A targeted physiotherapy approach has been shown to deliver sustained improvements in people with chronic disabling low back pain, with benefits persisting three years after treatment, according to results from a large Australian clinical trial.
Most interventions for low back pain provide only modest and short-lived relief. Cognitive functional therapy, which focuses on changing unhelpful pain beliefs, movement behaviours and lifestyle factors, has previously demonstrated strong short-term outcomes. The new findings address the key question of whether these benefits can be maintained over the long term.
Three Year Follow Up Trial
The study reports the three-year follow-up of the RESTORE trial, a randomised, controlled, phase 3 study conducted across 20 primary care physiotherapy clinics in Australia. Adults with low back pain lasting more than three months, moderate activity limitation and average pain of at least 4 out of 10 were randomly assigned to usual care, cognitive functional therapy alone, or cognitive functional therapy combined with movement sensor biofeedback.
In total, 492 participants were randomised, with 312 successfully followed up at three years. Participants in the cognitive functional therapy groups received up to seven treatment sessions over 12 weeks, plus a booster session at 26 weeks. The primary outcome was pain-related physical activity limitation, measured using the Roland Morris Disability Questionnaire, with pain intensity assessed as a secondary outcome.
Sustained Improvements Over Usual Care
At three years, both cognitive functional therapy groups showed significantly greater reductions in activity limitation compared with usual care. The mean difference was –3.5 points for cognitive functional therapy alone and –4.1 points for therapy combined with biofeedback, indicating clinically meaningful and sustained benefit.
Pain intensity was also lower in both intervention groups, with reductions of –1.0 and –1.5 points respectively compared with usual care. Differences between the two cognitive functional therapy approaches were small and not statistically significant, suggesting that the addition of biofeedback did not provide a substantial long-term advantage.
Implications For Chronic Pain Management
The results demonstrate that a relatively brief course of cognitive functional therapy can lead to long-lasting improvements in both function and pain for people with chronic disabling low back pain. Such durable effects are uncommon in this field and highlight the potential of psychologically informed, movement-focused interventions.
Researchers conclude that widespread implementation of cognitive functional therapy could markedly reduce the burden of chronic low back pain.
Reference
Hancock M et al. Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): 3-year follow-up of a randomised, controlled trial. The Lancet Rheumatology. 2025;7(11):e789-98.
