Cognitive Functional Therapy in Physical Therapy

January 26, 2021

Traditionally, the management of lower back pain and other chronic conditions requiring long-term therapy has been approached in a unidimensional manner, with emphasis only on physical movements or exercise. Therefore, individuals who do not respond to these generalized methods may have difficulty finding a treatment tailored to their condition. Cognitive functional therapy was recently developed by Peter O’Sullivan, a musculoskeletal physiotherapist and clinical researcher, in response to this need.i 

Cognitive functional therapy aims to provide individualized care that takes into account the unique biopsychosocial background of each patient within physical therapist practice. For example, a physical therapist who practices cognitive functional therapy may consider their patient’s heredities, behavior, and socioeconomic status when considering treatment plans. This approach also allows the therapist to identify and help mitigate fears, beliefs, and behaviors that might have led to unfavorable treatment outcomes in the past. A variety of traditional psychological therapeutic techniques may be incorporated into cognitive functional therapy sessions, such as motivational interviewing, to help the client discover and internalize the drive to make positive behavioral changes. 

Though the approach to cognitive functional therapy can vary by physical therapist, there are a few key steps that are central to most practices. Patients are first evaluated through the completion of a body pain chart and multidimensional questionnaire in order to assess both physical state and the patient’s emotions surrounding pain, pain management, and their beliefs about therapy, respectively. Interviewing may then commence by giving the patient an open-ended prompt, like “tell me your story,” and then proceeding with more specific, non-judgmental questions. The physical therapist may thus  evaluate what sort of physical, emotional, and mental obstacles hinder patient progress. These obstacles can then be addressed by helping the patient better understand their own pain, initiating controlled exposure to movements or positions feared by the patient, or discussing possible lifestyle changes that lead to improved pain management (such as increased exercise).ii 

Randomized trials have shown that cognitive functional therapy has improved long-term efficacy when compared to exercise-based and manual physical therapy.iii Similarly, patients who undergo cognitive functional therapy report improved ability to both control and understand their own pain.iv These findings would suggest that cognitive functional therapy is an attractive option for patients considering physical therapy, particularly those experiencing chronic conditions that have not had success with traditional therapeutic methods. 


i O’Sullivan P (2005). Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Manual therapy, 10(4), 242–255. https://doi.org/10.1016/j.math.2005.07.001 

ii Peter B O’Sullivan, J P Caneiro, Mary O’Keeffe, Anne Smith, Wim Dankaerts, Kjartan Fersum, Kieran O’Sullivan (2018). Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain, Physical Therapy, Volume 98, Issue 5, Pages 408–423, https://doi.org/10.1093/ptj/pzy022 

iii Fersum K, O’Sullivan P, Kvåle A, Skouen J (2009). Inter-examiner reliability of a classification system for patients with non-specific low back pain. Man Ther. 14:555–561. 

iv Bunzli S, McEvoy S, Dankaerts W, O’Sullivan P, O’Sullivan K (2016). Patient perspectives on participation in cognitive functional therapy for chronic low back pain. Phys Ther. 96:1397–1407.