Sheeran , L., Hemming, R. and Sparkes , V. School of Health Care Sciences

1. Classification Based Cognitive Functional Group Therapy delivered in Group Setting (CB-CFT/G) in Non-Specific Chronic Low Back Pain: Feasibility Study Sheeran, L., Hemming, R. and Sparkes, V. School of Health Care Sciences Cardiff University, United Kingdom

2. Background • NSCLPB is a common and challenging disorder with treatments that produce long-term improvements currently unknown(Cochrane Database of Systematic Reviews, 2005-2011). • Lack of success may be due to (1) not considering NSCLBP as multi-factorial; influenced by cognitive, physical and lifestyle factors and (2) lack of multi-dimensional classification systems that direct treatments considering all important factors. • “Cognitive functional therapy (CB-CFT)”, based on bio-psycho-social classification system (CS) (O’Sullivan 2005), was developed to identify and target individual’s cognitions (beliefs, fears), spinal movements & posture and lifestyle behaviours that are considered maladaptive and pain provoking, to actively promote self-efficacy and a long term change. • Physiotherapy clinicians and managers stated that the intensive one to one input required to deliver this type of intervention may pose a barrier for implementation in today’s national health service in the UK, challenged by the limited resources (Sheeran et al 2013).

3. Aim of this study • To investigate whether CB-CFT delivered in a group setting (CB-CFT/G) is: • Feasible in primary care NHS • Can bring benefits to patients in terms of pain, disability, function, physical activity and self-efficacy • To support planning of a well defined multi-centre RCT

4. Methods • Prospective control studycompared the effect of CB-CFT/G vsbest current practice. • Inclusion criteria:NSCLBP > 8 weeks localized between T12 and buttock line, clear mechanical basis • Exclusion criteria: specific LBP (disc herniation with clear radicular nerve root symptomology, stenosis, spondylolisthesis, active rheumatology disease), non-mechanical widespread LBP, spine surgery < 3/12, malignancy, acute trauma, diagnosed with psychiatric disorder. • Primary outcome: OswestryDisability Questionnaire (ODQ) • Secondary outcomes: Visualanalogue scale (VAS), International Physical Activity Questionnaire (IPAQ), Tampa Scale for Kinesiophobia (TSK), Distress and Risk Assessment Method (DRAM), StarTBack • Statistical Tests: Independent T-test to assess between group difference in mean change scores (p<0.05).

5. StudyChart 42 patients recruited and assessed for eligibility 3 excluded for predominant yellow flags 39 fulfilled selection criteria and were offered to participate in this study 12 declined due to time commitments related to 2nd data collection N=27 consented 13 assigned to CLASTER 14 assigned to Control None lost to follow up 13 completed study 10 completed study 4 lost to follow up (no time to attend final assessment) Baseline Testing(t0) CSPI Control Post Intervention Testing (t1) I year follow-up (t2)(Jan 2014)

6. CB-CFT/G Intervention • Based on CB-CFT (Fersum 2012), modified for the UK NHS system. • Focused on: • Targeting individual’s cognitions (beliefs, fears), spinal movements & posture and lifestyle behaviours, considered maladaptive and pain provoking. • Patients mindfulness to recognize their pain as not a reflection of damage but rather a complex process where the person becomes trapped in a vicious cycle of habitual movement and lifestyle behaviours perpetuating pain and disability. • Building self-efficacy, confidence, adaptability and providing hope and opportunity for change thus enhancing self-care and stimulating self-management.

7. CB-CFT/G cont. • Group based with patients allocated into specific groups based on their classification type. • Each group targets specific movement and lifestyle behaviours with attention to the preset individual goals. • Eight 1 hour sessions over 6 weeks (2x/week on week 1 and 2 and then 1x/week for the rest), max 5-7 per group. • Four components: • Cognitive - Aiming to develop an understanding of the relationship between pain and the way patients habitually move and control their spine. • Specific movement exercises designed to normalize mal-adaptive movement behaviours as directed by the classification (lumbar control during dynamic tasks and postures). • Targeted functional integration of ADL reported as pain provoking • Physical activity programme tailored to the particular goals set by each patient (gym, walking, lifting etc).

8. Results – Subjects at Baseline

9. Results – The effect of CB-CFT/G and Best Current Practice (Control)

10. Results p<0.05* p<0.001** * * * ** *

11. Patient satisfaction and self-efficacy post CB-CFT/G and Best Current Practice (Control)

12. Conclusions • CFT/G is feasible in primary care NHS setting and appears to bring clear benefits to patients with NSCLBP. • Concurrent change of spinal movement/posture behaviour and longterm effects are currently being evaluated to aid in better understanding of the mechanisms underlying observed clinical improvements. • This study was conducted in view of planning a well designed phase II multi-centre RCT evaluating clinical and cost effectiveness of CB-CFT/G for people with NSCLBP.