Ep 284: No more CFT for chronic back pain? With Dr Henrik Bjarke Vægter

[00:00:00] I'm Claire Ardern, Editor of the APT Orthopedics Independent Study Courses, and I'm happy to announce that it's here. Current Concepts of Orthopedic Physical Therapy, the 6th Edition, is now available. This is the most rigorously peer reviewed edition yet. It's built to elevate your practice. You already know how important it is to stay current in your practice. Evidence evolves, best practices change, and your patients deserve the most up to date care you can give them. This is exactly what the 6th Edition was built for. There's 12 comprehensive sections

[00:00:30] covering every major body region from head to toe, all grounded in the latest evidence. Each section walks you through the anatomy, examination, diagnosis, and intervention, and wraps up with real-world case scenarios designed to sharpen your clinical reasoning so you can apply what you learn the moment you walk back to a clinic. Whether your patient's presentation is complex or not, Current Concepts gives you the evidence-based framework to examine more confidently, diagnose more accurately, and treat more effectively.

[00:01:01] Also, if you're preparing for your OCS exam, this is your resource your peers have relied on for years to walk into that exam ready. Visit orthopt.org to register for the 6th Edition today. When people have a high degree of trauma, anxiety, stressors in life that can be family situation, economic situation, then the arousal or the protective behavior, that's not only driven by their back pain.

[00:01:30] So that also means that changing beliefs about pain, exposing them to movement, feared movements, only address maybe a smaller part of the bigger problem. Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice.

[00:01:54] I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. The RESTORE trial published in 2023 really put Cognitive Functional Therapy, or CFT, on the map as an effective approach for managing chronic disabling low back pain.

[00:02:18] Since then, there's been more research supporting CFT, including a large network meta-analysis that was published in early 2026. Today, we're exploring the results of the CONFETTI trial, which tested a new iteration of CFT, CFT+, which is a model of combined care delivered by a physiotherapist and a psychologist in the setting of an interdisciplinary pain clinic.

[00:02:42] My guest is Dr. Henrik Bjarke-Vektor, who's an experienced physiotherapist and head of the Interdisciplinary Pain Centre at Audensure University Hospital in Denmark. He's Professor of Physiotherapy and Pain Treatment at the University of Southern Denmark's Department of Clinical Research, and he led the CONFETTI trial. Dr. Henrik Bjarke-Vektor, welcome to JOSPT Insights. Thank you very much. Our listeners will know about cognitive functional therapy.

[00:03:11] It's been on the minds of many of us in the musculoskeletal rehabilitation sphere for a while now. Today, we're here to talk about CFT, and you and the team have been doing lots of work on CFT as a model. We'll get to the results of your trial and some of the research work you've done in a moment.

[00:03:31] First, I think it's helpful, though, to set the scene and talk about what got you thinking about cognitive functional therapy and then iterating on that version, on the existing version of CFT. So we initially became interested in cognitive functional therapy because we were looking for some better ways of helping people with severe disabling chronic low back pain that we had referred to our tertiary care pain centre.

[00:03:59] These are patients who have typically been through many different treatments before they reach us and often without sufficient benefit. And they have also other complexities and comorbidities that I think we can address a little later when we're discussing the trial.

[00:04:18] We had some early clinical experience and we also did some pilot work with cognitive functional therapy back in 2017 on a select group of patients from our waiting list. And the results were quite encouraging. In that pilot study, we saw patients who made quite substantial change to their low back pain, but also disability. And sometimes also with relatively few consultations.

[00:04:45] So we thought this might be something that we could add to the treatment in the interdisciplinary pain clinic. But we also saw some important limitations. Some of the patients had quite high levels of psychological distress and also other complexities. And it was our interpretation that that made it difficult for them to engage with CFT. That was actually the starting point for CFT+.

[00:05:12] We were interested in whether we could preserve the strength of CFT, but also bring some psychological expertise into the treatment earlier for patients who needed it. You've got a particular patient population. And I think it's important to underscore you're in an interdisciplinary pain clinic, so a specialised clinic dealing with people who have been through all of the treatments and are really struggling. You mentioned CFT+, there, Henrik.

[00:05:40] Let's go to CFT+, because as we mentioned at the start, you've taken CFT and built on it. You describe it as a stepped care model of CFT that's enhanced with psychological support. Tell us about what that model looks like in practice and what adding the specific psychological support is aiming to do. It's not cognitive functional therapist with a psychologist simply added on top.

