Training clinicians to competently deliver Cognitive Functional Therapy
How do we train physiotherapists to competently deliver best care for people with low back pain?
Traditionally, physiotherapists’ training has focussed on developing competencies in practical skills such as examination techniques, manual therapy treatments and exercise prescription, in order to provide care for people with low back pain disorders. This has been driven by a predominant biomechanical understanding of low back pain combined with a management approach primarily focused on symptom reduction without necessarily addressing the underlying causes [1-3].
Over recent years there has been a shift to understanding of low back pain being a result of a complex range of interacting biopsychosocial factors, unique for each person (Figure 1).
Figure 1. Multidimensional factors associated with resilience and vulnerability to disabling low back pain.
From "Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain". By O'Sullivan et al., 2018, Physical Therapy, 98(5), p.410. (https://doi.org/10.1093/ptj/pzy022). Copyright 2018 by the authors (Creative Commons).
Addressing these factors demands a broader set of skills and competencies than typically taught. Once serious pathology is excluded, best care guidelines call for clinicians to screen, explore and target the biopsychosocial barriers to recovery and identify and support the resilience factors in patients with low back pain. They also call for care to be person-centred, with the need to educate people about their pain and promote effective self-management of their condition [5-7]. Despite these recommendations many clinicians report they don’t have the skills or confidence to deliver this type of care [1-3]. Even when clinicians report delivering care within the biopsychosocial framework it is often not visible when observing their practice [8,9].
This broader range of skills and competencies include:
Skills in person-centred communication and care,
Skills to sensitively screen, explore and target personally relevant drivers of pain and disability, such as a patient’s beliefs, emotional and behavioural responses to pain,
Behaviour change techniques to help promote a positive mindset about pain and the body, upskill people to self-manage their condition and adopt a healthy lifestyle.
What can we learn about training physiotherapists in psychologically informed care?
A recent scoping review  investigated the training of physiotherapists to deliver individualised biopsychosocial interventions for people with musculoskeletal pain in clinical trials. It identified that current training described in trials was associated with inadequacies in reporting, training, competency assessment, and fidelity checking.
The paper concluded:
“The findings highlight why previous interventions could have shown small effect sizes and point to areas for improvement in future interventions.
These findings can help inform future research and facilitate more widespread implementation of physical therapist–delivered biopsychosocial interventions for people with musculoskeletal pain and thereby improve their quality of life.”
What we have learnt from our previous research?
Our team has been developing an intervention over the past two decades that addresses the multifactorial nature of low back pain in a person-centred way. The result, Cognitive Functional Therapy, is a form of psychologically informed physiotherapy, developed for individualising care for people with disabling chronic low back pain . One small trial in rowers with chronic low back pain demonstrated efficacy over usual care . In this trial one physiotherapist trained to competency delivered Cognitive Functional Therapy. Two other trials of Cognitive Functional Therapy demonstrated efficacy of Cognitive Functional Therapy over manual therapy and exercise [13,14] and group education and exercise . Both trials involved the training of three physiotherapists to competently deliver Cognitive Functional Therapy. This involved training in knowledge, skills and direct mentoring while treating patients with disabling low back pain over a 5-6 month period (average 100 hours of training). One other trial of Cognitive Functional Therapy  conducted by another group did not demonstrate long term efficacy of Cognitive Functional Therapy compared to core exercise and manual therapy. In this trial Cognitive Functional Therapy was delivered by one new graduate physiotherapist, and there was a lack of reporting of competency assessment or treatment fidelity.
Our next question was: can we scale up training to larger groups of clinicians?
We conducted a brief training of Cognitive Functional Therapy in a group of 23 Finnish physiotherapists . This involved 7-days of lectures, patient demonstrations and basic communication skills training. However, there was NO direct mentoring and training with patients with low back pain.
While there was evidence that this training could improve physiotherapists’ use of validating communication , we found that this training was NOT perceived by the physiotherapists in the training program as sufficient for the development of competency for physiotherapists to deliver Cognitive Functional Therapy for people with chronic low back pain . The Physiotherapists who underwent the training identified the need for additional support and mentoring when trying to implement Cognitive Functional Therapy in their clinical practice. This work highlighted to us that time constrained training without direct mentoring and feedback with patients is unlikely to result in physiotherapists developing competency in Cognitive Functional Therapy.
