Cognitively informed exercise and educational group in persistent low back pain


Low Back Pain (LBP) is the largest cause of years lived with disability worldwide. UK guidelines recommend a combined physical and psychological programme (CPPP), preferably delivered in groups, as a treatment option. A CPPP based on the fear avoidance model of pain was evaluated in 2013, where just 36% of patients achieved a clinically meaningful improvement in disability. The programme was revised (2017) to include a focus on pain self-efficacy, the largest mediating factor in LBP-related disability. The aim of this service evaluation (SE) was to evaluate whether the revised programme improves LBP-related disability, with a secondary aim to evaluate the programme content.


SE of a CPPP in an NHS musculoskeletal physiotherapy clinic in Bristol. Eligibility criteria included; persistent mechanical LBP, medium or high on the STarT back tool and >16 years. The CPPP consisted of 6 weekly sessions of 90 minutes duration specifically targeting pain self-efficacy by facilitating group members to share positive coping strategies, fostering a strong group identity, and highlighting early patient successes.

The CPPP was led by a physiotherapist and assistant, trained by a clinician experienced in cognitive behavioural therapy and motivational interviewing for pain management. Sessions included an educational topic including pain physiology, addressing unhelpful back pain beliefs, graded exposure to activity, adapting unhelpful activity patterns, relaxation and sustainable exercise programmes, alongside 30 minutes of exercise.

Evaluation methods included: Roland Morris Disability Questionnaire (RMDQ), Tampa Scale of Kinesiophobia Short Form 11 (TSK11), Pain Self-Efficacy Questionnaire (PSEQ) and the Depression Anxiety and Stress Scale (DASS). Pre and post programme scores were analysed using descriptive statistics and the percentage meeting the published minimally clinically important difference (MCID).


6 groups (n=31) consented to the evaluation, with 23 (74%) completing the CPPP between August and December 2017. Of the 23 completers, the mean age was 53 (range 30-78) and 64% were female. Clinically meaningful changes were found in 5 (22%) participants for disability, (RMDQ mean change of -1.9 ), 10 (43%) for pain self-efficacy (PSEQ mean change of 6.4) and 6 (26%) for fear avoidance (TSK11 -1.6 points). Minimal changes were demonstrated for psychological distress in all three DASS domains (depression, anxiety, stress).

Cost and savings

There was no cost analysis undertaken.


The revised CPPP demonstrated greater mean improvements in disability than the previous programme; however fewer patients met the MCID. Pain self-efficacy was enhanced although improvements in disability and fear avoidance were comparable to similar interventions in the literature. None of the overall changes met the MCID which is again comparable to similar interventions in the literature; however an extension of this SE could usefully draw on more patients and inclusion of a follow up at 6 or 12 months.

The CPPP will continue whilst further research is undertaken to establish the MCID for this patient population. Comparison of the programme to one-to-one physiotherapy where management can be personalised will inform future allocation of resources within the service.

Top three learning points

  1. This intervention is able to improve pain self efficacy, fear avoidance and function in a population with persistent low back pain
  2. The changes were small and only a small percentage reached the minimally important change scores set in this evaluation
  3. Comparison between group and 1:1 outcomes for this population would benefit from future evaluation

Funding acknowledgements

This work was not funded.

Additional notes

Presented at Physiotherapy UK 2018.