Physiotherapists Perceptions and Experiences in Treating Chronic Low Back Pain Patients with Esoteric Connective Tissue Therapy

Katharine Greenaway^1,2* and Joanna Bohatko-Naismith^1
*Correspondence: Katharine Greenaway, College of Health, Medicine and Wellbeing, School of Health Sciences, The University of Newcastle, Callaghan, Australia, Email:

Keywords

Chronic low back pain • Connective tissue • Physiotherapy

INTRODUCTION

Over the last 30 years chronic low back pain (CLBP) has been identified as the greatest cause of global disability [1]. When acute back pain becomes chronic generally two-thirds of sufferers will not recover fully after 1-2 years [2]. There is no definitive effective general treatment and/or connective tissue (CT) treatment for CLBP. There is also very little research on treatments for CLBP patients reporting longer than 6 months follow up of the research participants [3]. One study by Citak-Karakaya, et al. did do a follow up of one year post treatment intervention of connective tissue massage (CTM), high voltage galvanic stimulation and ultrasound therapy on 20 female subjects with fibromyalgia. Although the symptoms were generalised musculoskeletal pain, restricted function and poor sleep, the CTM treatment was applied to their backs. There were 14 subjects in this study’s one year follow up and 50% of them had maintained the benefits of the treatments without using medication or other manual therapies [4]. The limitations of this study in applying these results to patients with CLBP were in using a combination of therapies for non-specific musculoskeletal pain and the 30% drop out in the numbers of participants followed up. Recent research has reported that adverse changes occur within the CT in people with CLBP. These changes appear in the layers of CT and are thickened with less fluid content and greater stiffness in the area of the back pain [5]. This suggests treatment interventions focussing on CT may be worth exploring. Esoteric connective tissue therapy (ECTT) has evolved as a low impact manual treatment modality over the last 13 years and there are now approximately 142 trained and accredited ECTT practitioners worldwide (Esoteric Practitioner Association). ECTT involves gentle small circular movements to the clients’ sacrum, spine, head, arms and legs with the aim to enhance the energetic flow, fluidity and flexibility of the CT. Many ECTT practitioners including registered physiotherapists have anecdotally reported significant reduction in pain and improved movement and function in clients with CLBP following treatment programs of ECTT. In a published single arm trial with people suffering chronic musculoskeletal pain, participants receiving ECTT demonstrated a 56% reduction in pain after 5 treatments, a 45% reduction in pain at 6 months and a 54% reduction in pain at the 7-9 year follow-up [3]. Despite the positive signs of this new and growing modality, ECTT has not been well researched. Importantly, the experiences and views of ECTT practitioners and clients receiving ECTT have not been formally explored.

Connective tissue (CT) is a vital tissue that is responsive, adaptive and communicative and has many roles in the body. It is the fundamental tissue of the body, at birth the body is all connective tissue originating from a universal body of cells. The cells of the CT originate from the mesoderm layer of the original neural tube, as the fetus develops the CT develops further into other tissue for what is needed e.g. brain tissue, organ tissue, bone tissue, muscle tissue, nerve tissue, ligament tissue, even blood is medically accepted as fluid CT [6].

Connective tissue provides structure, support and connection throughout every part of the physical body. For example, at a microcosm level, CT fibers within the cells provide the structural support required by cells to maintain their shape. At a macrocosm level, sheets of CT in the body called fascia support and hold the layers of muscles from the erector spine muscles, down the spine to the lateral areas of the lower back like a waist coat called the Thoracolumbar fascia (Figure 1).