In contrast, Cowell and co-workers  implemented a comprehensive 10-month training program with 10 physiotherapists, with the aim of developing competency in Cognitive Functional Therapy. This program consisted of formal educator-based training to develop knowledge and awareness of multidimensional causal pain mechanisms for low back pain, effective communication practice and targeted interventions for low back pain patients using Cognitive Functional Therapy. This was followed by skills training and one on one mentoring sessions while the physiotherapists treated patients in their own work environment. Following training physiotherapists reported changes in communication and clinical skills and confidence to manage patients with low back pain. Physiotherapists demonstrated in their clinical encounters, patient-focused style of communication demonstrated by a collaborative and responsive style of verbal and nonverbal communication to solicit, explore, and validate patients’ concerns .
This research, combined with current understanding from implementation studies about the best methods for training physiotherapists guided us in planning the training for the RESTORE trial.
Road map for training of competency in physiotherapists
in clinical trials
Our recent scoping review proposed a comprehensive roadmap for planning and reporting training physiotherapists to deliver biopsychosocial interventions in clinical trials .
Figure 2. Roadmap for training physiotherapists to deliver biopsychosocial interventions in clinical trials
What did we do in the
In contrast to our previous trials of Cognitive Functional Therapy that used a small number of trained physiotherapists, we wanted to investigate whether a large group of physiotherapists could be trained to competently deliver the intervention, improving external validity of the findings. Therefore, we recruited 18 physiotherapists to undergo training in Cognitive Functional Therapy to provide care in RESTORE trial. We adopted the road map proposed by Simpson et al., (2021) , in training the physiotherapists across two cities. The following outline shows how we used the roadmap for training.
Step 1: Defining the intervention
Content and components:
Cognitive Functional Therapy  involves:
Individualised person-centred care 
Alignment to best care guidelines [5-7]
Screens for serious pathology (e.g. cancer, infection, fracture, corda equina)
Screens for biopsychosocial barriers for recovery
Facilitates a person’s understanding about their condition, prognosis and best management
Targets care towards biopsychosocial barriers to recovery
Promotes self-management including pain exacerbation plans
3. Use of a multi-dimensional clinical reasoning framework to help
physiotherapists negotiate clinical complexities and identify modifiable targets
for care (Figure 3).
Cognitive Functional Therapy has three key foci:
Making sense of Pain
Guiding a re-conceptualisation of pain from a biopsychosocial perspective through the lens of the patients own story and experiences.
Exposure with Control
Guiding pain and movement control strategies to build confidence for people to re-engage in valued activities (physical, work, social etc).
Promoting positive physical, social and psychological health.
Figure 4. Interplay of clinician- and patient-specific factors in the clinical journey with cognitive functional therapy.
From "Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain". By O'Sullivan et al., 2018, Physical Therapy, 98(5), p.419. (https://doi.org/10.1093/ptj/pzy022). Copyright 2018 by the authors (Creative Commons).
Figure 3. Radar graph outlining the multidimensional profile of a case before and after the cognitive functional therapy (CFT) intervention.
From "Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain". By O'Sullivan et al., 2018, Physical Therapy, 98(5), p.417. (https://doi.org/10.1093/ptj/pzy022). Copyright 2018 by the authors (Creative Commons).
Up to 7 sessions over 3 months, and a booster session at 6 months.
We added the booster session, as we had found that in previous trials with quite disabled populations [15, 20], there was some reduction in treatment effect after 6 months. This also reflects best practice care for people with chronic health conditions who may require some ongoing support.
The consultations were longer than normal physiotherapy consultations to allow for in-depth interview, examination and management planning (1 hour initial consultation and 30-45 minute follow-up consultations).
Scope of practice
We included patients with disabling chronic low back pain where serious pathology had been excluded. Unlike many previous trials we included people with high levels of pain, distress and disability, people over 65 years of age and those with previous spine surgery, mental health challenges and other health comorbidities.
Step 2: Training to Competency
Two expert trainers credentialed in Cognitive Functional Therapy conducted the training.
Content of the intervention
We clearly defined the content of the training intervention. This was supported by:
Publication describing Cognitive Functional Therapy 
Videos of experts demonstrating Cognitive Functional Therapy with patients with chronic low back pain
The format and structure of the training (Figure 5)
One 2-day knowledge training workshop – lecture, open discussion and patient demonstration
One 2-day skills training workshop – person-centred communication, behavioural experiments, Cognitive Functional Therapy treatment plans.
