Manual Therapy 25 (2016) 104e108

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

Case report

Lack of confidence in the lower limb: Cognitive Functional Therapy

(CFT) for a unilateral loading impairment in chronic non-specific low
back pain. Case report
Ney Meziat Filho a, *, Roberta Mendonça b, Leandro Alberto Calazans Nogueira c
a
Departamento de Ci^ encias da Reabilitaça~o, Centro Universitario Augusto Motta e UNISUAM, Rio de Janeiro, Brazil
b
Programa de Po s-Graduaça ~o em Ci^ ~o, Centro Universita
encias da Reabilitaça rio Augusto Motta e UNISUAM, Departamento de Fisioterapia, Escola Naval,
Rio de Janeiro, Brazil
c
Departamento de Ci^ ~o, Centro Universita
encias da Reabilitaça rio Augusto Motta e UNISUAM, Instituto Federal do Rio de Janeiro (IFRJ), Rio de Janeiro, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: This case report presents the effect of Cognitive Functional Therapy (CFT) in a patient with chronic non-
Received 29 October 2015 specific low back pain associated with unilateral loading impairment of the left lower limb. The patient
Received in revised form believed surgery was the only possible way to treat the cause of the problem. The management of this
15 February 2016
idea was to change such belief. Manual therapy and active exercises were combined in order to
Accepted 18 February 2016
encourage the patient to trust his back and lower limb again. One month and a half after the first
appointment, the treatment resulted in complete absence of pain and disability. The patient returned to
Keywords:
work and he was able to climb stairs and load his left limb normally.
Low back pain
Lower limb
© 2016 Elsevier Ltd. All rights reserved.
Cognitive Functional Therapy

1. Background
Cognitive Functional Therapy (CFT) is a multidimensional bio-
psychosocial approach for the management of patients with LBP
(O'Keeffe et al., 2015; Rabey et al., 2015). There are many different
patterns of maladaptive functional behaviours described in O'Sulli-
van's Multidimensional Classification System (O'Sullivan, 2005). One
that could exist in isolation or combined with another pattern and is
poorly described in the literature is loading impairment (Vibe Fersum
et al., 2009). Therefore, the aim of this case report is to describe the
pattern and also present the effect of CFT in a patient with unilateral
loading impairment experiencing chronic disabling LBP.
2. Methods
2.1. History
A 49-year-old male dental surgeon who used to have a normal
life, which included exercises at the gym and soccer matches,
presented with six years of disabling low back pain. Once after
* Corresponding author. Departamento de Cie ^ncias da Reabilitaça
~o, Centro Uni-
versitario Augusto Motta, Praça das Naço
~ es 34, 3◦ andar, Bonsucesso, Rio de Janeiro,
RJ, 21041-010, Brazil.
E-mail address: neymeziat@gmail.com (N. Meziat Filho).
playing with his children in a pool, he started to feel unilateral pain
in the lower back. In the same day, the pain worsened and
disturbed his sleep at night. It was even necessary to get up to take
some painkillers. The following morning he woke up feeling
numbness in the left lower limb. The patient saw a physician and he
was referred for x-ray and magnetic resonance imaging (MRI). The
MRI showed two prolapsed discs L4/L5 and L5/S1. The doctor rec-
ommended surgery, but the patient decided to look for another
treatment option. The patient was treated with acupuncture, global
postural reeducation (GPR), and hydrotherapy, and he also lost
some weight. The patient was absent from work for 30 days and
then came back gradually. He did not return to the gym or play
soccer because he still had discomfort in his back. Such discomfort
and also the disability were reported to have persisted during the
six year gap between the first and the second acute episode of low
back pain.
The second episode occurred after bending over to pick a bottle
inside the refrigerator. He felt pain on the left side of the lower back
and down his left thigh and knee anteriorly, but without numbness
(Fig. 1). He avoided walking for almost 30 days and was sent for
another x-ray and MRI. The results showed degenerative changes in
the segments L1/L2, L4/L5, and L5/S1 (Fig. 2). The doctor said that
the only way to solve the problem would be surgery, due to the disc
degeneration and the narrowing space compressing the nerve. The