In its optimal state, CT is fluid and flexible and allows an abundant rotation of the spine including the sliding and gliding of the joints without pain or stiffness. In addition, CT allows for the organs in the body to subtly move and function in balance with each other. CT is also an important support for the body’s immune system, its overall vitality and well-being as it transports white blood cells, hormones and bio chemicals to where they are required. In summary the CT provides balance for the body’s systemic function and the musculoskeletal function and thus plays a vital role in the body’s homeostasis [7]. Over the last 13 years ECTT has been used by physiotherapists, osteopaths, remedial massage therapists and body workers. There is growing anecdotal case study evidence on the long-term benefits that people with CLBP are having from receiving ECTT treatment programs, though until now there has been very little validated research studied and published on the potential benefits of ECTT. Many ECTT practitioners including registered physiotherapists have anecdotally reported a significant reduction in pain, improved movement and function in clients with CLBP following treatment programs of ECTT. From 2006-2009 a single arm trial was conducted with people suffering chronic musculoskeletal pain, these participants received the same protocol of ECTT treatments weekly for 6 weeks. They demonstrated a 56% reduction in pain after 5 treatments, a 45% reduction at 6 months and a 54% reduction at the 7-9 years follow-up [3].

Research Methodology

Despite the positive signs of this new and growing modality, ECTT has not been well researched. Importantly, the experiences and views of ECTT practitioners and patients receiving ECTT have not been formally explored.

Objective

The purpose of this study was to explore the experiences and perceptions of physiotherapists treating their chronic low back pain patients with ECTT.

Method

Ethics Approval for this study was sought and obtained from the University of Newcastle Human Research Ethics Committee, Protocol effective from 15.7.21, H-2021-0184.

Study design

A qualitative study design was used to explore the experiences of individuals who shared a common interest via a focus group that was used to gain an insight into the perceptions and experiences of ECTT practitioners. A focus group is a forum that allows for participants to interact with each other and stimulate discussion as the topic of interest is explored in greater depth [8].

Participants

Purposive sampling was used to recruit ECTT practitioners who are registered physiotherapists. Purposive sampling is a non-random recruitment method in which participants are deliberately chosen for their particular attributes and knowledge of the topic of interest. This study included physiotherapists with clinical experience using ECTT on patients with CLBP. Generally, ECTT practitioners come from a diverse background of body work therapies and registered physiotherapists were targeted for this focus group due to their extensive scientific education and training in physical interventions for lower back pain. The participants were invited to participate in a 1.5 hour online focus group. According to Morse (2000), 6-8 participants in a focus group allows for diverse views on the participants’ varying experiences, whilst still being manageable in an online setting [9].

Inclusion criteria

• Registered physiotherapist who has studied and completed training in ECTT via Universal Medicine (universalmedicine.com.au).

• Insured member practitioner of the Esoteric Practitioners Association (EPA), the peak body for ECTT practitioners.

• Minimum of 3 years clinical experience in using ECTT.

• Currently treating 1 client per fortnight with CLBP using ECTT.

• Access to the Zoom platform on a computer.

• Fluent in spoken English.

Recruitment

There are currently 8 physiotherapists working as accredited ECTT practitioners across the world. Potential participants were approached using their email contact details freely available on the EPA website (epainternational. com). An email was sent to all potential participants inviting them to participate in an online focus group. The email included a copy of the Participant Information Statement and a Consent Form. Potential participants were asked to read the Participant Information Statement and provide written consent if they were interested in participating in the study. The consent form was electronically signed and returned by email by 6 of the potential 8 participants to the student researcher. The focus group participants were 3 UK, 2 German and 1 Australian trained physiotherapist. The participants were invited to email the student researcher if they had any questions about the study.

An online focus group was deemed appropriate as all potential practitioners live in various countries (Table 1).

Zoom is a collaborative cloud-based videoconferencing service and was chosen as the platform for conducting the online focus group [10]. Once written consent was received, the 6 participants were offered a selection of times and dates for the zoom meeting. Participants were advised of the time and date of the focus group via email and were later sent a password protected Zoom meeting invitation for the focus group.

Data collection

The focus group discussion was led by the student researcher, prior to the start of the recording the participants were reminded that the discussion would be audio recorded. Participants were asked to respect each other by keeping the details of the focus group discussion private. The following questions were used by the student researcher to prompt discussion to ensure key areas of the topic were covered:

• In your experience in treating CLBP patients with ECTT what are the observed benefits?

• Have you had CLBP patients report reduced levels of pain? If so, for how long has this benefit lasted?

• What is your experience in using ECTT with CLBP patients that have leg pain due to spinal nerve involvement compared with other therapies you have used?