Four 2-day mentoring workshops with two groups of 9 physiotherapists (one in Sydney and one in Perth) in which each physiotherapist treated a new patient with chronic low back pain during each 2-day workshop, while being mentored by a trainer (in front of the group). At the end of the consultation the patient was discussed within the group, the multi-dimensional clinical reasoning form was used to identify key targets for care. The trainer provided written personalised feedback on the session to the physiotherapist. All mentoring consultations were video recorded and the physiotherapist was asked to watch the video of their own patient consultation and self-rate their performance against the competency checklist. The trainer then provided feedback via a competency checklist.
Figure 5. Outline of the Cognitive Functional Therapy training program
We delivered a 2-day skills training workshop that trained physiotherapists in:
Exploring patient’s emotions and beliefs
Dealing with distressed and fearful patients
Behavioural experiments for a range of clinical presentations
Clinical reasoning process
Formulations to help patients make sense of their pain through their own story and experience
Planning Cognitive Functional Therapy interventions, progressions, exacerbation plans.
These training sessions were delivered through lectures, patient videos, practical demonstration, role play.
Most importantly, these skills were then integrated into clinical practice during the subsequent mentoring workshops where the physiotherapists worked directly with patients with chronic low back pain. In this process physiotherapists were able develop and refine their skills across the 6-month training program.
One credentialed Cognitive Functional Therapy trainer conducted each workshop.
Training and feedback was personalised to the individual physiotherapist.
Between each month of training physiotherapists were asked to practice their skills, integrate learning to their daily clinical practice and build competencies in key identified areas.
A private Facebook page allowed physiotherapists share their experiences and challenges they faced between the workshops.
Scope of practice
Scope of practice for Cognitive Functional Therapy was clearly outlined at the start of the training program.
Patients with serious spinal pathology (eg. cancer, infection, fracture, cauda equina syndrome were excluded).
Physiotherapists were able to cross refer patients back to their general practitioner or a clinical psychologist if they demonstrated high sustained levels of distress, reported unresolved trauma with signs of post-traumatic stress, and or reported untreated co-morbid mental health conditions.
Intention of suicidality triggered immediate contact and referral to the general practitioner.
Change in physiotherapist skills and behaviour was monitored monthly by the trainer during the mentoring workshops, by providing feedback using a competency checklist as they assessed and treated a patient with chronic low back pain.
80 hours training over 6 months. Physiotherapists who did not achieve competency at the end of the training were given further feedback and an additional month to practice skills before being re-tested for competency.
Step 3: Achieving Competency
Physiotherapists were rated on a checklist of key competencies considered essential to deliver Cognitive Functional Therapy.
Interview (11 items)
Örebro Musculoskeletal Pain Questionnaire, patient story, pain features, pain cognitions, emotions, behaviours, social, lifestyle factors, goals, general health, red flags, imaging
Physical examination (9 items)
Observation, behavioural experiments, assessment of levels of conditioning
Making sense of pain (8 items)
Patient-centred education, goal setting, exacerbation plan (if indicated)
Exposure with control (5 items)
Graded exposure with control, generalisation, targeted conditioning
Lifestyle change (3 items)
Addresses lifestyle factors where relevant
Identifies barriers (1 item)
Considers cross-referral when indicated
Communication style (14 items)
Patient-centred communication, avoids unhelpful pain messages
Ability to develop individualised plan
Rating ranged from: un-developed, developing, developed, not applicable
Competency assessment was based on the competency checklist, where on the final workshop the physiotherapist assessed and treated a patient with chronic low back pain. Physiotherapists needed to demonstrate competency across all the domains. If the physiotherapist did not achieve competency they were not able to provide care in the trial. Physiotherapists who did not reach competency were given a month to practice before undergoing another assessment. In the RESTORE trial 16/18 physiotherapists reached competency at the end of 6 months. The extra 2 physiotherapists reached competency 6 weeks later.
Step 4: Support and fidelity assessment during the trial
During the trial, physiotherapists were able to ask questions regarding complex cases via the Facebook page or via phone with one of the trainers. A clinical psychologist associated with the trial was contactable to discuss highly distressed patients. A one-hour group Zoom meeting was scheduled every 3-4 months for physiotherapists to ask trial questions and discuss complex cases.
Every 7th trial patient the physiotherapist treated was videoed and fidelity checked against the competency checklist by one of the trainers and an external Cognitive Functional Therapy trainer.
