Manual Therapy 21 (2016) 303e306

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Manual Therapy
journal homepage: www.elsevier.com/math

Case report

Changing beliefs for changing movement and pain: Classicationbased cognitive functional therapy (CBeCFT) for chronic non-specic
low back pain
N. Meziat Filho*
~o em Ci^
~o, Centro Universita
!rio Augusto Motta e UNISUAM, Rio de Janeiro, Brazil
!s-Graduaa
Programa de Po
encias da Reabilitaa

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 24 November 2014
Received in revised form
7 April 2015
Accepted 8 April 2015

This case report presents the effect of classication-based cognitive functional therapy in a patient with
chronic disabling low back pain. The patient was assessed using a multidimensional biopsychosocial
classication system and was classied as having exion pattern of movement impairment disorder.
Management of this patient was to change her belief that bending over and sitting would cause damage
to her disc, combined with active exercises for graded exposure to lumbar exion to restore normal
movement. Three months after the rst appointment, the treatment resulted in reduced pain, the
mitigation of fear avoidance beliefs and the remediation of functional disability. The patient returned to
work and was walking for one hour a day on a treadmill. The cognitive intervention to change the patient's negative beliefs related to the biomedical model was important to make the graded exercises and
the lifestyle changes possible.
2015 Elsevier Ltd. All rights reserved.

Keywords:
Low back pain
Cognitive therapy
Movement
Behaviour

1. Background

2. Methods

Low back pain (LBP) is the primary cause of years lived with
disability all over the globe (Hoy et al., 2014). Although 90% of LBP
pain cases are non-specic, clinical management still focuses on the
structural anatomical and biomechanical model and over-treating
is also common (Deyo et al., 2009; O'Sullivan, 2012; Zusman,
2013). There is still a lack of clear evidence for one specic treatment intervention being superior to another (Assendelft et al.,
2004; Furlan et al., 2005; Hayden et al., 2005; Ostelo et al., 2005;
Staal et al., 2008). Consequently, current clinical practice is failing
to manage non-specic chronic low back pain (CLBP) effectively.
The main reason is probably that there is a lack of a multidimensional approach that deals with cognitive, physical and lifestyle
factors at the same time (Rabey et al., 2015; Vibe Fersum et al.,
2013). Therefore, the aim of this case report is to present the effect of classication-based cognitive functional therapy (CBeCFT)
in a patient experiencing chronic disabling low back pain.

2.1. History

!s-Graduaa
~o em Cie
^ncias da Reabilitaa
~o, Centro Universita
!rio
* Programa de Po
~ es 34, 3" andar, Bonsucesso, Rio de Janeiro, RJ, 21041Augusto Motta, Praa das Nao
010, Brazil. Tel.: 55 21 3882 9797.
E-mail address: neymeziat@gmail.com.
http://dx.doi.org/10.1016/j.math.2015.04.013
1356-689X/ 2015 Elsevier Ltd. All rights reserved.

A 32-year old female, sedentary even before the onset of

symptoms, presented with four months of disabling LBP. The
symptoms, localized in her lower back and groin area, started
suddenly after lifting a bathroom sink from the oor (VAS
pain 10/10). According to the patient, her body became asymmetric: my right shoulder was higher than my left shoulder and I felt
my right leg was shorter. The patient was taken to the emergency
room and had an X-ray of her back and hips which had normal
results. After one week of taking ibuprofen the patient felt much
better (pain 4/10), but she was still not able to sit or bend forwards. A few days later, although the patient could not nd a
specic reason, the pain became much worse, shooting down her
right leg and foot. The patient was told to increase the dose of
ibuprofen and was sent to physical therapy. However, after just one
appointment with a physical therapist and a couple of days of
repeating the exercises at home (hamstring stretching and
Mckenzie extension exercise in a prone position), the pain became
worse again (pain 10/10). Within three weeks of the incident and
still in acute pain, the patient had an electroneuromyography. According to the patient, the examination did not show any

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N. Meziat Filho / Manual Therapy 21 (2016) 303e306

