hypothesis: that a person-centred classification-based cognitive functional approach to
management of NSCLBP disorders would be more effective than MT-EX approach.
Intervention/Indicator Intervention of interest

Independent variables Treatment

Levels Manual Therapy/Exercise, CFT

Dependent variables Pain, Functional Disability

Levels FABQ, Hopkins Symptoms, Lumbar ROM, Satisfaction, sick leave days, care-seeking

Study design RCT

Subjects Adults with CLBP in Norway

Sample Size 94

Inclusion criteria age between 18 and 65 years, diagnosed with non-specific chronic low back pain for >3
months, localized pain from T12 to gluteal folds, provoked with postures, movement and
activities
Exclusion criteria were continuous sick-leave duration for >4 months, as it was considered that specific
work-related intervention would have been required, acute exacerbation of LBP at time of
testing in order to avoid regression to the mean, specific LBP diagnosis (radicular pain,
disc herniation, spondylolisthesis, stenosis, Modic changes), any low limb surgery in the
last 3 months, surgery involving the lumbar spine, pregnancy, diagnosed psychiatric
disorder, widespread constant non-specific pain disorder, pain without a clear mechanical
behaviour, active rheumatologic disease, progressive neurological disease, serious cardiac
 or other internal medical condition, malignant diseases, acute traumas, infections or
acute vascular catastrophes.
Subject selection Physiotherapy Clinic in Norway

Threats to Validity Maturation effect

Statistical Analysis Paired T-Test of pre and post outcome measures

Results Both groups showed significant improvements however, CFT had larger
statistically/clinically significant value. There was a decrease in both pain/disability as
well as secondary outcomes.

Study Author’s Conclusions: Do not copy-paste. Create a summary of the authors’ conclusions
CFT showed more significant changes in short term and long term effects in the management of CLBP.

Your interpretation: What conclusions did you draw from the results and conclusions?
CFT is a useful strategy that can be used to manage symptoms of CLBP in the long-term.

Study Quality: Describe factors about the study that would increase or decrease its quality and how confident you are in
its findings.
Contained a comparison group, however no control group of no treatment was included. The study was of good quality
and has future use clinically.

Applicability to PICO Question: How does the information in the study specifically apply to your PICO question? How can
you make a connection between the study results and the question you are trying to answer?
It contains information that is pertinent to my population, intervention and outcome.