http://dx.doi.org/10.1016/j.math.2016.02.007
1356-689X/© 2016 Elsevier Ltd. All rights reserved.
 N. Meziat Filho et al. / Manual Therapy 25 (2016) 104e108
Fig. 1. Symptoms drawn on the body chart by the patient.
patient took some rest and medication. He was treated with
acupuncture, and he started to walk with little pain.
“He (the surgeon) told me, ‘The surgery, you will not escape
from it. Everything is treating the effect. It is taking your pain away,
Fig. 2. Second magnetic resonance image.
105
but is not solving the cause that is a matter of wear and tear ’’
(Video 1).
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
2.2. Examination
At the physical examination one month after the second episode
of the symptoms, the patient's pain was 3/10, and he presented
with 28% on the Oswestry Disability Index (ODI) (Coelho et al.,
2008). He was only working part-time at this stage. The patient
was not afraid of bending over or sitting, but he was not confident
in his left lower limb while walking because he felt his thigh was
tense. He said that this lack of confidence was present even when
he was with mild pain between the onset of the symptoms and the
recent flare-up. For the Fear-Avoidance Beliefs Questionnaire
(FABQ), the physical activity dimension was 27 points, and the work
dimension was 29 points (de Souza et al., 2008). He was low risk
according to the Start Back Screening Tool (Pilz et al., 2014).
The patient was asked to show the movement or tasks that
reproduced the symptoms. He said that the main problem was the
lack of confidence and stiffness in his left lower extremity when
walking and climbing stairs. He reported stiffness and pain on the
left side of the low back while in rotation of the spine, such as when
cleaning himself after elimination and when washing his back
during a shower. He also reported that he felt an increase in pain
when he had to run to cross a street. Active flexion, extension, and
neutral 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 rotation. Palpation of the lumbar
erector spinal muscles at L4 and L5 showed muscle tension on the
left side. A lack of pelvic and thorax rotation as well as upper limb
movements was noted during walking (Video 2). While climbing
the step of a ladder, it was possible to observe an avoidant behav-
iour associated with the weight loading on the left lower limb. The
patient abducted the upper limb to recover the balance (Fig. 3 and
Video 3).
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
The slump, straight leg raise, and prone knee flexion were all
negative, and there were no neurological signs.
2.3. Intervention
Management of this patient was based on three closely related
elements: maladaptive cognitive, functional and movement, as well
as lifestyle behaviours, in an integrated manner. The objective of
the cognitive intervention was to change the patient's belief that
the surgery would be the only way to treat the cause of the prob-
lem. Reflective questioning was used to engage the patient in
thinking through his ideas and to be able to determine the validity
of his beliefs about the problem (Moran, 1998). The fact that there is
a very high prevalence of degenerative disc disease in asymptom-
atic people and that the presence of a narrowing disc space did not
predict LBP were mentioned.
Since the patient presented with a functional avoidant behav-
iour associated with the weight bearing in the left lower limb, he
was exposed to lunge squat exercises focussing the loading in the
left lower limb (Fig. 4, Video 4). The patient was asked to relax the
abdominal wall and breathe. Also, he was encouraged to trust in his
left lower extremity. After a set of 10 repetitions, he was tested
again in the ladder and he started to present a different behaviour
with more confidence in the left lower limb and a more relaxed
106 N. Meziat Filho et al. / Manual Therapy 25 (2016) 104e108
Fig. 3. Weight-bearing ability on the right and left lower limb during the task of climbing a ladder.
posture (Video 5). The exercises and the retest were repeated for
two more sets of 10 repetitions, and the pattern continued to be
modified. The movement of active rotation of the back in standing
and sitting was also more comfortable after the lower limb
Fig. 4. Lunge squat exercises focussing the loading in the left lower limb.
exercises compared to the initial test. The patient was instructed to
repeat the lunge exercises for two sets of 10 repetitions daily at
home. With the aim of helping the patient change his poor lifestyle
behaviour, he was encouraged to walk and climb stairs instead of
driving and taking an elevator.
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
At the second appointment, the patient repeated the active
exercises but reported stiffness during the back rotation to the left.
With the aim of decreasing stiffness and pain, a pelvic thrust
manipulation in prone position was performed using a drop table
(Video 6). That was the only passive approach used during the
treatment to relax the muscle guarding, restore trunk rotation
movement, and facilitate active exercises.
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
3. Results
One week after the first appointment, the patient's pain
decreased from 3/10 to 1/10 and the disability from 28% to 16% in
the ODI. The FABQ-physical activity was 15 points, and the FABQ-
work was 21 points. The patient was able to perform the lunge
exercise with the upper limbs in a more relaxed manner and he
reported more confidence in his left lower limb (Video 7). Also, he
was able to run (Video 8). He went back to his full-time job as a