[00:06:05] So the idea of the model we tested in the CONFETTI trial is the idea is integration between the physiotherapist and the psychologist in the room with the patient at the same time to identify and address relevant factors in the moment. CFT gives us a good framework for helping people make sense of their pain, understand the interactions between cognition, emotion, bodily responses and behavior.

[00:06:33] So psychological focus is already part of the CFT approach. It is one thing to explain to somebody that they are protecting their back, raising, avoiding, being hypervigilant. And the patients we see, it's something quite different for that person to actually experience that in their own body. We think the psychologist can add something really important to that process. So that was the idea. We see psychologists here can work at different levels.

[00:07:03] An example is that something may come apparent right away in the moment in the session with the physio and the psychologist during the exposure part of the experiential. So for example, a patient may become really fearful during a movement, moving in a particular way. But it's also on a broader level. During the patient story, patients believe in themselves.

[00:07:24] We have many patients with previous trauma, anxiety, depression, or maybe the way they have learned to respond to threat in life in general. We also sometimes see there's a discrepancy between what patients tell us and what the physio and psychologist observe when they watch them move. Protective behaviors may become quite apparent. And that's where we thought the combination of the physiotherapy and the psychologist could be particularly valuable.

[00:07:53] So the psychologist may be able to identify these processes or help the physiotherapist unravel or maybe even unravel in a more safe or comfortable way than the physiotherapist may be able to do in the moment when they are exposing or testing body or movement processes here. We set it up where the physio and the psychologist was in the room together with the patient at the same time in the first couple of sessions.

[00:08:22] But we didn't necessarily think that the physio and psychologist had to be in every consultation together. We made it more flexible and say the first two sessions was with this focus. And then based on their clinical reasoning afterwards, they decided together with the patient how the remaining part of the intervention was planned. I think that's a really important point that in the beginning, at least, you have essentially three people in the room.

[00:08:50] You have the patient supported by the physiotherapist and by the psychologist. How did you originally broach that idea to bring the two clinicians together who might not necessarily have experienced working together before, Enric? Or is this different because you're in an interdisciplinary pain clinic already that it feels much more natural? I definitely think that was the reason why we believed it was possible.

[00:09:15] Because part of our everyday treatment is that medical doctors and nurses are working together in the same room with the patient at the same time. So we had some experience, but we didn't have experience with other professionals, not on a more systematic basis. We were just optimistic that, of course, this can happen. We brought together the physios and the psychologists.

[00:09:38] We ran some workshops together with Rob Schürtze from Perth, who is a psychologist and works in the CFT group there. Because we were quite aware that the hard work was to make the psychologist confident with the CFT approach. And also, in some way, make the psychologist and physiotherapist not just be in the room together at the same time, but also be able to work together and use each other's strengths at the right time.

[00:10:06] It probably turned out that this was much more difficult than we anticipated it to be. And there was also some learning process going on throughout the trial. The physiotherapists in the trial were really confident physios in CFT. They've been practicing it for many years. They had also been involved in the pilot trial we did. So they had experience with the patient population as well.

[00:10:31] It was a bit tougher for the psychologists, especially in the beginning, to figure out what is my role. Because it was not only to do psychologist work. It was also figuring out how can I support the CFT approach? How can I help the CFT approach become a success? So what are the factors that I need to address as a psychologist to make CFT work? Because it was still a CFT trial. It was not a psychologist trial.

[00:11:00] So they were struggling a bit in the beginning to figure out, because they are used to doing psychologist work to complex chronic pain patients and talk about acceptance and commitment therapy and mindfulness and stuff like that. But here they also had to take a role where they were supporting the CFT approach. So it sounds like it was a learning experience for everyone in the room, and that was an ongoing learning experience.

[00:11:27] Also a learning experience for your team as a trial group to figure out how to train people and how to provide that environment to support people to deliver the intervention in the way that you were intending it. Let's move on to the CONFETTI trial. Wonderful, catchy acronym for a trial. We love that. You compared CFT, this CFT plus intervention that you developed, to an interdisciplinary pain management program.

[00:11:55] What was the rationale for comparing those two interventions specifically? We're working in an interdisciplinary pain clinic. We see patients in the interdisciplinary pain clinic. So for us, it didn't really make sense to ask whether CFT plus was better than minimal care or a waiting list. So we wanted to know whether it could improve on what we already considered as an appropriate care pathway for this complex population.