What did Physiotherapists think about the training?
The physiotherapists found the training challenging and rewarding . They described the process like being a learner driver (Figure 6). At the beginning they had to learn about Cognitive Functional Therapy and develop basic skills. After this they started to work with patients with chronic low back pain (‘learnt to drive’) with the support and guidance of a skilled instructor. At the beginning this was reported to be scary, threatening and tiring – while the instructor guided them when they veered off track. As they gained confidence, they were able to work with less need for guidance and support from the mentor.
The physiotherapists highly valued the process and structure of the learning. This process involved observing a highly skilled trainer deliver care, followed by experiential learning delivering care individually in front of a small training group and trainer.
Figure 6. Outline of the roadmap of training competency in Cognitive Functional Therapy, including the perceived facilitators and barriers reported by the physiotherapists who underwent the training.
Delivery of Cognitive Functional Therapy after training
Delivery of Cognitive Functional Therapy during the trial was described by physiotherapists as analogous to ‘driving on Probationary plates’ (Figure 7). This analogy illustrates the journey after training to competency as one of transformation, involving refinement of new competencies while navigating new complexities associated with delivering Cognitive Functional Therapy. This included broadening their scope of practice, developing comfort with people's emotions and working more as a coach than a ‘fixer’. Physiotherapists described being witness to significant patient transformations during the trial that were rewarding and transformative for their practice. They felt that Cognitive Functional Therapy allowed for transformation of broader aspects of the patient’s life than a more traditional, physically focused management approach. They faced challenges working with highly disabled and distressed people with mental health challenges. The physiotherapists described in come instances wanting additional multidisciplinary co-care for patients with significant co-morbidities such as obesity and severe mental health concerns. Ongoing support during the trial was felt to be integral to navigating complexity of a patient cohort with high pain-related disability.
Driving on Probationary plates:
Implementation of Cognitive Functional Therapy in the RESTORE trial
Figure 7. Themes from perceptions of physiotherapists delivering Cognitive Functional Therapy in the RESTORE trial.
Pathway forward beyond the RESTORE trial?
We believe that the training program delivered to physiotherapists in the RESTORE trial provides a helpful roadmap toward training clinicians to competently to deliver Cognitive Functional Therapy for people living with chronic low back pain. The roadmap was used by skilled trainers to ensure the requisite knowledge, skills and clinical competence for treating physiotherapists to deliver Cognitive Functional Therapy. Our team is in the process of developing a tiered training program to support training of clinicians in Cognitive Functional Therapy in a series of implementation studies to assess the generalisability of the training program in different care settings and countries. Our plan is to provide equitable training internationally for clinicians as part of a Cognitive Functional Therapy implementation program.
Some people are critical of the amount of training required to train clinicians to competently deliver Cognitive Functional Therapy
Our response is: How long does it take to train a clinical psychologist or surgeon to develop clinical competencies?
80 hours is very little in comparison.
Chronic low back pain is a exceptionally costly condition that has been poorly managed. We need to train a workforce to upskills clinicians to provide effective care for people suffering from chronic low back pain.
The RESTORE trial demonstrated large and sustained clinical and economic benefits over usual care for people with chronic low back pain. This was reflected in the mostly work productivity savings of AU$5000 for each person over a year who underwent Cognitive Functional Therapy. Training a workforce to provide this care could provide relief for people suffering chronic low back pain with huge cost savings to society.
Authors: Peter O'Sullivan, Peter Kent, JP Caneiro, Anne Smith, Phoebe Simpson,
Riikka Holopainen, Kieran O’Sullivan, Ian Cowell, Mark Hancock
Driver C, Kean B, Oprescu F, Lovell GP. Knowledge, behaviors, attitudes and beliefs of physiotherapists towards the use of psychological interventions in physiotherapy practice: a systematic review. Disability and Rehabilitation 2017; 23;39(22):2237-49.
Foster NE, Delitto A. Embedding psychosocial perspectives within clinical management of low back pain: integration of psychosocially informed management principles into physical therapist practice—challenges and opportunities. Physical Therapy 2011; 91(5):790-803.
Synnott A, O’Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, O'Sullivan K. Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. Journal of Physiotherapy 2015;61(2):68-76.
O’Sullivan PB, Caneiro JP, O’Keeffe M, Smith A, Dankaerts W, Fersum K, O’Sullivan K. Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Physical Therapy 2018; 98(5):408-23.