abnormalities. The patient was sent for an MRI of the lumbar spine.
The results showed a disc protrusion at the L4eL5 level, which was
considered to be the cause of her symptoms (Fig. 1). Several medications were prescribed, including oral corticosteroids and opioids
analgesics, and the following advice was given:
I was told that it could take 8-12 weeks to recover fully and for my
disc to return to place and stop pressing against my nerves. I was
advised that I might need surgery if my disc did not return and I
was still in pain after 12 weeks. I was also told I should avoid
bending over and using stairs if possible, which was a hard task
since I live in a two storey house. My husband and I were trying to
get pregnant and they told me that I could worsen my back if I got
pregnant and that even if my issue was resolved, I was still at risk of
herniating my disc again in the future while doing routine housekeeping activities like picking up a trash can.
After two months, the patient still had pain in her back, groin
area, buttocks and right leg below the knee (Fig. 2). According to the
patient all mobility was lost and it was hard to take care of herself.
The patient decided to return to her home country to seek medical
treatment. When in her hometown, the patient was sent for
another MRI scan and also advised to have surgery if her symptoms
did not get better in one month. The patient had epidural injections.
When sent to aquatic therapy her report was: They told me that I
should avoid bending over and they gave me a back brace to use. The
pain improved greatly and the patient gained mobility, but was still
unable to remain seated for more than 20 min, or to care of herself
without help.
Another MRI scan of her lower back and also of her hips was
performed. Nothing different was found other than the disc protrusion which was still there. Four months had passed by since the
acute episode. The daily functions considered to be normal by the
patient were still impossible to complete: I thought surgery would
be my only option if I ever wanted to be pain free and able to return to
my normal life. However, I decided to try physical therapy once more
before having surgery.

Fig. 2. Symptoms drawn on the body chart by the patient.

2.2. Examination
During the physical examination four months after the onset of
the symptoms, her pain was 4/10 and her disability was 42% on the
Oswestry Disability Index (Coelho et al., 2008). The dimensions
related to lifting heaving objects and remaining seated were the
most altered (4 points on each). The patient was afraid of lifting
weights, bending over and sitting. For the Fear-Avoidance Beliefs
Questionnaire (FABQp), the physical activity dimension was 19
points (de Souza et al., 2008).
Her sitting posture was upright with anterior pelvic tilt and
lumbar lordosis. The patient maintained her lumbar lordosis and
avoided exion when sitting to standing and while asked to bend
forward to pick a pencil off the oor. During this painful task, her
active range of motion (ROM) was 30" of hip exion with no lumbar
exion (Fig. 3). Active extension and side bending were pain free
with full ROM. When passive ROM was tested in the side lying
position, the patient presented a hypo-mobile lower lumbar in
exion. Palpation of the lumbar erector spinal muscles at L4 and L5
was bilaterally sensitive with light touch. It was possible to feel the
co-contraction of the abdominal wall and erector spinal muscles
while the patient bent over or sat down.
Although the pain was also below the knee, the slump and
straight leg raise tests were both negative and there were no
neurological signs. Based on the painful loss of normal physiological movement in the exion direction, the patient was then classied as exion pattern of movement impairment disorder, with
a combination of peripheral and central drivers of pain (Dankaerts
and O'Sullivan, 2011; Vibe Fersum et al., 2009).
2.3. Intervention

Fig. 1. First Magnetic resonance image.

Management of this patient was based on three closely related

elements (Table 1): Maladaptive cognitive, functional and movement, as well as lifestyle behaviours, in an integrated manner. The

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N. Meziat Filho / Manual Therapy 21 (2016) 303e306

Fig. 4. After two weeks.

Fig. 3. First appointment.

objective of the cognitive intervention was to change the patient's

belief that bending over and sitting would cause damage to her
disc. Reective questioning was used to engage the patient in
thinking through her own ideas and to be able to determine the
validity of her beliefs about the problem (Moran, 1998). The facts
that there is a very high prevalence of disc protrusion in asymptomatic people and that the presence of a disc protrusion did not
predict LBP were mentioned.
With the aim of reconceptualising pain and diminishing the fear
of damage, and catastrophising when feeling pain, a book with
metaphors and stories was given to the patient (Gallagher et al.,
2013). In addition, the patient started to read more positive
Internet material regarding chronic pain management at home:
Some material about chronic pain allowed me to understand my
condition better and helped me to manage my pain.
Due to the fact that the patient presented a movement impairment disorder with a exion pattern, the strategy of treatment for
the maladaptive functional behaviour included active exercises for
graded exposure to lumbar exion with the aim of restoring normal
movement. The exercises were practised with supervision during
the appointment before the patient was instructed to start doing
them at home. It was very important to ask about her thoughts
during the experience of completing the exercises at the consultation. Initially the patient was afraid of causing damage to her disc
and started to become more condent and showed less muscle cocontraction since there was minimal pain experienced during the
initial exercises. The patient was asked to relax her lower back
muscles and abdominal muscles when sitting and take walks to
increase her level of physical activity. An explanation of the impact
of lifestyle changes in chronic pain was given.