[00:12:20] Like I said before, it is severely disabling chronic back pain patients. And they had been referred to the pain center. So we also needed to think about that. We had to offer treatment that was appropriate for this group. So we didn't really see many other good choices in terms of randomization and also in some way being able to blind patients to these different pathways.

[00:12:49] The idea was that we tested it as a step care pathway. We had an idea that CFT plus was a different approach than the interdisciplinary pain clinic, where at least historically, the focus was more on acceptance of pain and adjusting to the pain condition,

[00:13:11] where we considered CFT plus as a treatment approach that might actually be able to change people's trajectory in some way, help them reduce disability. So we thought it was two different aims of the treatment. The idea was that they started with a CFT for three months, supported by the psychologist, thus the plus. And if that was sufficient, we figured that they would not necessarily need the full interdisciplinary program afterwards.

[00:13:40] But if they needed that, they would still have an opportunity to get the pharmacological, social care, maybe even an even broader psychological approach afterwards if that was necessary. So the idea was actually to say, can starting with CFT plus provide a targeted and potentially more efficient pathway? I'm glad we talked through that rationale because it is quite complex.

[00:14:08] And you've illustrated some of the complex decisions you make when you're designing research and when you're designing a complex trial to run in an interdisciplinary pain clinic. In the CONFETTI trial, you recruited 133 patients from the interdisciplinary pain clinic. This was in Denmark and you randomly assigned them to receive, as you say, the CFT, start with CFT plus with that stepped care approach or to go straight into the interdisciplinary care model approach.

[00:14:37] What did you find? Our primary outcome was the proportion of patients who achieved an improvement of at least eight point on the respiratory disability index at 12 months. And we found that 22% of the patients who were randomized to CFT plus achieved that outcome compared with 18% in the interdisciplinary pain management group. The mean disability trajectory over time did also not differ between the two groups

[00:15:05] and we didn't see any significant between group differences for any of our secondary outcomes. So I think straightforward conclusion on the trial is that CFT plus was not superior to interdisciplinary pain management in this population. And some of our listeners might find that a bit surprising. At the start of 2026, JOSPT published a quite large network meta-analysis that looked at the effects of CFT.

[00:15:33] The network meta-analysis included data from over 10,000 patients. So it felt like certainly for me, reading that network meta-analysis alongside the results of your trial, I thought, oh, this is not what I expected. And I wonder how you all felt as well in the trial. The headline results of the network meta-analysis was CFT compared to usual care produced a large effect on reducing disability. In the CONFETTI trial, you didn't see that.

[00:16:01] So why do you think your trial results were a bit different to what we've seen in that network meta-analysis or what we've seen in other trials? Yeah, I think that's probably one of the most interesting questions right now. And I don't necessarily see that our finding from the CONFETTI and the finding from the network meta-analysis are contradictory because I think there are several important differences. The first one, I think, is that the population matters.

[00:16:31] Of course, I can only talk about the patients that we have included in our trial. And participants in the CONFETTI trial were not simply people with chronic nonspecific back pain. They are people who have reached tertiary care, pain care after multiple other treatments. And most of them had substantial psychological comorbidity and major social and life stresses.

[00:16:54] So I think that clinically, we feel that the CONFETTI population are probably much more complex than what we see in other trials. And it definitely is also more complex than what we saw in our pilot work where we recruited patients from the waiting list. One of the things we see here is that when people have a high degree of trauma, anxiety, stressors in life,

[00:17:19] that can be family situation, economic situation, then the arousal or the protective behavior, that's not only driven by their back pain or their chronic back pain. So that also means that changing beliefs about pain, exposing them to movement, feared movements, only address maybe a smaller part of the bigger problem. And I think we have learned that during the CONFETTI trial,

[00:17:48] that many of the back pain patients that were included here, there were so many other potential psychological and social stressors that complicated the intervention or at least the benefit of the intervention. Second, I also think the comparator, of course, matters here. So in the network meta-analysis of CFT, you mentioned, they compared with usual care. And in the CONFETTI trial, we compared against a more established,

[00:18:16] all-blown interdisciplinary pain management program, which I think also is a more relevant comparator for this intervention. But I also think that the fact that patients were blinded and gaining active, effective treatments in both groups, that also mirrors other comparator trials where an intervention is compared to another active treatment, that it's a different response and it's also probably a different question.