dental surgeon. The pelvic manipulation performed at the second
appointment helped to abolish the stiffness and the pain during the
trunk rotation movement (Video 9 e Before the manipulation,
Video 10 after the manipulation).
 N. Meziat Filho et al. / Manual Therapy 25 (2016) 104e108
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
Three weeks after the beginning of the treatment, the patient
was pain-free and with 8% of disability in the ODI, 9 points in the
FABQ-work, but still 24 in the FABQ-physical activity. He reported
that he did not perform the exercises regularly but started to use
the stairs instead of the elevator in his workplace building. He said
that he had completely recovered the confidence in his left lower
limb. It was possible to observe that the functional behaviour had
changed during the reassessment. There was much more thoracic
and pelvic rotation while walking (Video 11) and a more relaxed
movement pattern of the upper limbs while climbing the ladder
with the stance of the left limb (Video 12).
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
Six weeks after the first appointment, the patient was pain-free
and with no disability in the ODI and 0 points in both the FABQ
dimensions. He reported that his life had gone back to normal after
the treatment. Also, he said the new mindset helped him recover
his confidence (Video 13).
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
Fig. 5. Weight-bearing ability on the right and left lower limb during the task of climbing a ladder in the fourth appointment.
107
“I completely eliminated my back problem from my mind”.
In the last appointment the patient was completely confident on
his left lower limb while climbing the ladder (Fig. 5), and he was
able to jump from the ladder (Video 14).
Supplementary data related to this article can be found online at
http://dx.doi.org/10.1016/j.math.2016.02.007.
4. Discussion
This case report emphasises the importance of a multidimen-
sional biopsychosocial approach as one method for assessing and
treating LBP (Dankaerts and O'Sullivan, 2011). This patient was told
that surgery would be the only way to treat the cause of the
problem. He thought that the weight bearing in the left lower limb
was dangerous and that the discomfort in the thigh could be a sign
of disc degeneration (Bunzli et al., 2015). Those negative beliefs
could explain the cycle of pain, fear, and avoidance of loading in his
lower extremity and the maladaptive lifestyle behaviour since the
first acute episode.
Another important assumption is that the patient was submit-
ted to two early MRI exams without any important neurological
sign or red flag. There is evidence suggesting that an early MRI
without indication has a strong iatrogenic effect in acute LBP,
leading to prolonged disability and increased medical costs
(Webster et al., 2013). Patients with persistent LBP hold biomedical
beliefs about the cause of the problem, attributing pain to the
structural vulnerability of their spine (Baird and Haslam, 2013;
Bunzli et al., 2015). This belief is attributed to the advice given by
108 N. Meziat Filho et al. / Manual Therapy 25 (2016) 104e108
healthcare practitioners after the results of spinal radiological im-
aging (Lin et al., 2013).
The functional maladaptive behaviour was observed when the
patient walked and climbed stairs with his left lower limb. The
abdominal wall and spinal erector muscles were very tense when
palpated while the patient was standing. There was a lack of
thoracic and pelvic rotation in the gait that suggests an increased
activation of the trunk muscles during walking. This behaviour is
associated with chronic non-specific LBP (Ghamkhar and Kahlaee,
2015).
The patient also presented avoidant behaviour when loading the
left lower limb while climbing stairs. The lack of balance and the
opening of his arms were clearly different from the same task with
his right side and coincident with his lack of confidence in this part
of his body. There is evidence that people with chronic LBP present
an increased two points discrimination associated with an
expanded perceived image of the lower back compared with
healthy individuals (Nishigami et al., 2015).
The history of physical activities avoidance between the onset of
the symptoms and the flare-up raised the hypothesis of a persistent
functional maladaptive behaviour even with a little discomfort in
the back. The patient probably continued to protect the left lower
limb from the normal weight bearing functional activities of daily
life such as climbing stairs and relaxed walking. The belief that the
spine and the left lower limb should be protected could have
contributed to the maladaptive lifestyle behaviour and to the flare-
up of the patient's LBP.
The thrust manipulation was the only passive approach used
with the patient during the whole treatment. In the second
appointment, the patient reported pain and stiffness of the trunk
rotation. The active strategy for relaxing the trunk muscles during
the squat exercises was not enough to fully recover the trunk
rotation. Thus, the high velocity and low amplitude technique was
applied on a biopsychosocial perspective only with the aim of
relaxing the trunk muscles and restoring the active rotation
movement.
5. Conclusion
This case report described the benefits of CFT for a patient with
unilateral loading impairment and non-specific CLBP. This therapy
protocol resulted in reduced pain, the mitigation of fear avoidance
beliefs, and the remediation of functional disability.
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