O’Sullivan K, O’Keeffe M, O’Sullivan P. NICE low back pain guidelines: opportunities and obstacles to change practice. British Journal of Sports Medicine 2017; 51(22):1632-3.
Lin I, Wiles L, Waller R, Caneiro JP, Nagree Y, Straker L, Maher CG, O'Sullivan P. Patient-centred care: the cornerstone for high-value musculoskeletal pain management. British Journal of Sports Medicine 2020; 54(21):1240-2.
Australian Commission on Safety and Quality in Health Care. Australian Low Back Pain Clinical Care Standard. Sydney: ACSQHC; 2022.
Fritz J, Söderlund A, Sandborgh M. The complexity of integrating a behavioral medicine approach into physiotherapy clinical practice. Physiotherapy Theory and Practice 2018: 1182-1193.
Hsu C, Evers S, Balderson BH, Sherman KJ, Foster NE, Estlin K, Levine M, Cherkin D. Adaptation and implementation of the STarT back risk stratification strategy in a US health care organization: a process evaluation. Pain Medicine 2019; 20(6):1105-19.
Simpson P, Holopainen R, Schütze R, O’Sullivan P, Smith A, Linton SJ, Nicholas M, Kent P. Training of physical therapists to deliver individualized biopsychosocial interventions to treat musculoskeletal pain conditions: a scoping review. Physical Therapy 2021; 101(10):pzab188.
Vibe Fersum K, Smith A, Kvåle A, Skouen JS, O'Sullivan P. Cognitive functional therapy in patients with non‐specific chronic low back pain—a randomized controlled trial 3‐year follow‐up. European Journal of Pain 2019; 23(8):1416-24.
Ng L, Cañeiro JP, Campbell A, Smith A, Burnett A, O'Sullivan P. Cognitive functional approach to manage low back pain in male adolescent rowers: a randomised controlled trial. British Journal of Sports Medicine 2015; 49(17):1125-31.
Vibe Fersum K, O'Sullivan P, Skouen JS, 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):916-28.
Vibe Fersum K, Smith A, Kvåle A, Skouen JS, O'Sullivan P. Cognitive functional therapy in patients with non‐specific chronic low back pain—a randomized controlled trial 3‐year follow‐up. European Journal of Pain 2019; 23(8):1416-24.
O'Keeffe M, O'Sullivan P, Purtill H, Bargary N, O'Sullivan K. Cognitive functional therapy compared with a group-based exercise and education intervention for chronic low back pain: a multicentre randomised controlled trial (RCT). British Journal of Sports Medicine 2020; 54(13):782-9.
Castro J, Correia L, de Sousa Donato B, Arruda B, Agulhari F, Pellegrini MJ, Belache FT, de Souza CP, Fernandez J, Nogueira LA, Reis FJ. Cognitive functional therapy compared with core exercise and manual therapy in patients with chronic low back pain: randomised controlled trial. Pain 2022; 163(12):2430-7.
Holopainen R, Piirainen A, Karppinen J, Linton SJ, O’Sullivan P. An adventurous learning journey. Physiotherapists’ conceptions of learning and integrating cognitive functional therapy into clinical practice. Physiotherapy Theory and Practice 2022;38(2):309-26.
Holopainen R, Simpson P, Piirainen A, Karppinen J, Schütze R, Smith A, O'Sullivan P, Kent P. Physiotherapists' perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions: a systematic review and metasynthesis of qualitative studies. Pain 2020;161(6):1150-68.
Cowell I, McGregor A, O’Sullivan P, O’Sullivan K, Poyton R, Schoeb V, Murtagh G. Physiotherapists’ approaches to patients’ concerns in back pain consultations following a psychologically informed training program. Qualitative Health Research 2021; 31(13):2486-501.
Ussing K, Kjaer P, Smith A, Kent P, Jensen RK, Schiøttz-Christensen B, O’Sullivan PB. Cognitive functional therapy for people with nonspecific persistent low Back pain in a secondary care setting—A propensity matched, case–control feasibility study. Pain Medicine 2020; 21(10):2061-70.
Simpson P, Holopainen R, Schütze R, O’Sullivan P, Smith A, Kent P. Becoming confidently competent: a qualitative investigation of training in cognitive functional therapy for persistent low back pain. Physiotherapy Theory and Practice 2022; 26:1-3.