3. Results
After four appointments within a period of 14 days following the
rst appointment, the patient was able to bend over normally and
stay seated for 20 min (Fig. 4). The patient reported:
These physical therapy exercises were different from the ones I did
before, which included stretching and bending over. The exercises
also helped me to relax my back and hips. Within two weeks, I had
recovered a lot of mobility and was able to take care of myself again
without any help. I have been doing the physical therapy exercises
for about three weeks and also taking 30 minute daily walks and
feel much better at this point. While I am not 100%, I believe I will be
pain free in the future with continued progress and am no longer
considering surgery.
After 12 consultations over a period of 40 days, the patient
returned to her home in another country. The follow up continued
by e-mail. Three months after the rst appointment, the pain level
was 1e2/10, the disability (ODI) was 14% and the FABQp score was
three points. The patient returned to work and was walking for 1 h
a day on a treadmill.
4. Discussion
This case report highlights the importance of a multidimensional biopsychosocial approach for assessing and treating chronic
LBP (Rabey et al., 2015). This patient presented the common belief
that the pain felt when bending over was a sign of disc damage
(Bunzli et al., 2014). It was probably created by the advice from
healthcare practitioners' regarding the avoidance of low back

Table 1
Management protocol according to the cognitive, functional and movement, and lifestyle behaviours.
Main factors

Assessment

Intervention

Cognitive

Fear avoidance behaviour related to beliefs of disc

damage into lumbar exion

Functional and movement

Flexion pattern of movement impairment disorder

Lifestyle

Sedentary behaviour

$ Explanation of MRI results

$Reective questioning
$Experience of painless exercises
$Pain reconceptualisation
$Graded exposure exercises
- 4 point kneeling: rocking backward and active
mobilisation into lumbar exion;
- Sitting: relaxed sitting and bending forward
20 min/1 h walking a day

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N. Meziat Filho / Manual Therapy 21 (2016) 303e306

exion due to the L4eL5 disc protrusion in the MRI results. There is
evidence suggesting that early MRI without indication has a strong
iatrogenic effect in acute LBP, leading to prolonged disability and
increased medical costs (Webster et al., 2013). The guidelines (Chou
et al., 2007, 2009) recommend delaying imaging to allow for the
natural history of improvement to occur. A large group of patients
with persistent LBP hold biomedical beliefs about the cause of the
problem, attributing pain to the structural/anatomical vulnerability
of their spine (Baird and Haslam, 2013; Bunzli et al., 2014). This
belief is attributed to the advice given by healthcare practitioners
and the results of spinal radiological imaging (Baird and Haslam,
2013; Lin et al., 2013).
Although the use of an early MRI may have contributed to the
persistence of the patients's pain, there were symptoms that had
spread to the lower limb before this examination. This disseminated pain, without a sign of radiculopathy and no specic reason,
was probably a non-mechanical characteristic that leads to some
degree of central amplication of the pain (O'Sullivan et al., 2014;
Rabey et al., 2015).
In this case, the patient also started to read Internet texts about
degenerative disc diseases and surgical procedures. This probably
reinforced the negative beliefs and catastrophising thoughts,
contributing to the avoidance behaviour. This, in turn, led to a
signicant disability. The patient started to avoid bending over and
all the activities that produced low back exion, including a relaxed
sitting position. Fear avoidance behaviour and catastrophising are
compatible with high levels of disability and are important negative
prognostic factors for CLBP (Wertli et al., 2014a, 2014b).
The functional and movement behaviours of the patient were
highly linked to her negative thoughts. The patient was afraid of
moving into lumbar exion, and started to bend over using only her
hips while maintaining the lumbar lordosis. Her rst physiotherapy
treatments, less than three weeks after the onset of symptoms,
were based mainly on exercises towards the end range of lumbar
extension. It probably reinforced her avoidance behaviour related
to lumbar exion and may have contributed to the worsening of the
symptoms.
The rst attempts to bend over relaxing her lower back were
painful, but when it was explained to her that the lumbar exion
would not cause any damage to her disc and upon asking her some
reective questions, the patient started to relax the co-contraction
of the erector spinal and abdominal wall muscles. The pain started
to decrease and the patient could see the lumbar exion in the
mirror. The classication of a exion pattern of movement
impairment disorder, was made according to the criteria of
O'Sullivan's (2005). As bending over is a necessary task for normal
daily life, the aim of the graded exposure exercises was to restore
the patient's ability to bend and sit with condence, relaxed and
free from pain. Her lifestyle was another important factor. The lack
of physical activity and her fear avoidance behaviour made her even
less active after the onset of pain. The graded exposure to walking
probably helped the patient.
5. Conclusion
This case report illustrates the benets of a CBeCFT for a patient
with nonspecic CLBP. This therapy protocol resulted in reduced
pain, the mitigation of fear avoidance beliefs and the remediation of
functional disability. The cognitive intervention for changing the
patient's negative beliefs related to the biomedical model was
important for making the graded exercises and the lifestyle changes
possible.

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