[00:18:44] We're not asking what is the effect of CFT plus compared to not doing anything. So I think that the research question is also a bit different here. The last thing that may be relevant here is also the treatment matching. I mean, it comes back to the population in some way, but there's also something about the CFT approach. It requires a certain capacity from the patient who engages in this treatment

[00:19:12] and also practicing what you are working on between session. And for patients who are also dominated by post-traumatic stress, and we also have ADHD and autism social stressors, this can be extremely difficult also to deal with this. So the lessons we have learned from CONFETTI is not saying CONFETTI doesn't work or CFT plus doesn't work in tertiary pain care.

[00:19:40] It's more about selection, timing and integration within the interdisciplinary pain program that will be where we are now. As it is, I think, for so many complex interventions, and I think we can all appreciate how complex it is to work with people who have had longstanding pain and, as you say, have got many other coexisting issues going on.

[00:20:06] Do you think it makes a difference or would make a difference to address the psychological and the social aspect first? Or this requires a different model altogether? I think that would be what we are doing in clinical practice now in an interdisciplinary pain clinic, that is to integrate CFT into the clinical work, not as a first-line treatment for this population,

[00:20:33] but an integrated part where, depending on what are the main stressors, we try to address and deal with that in the order it makes sense for the patient. And we didn't do that in the CONFETTI trial. There we had an idea that starting with CFT would be a better pathway for this group. And as I said, we didn't find that. So, Henrik, is this a case of we don't throw the baby out with the bathwater?

[00:21:02] CFT, in its various iterations, has an important place in the armory of interventions people have available to help work with people who are experiencing chronic pain. We still use CFT and CFT Plus in our pain center today, and we also are interested in getting wiser in terms of the right selection of patients, the right timing, and the right integration.

[00:21:31] I think our position now is a bit more nuanced about CFT. When we started the pilot trial and also the CONFETTI trial, we were very optimistic that this was a really, really good treatment. Now, I would say for some patients in our tertiary care pain setting, CFT seems to make a difference. And they might not have otherwise experienced that in our program. So, we still have patients who are what we would probably call a classic CFT responder,

[00:22:00] where the approach really helps people make sense of the pain situation, making sense and the exposure strategies help people change their protective behaviors and move in different ways and approach activities that they like. But the numbers are not extremely high. So, we have a very selective process now for who the physios are seeing for CFT. They see approximately 20% of patients who are referred to the pain center.

[00:22:29] And between one in five and one in seven of the patients that they see, we have this classical CFT responder effect. So, we have a lot of patients where this is not the case. But we still see some meaning in working with the CFT approach, especially the part of making sense about the complete situation, not only pain in the back, but also how different stressors are influencing on the pain situation.

[00:22:59] Sometimes that can be done by the physio alone. And in some of the more complex situations, it makes sense to add the psychologist in the room at the same time. So, we still see CFT having a potential in tertiary care pain clinic, but we probably have a more nuanced way of thinking about the role and which patients it can help. Research-wise, that's also where we are looking.

[00:23:27] We are using clinical data that we collect on all the patients we have in the clinic and also in the CFT programs. So, hopefully, we can get closer to when does it work and for whom does it work and under what circumstances does it work in the tertiary care pain center. And that's still something we are struggling with trying to understand because it is a very complex situation.

[00:23:53] I think it will really resonate with listeners that you are tackling those questions because I think they're questions that everyone working in clinical practice has. And I appreciate you bringing the nuance to this discussion, Henrik. I think that's something that people always find challenging is we, in research, we often have to study, is it this or is it that? Whereas we all recognize that clinical practice is much more complex and you've brought that complexity to the discussion today too.

[00:24:23] The nuance is so crucial. I want to say a big thanks to you and all of the team. It's a huge trial. All of our listeners will recognize that anyone delivering a clinical trial has done a huge amount of work. We're very grateful for this work. We're grateful for you adding to this discussion and how we're constantly evolving our ideas of how to best provide care for people who are living with pain. Dr. Henrik Viakvekta, thanks for joining me today on JOSPT Insights.

[00:24:53] Thank you, Claire. And thanks for the invitation. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights on Apple Podcasts, Spotify, TuneIn, Stitcher, Google or your favorite podcast app. If you like JOSPT Insights, help others find us.

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