• In your experience have there been any adverse responses from treating CLBP patients with ECTT?

• How is ECTT different to other manual therapies you have used in treating patients with CLBP?

• How is applying ECTT for your body compared with other physiotherapy treatments you have used?

• Do you get new patients with CLBP referred to you for ECTT treatments from word of mouth?

• Do you get patients with CLBP referred by medical practitioners or other health professionals specifically for ECTT treatment?

• Is ECTT treatment for patients with CLBP more cost effective than other therapies you have used on patients with this condition?

The recorded discussion data was transcribed verbatim and imported into NVIVO 12 pro software for analysis. The de-identified data of the participants was analysed using thematic analysis.

Data analysis

Data analysis was conducted using NVIVO 12 Pro to assist with organising the data. The transcribed data was reviewed repeatedly by 2 researchers and organised into categories and codes. Four main themes emerged from the data.

Results

Six (6) participants were recruited for the focus group, all were ECTT practitioners and registered physiotherapists, 3 UK trained, 1 Australian trained and 2 German trained. All participants stated that their physiotherapy training was similar in terms of their treatment regime which was based on a protocol of: observe - assess - treat - reassess. It became clear throughout the discussion that they applied the ECTT techniques in a similar way for their CLBP patients.

Four main themes emerged from the data: 1) ECTT is a holistic, gentle therapeutic modality, 2) ECTT has long-term lasting benefits, 3) ECTT is less strain and less exhausting for physiotherapists and 4) ECTT is perceived as cost-effective.

Theme 1

ECTT is a holistic, gentle and therapeutic modality early in the discussion two participants stated that they have observed patients with CLBP were hypersensitive to touch and seemed nervous to have any form of hands-on therapy due to the fear of their pain worsening from manual therapy. They also noted that many of the CLBP patients stated they had ongoing emotional stress, anxiety with intermittent depression. Other participants had also observed that many patients with CLBP were nervous, with a seeming mistrust of hands-on therapies in case it made their pain worse. Participant 3 shared her experiences with ECTT. “ECTT is so gentle. And if you’ve had chronic pain for a long time, people can be very anxious about what you're going to do. They may have experienced other things and having something so gentle really gains their trust as well.” These participants found that ECTT was the most effective therapy they could use on these hypersensitive patients as it was so gentle and holistic in that it supported the whole body to relax. The theme that ECTT is a holistic gentle and therapeutic modality was expanded on by participant 1, who stated that: “ECTT is a very gentle treatment but a very powerful one at the same time. It is a non-threatening way of approaching the body, it seems to have a very deeply relaxing effect on the body and a lot of people they fall asleep in the treatments, or they just go very, very restful”. Participant 1 further added to the holistic nature of ECTT: “ECTT always considers the whole body and the whole global picture. And so you might start off just getting a feel of the body and suddenly go, oh actually the problem’s here in the hip, or this knee’s really stiff. ECTT takes care of a lot of those other issues in the body that might be contributing to the back problem”. As the holistic nature of ECTT supports the healing of other joint/muscle problems which maybe associated compensatory problems, easing these problems may indirectly ease the CLBP.

Theme 2

ECTT has long-term lasting benefits.

The physiotherapists discussed the strongest long-term lasting benefits of ECTT with CLBP clients were in the reduction of pain levels, improved movement and overall function. The definition of ‘long term lasting benefits ‘ was developed in the discussion with the participants concurring that these were benefits that lasted over 6 months or longer.

Participant 1 shared their experience of the long term chronic back pain benefits of ECTT: “I've certainly had plenty of cases where those pain scores have definitely reduced, usually within 4 to 6 sessions, on average, in a chronic pain case we've definitely had cases in the clinic where that benefit has lasted 6 months, even 12 months, a handful of patients that I have followed up at 12 months, with just an email or a phone call and these benefits seem to have lasted at least that long, possibly longer, because I haven't necessarily followed any one up any longer term than that.”

Participant 2 reported a particular patient returned to her for treatment of a non-back related problem at least 2 years after her ECTT program for her CLBP was completed. The patient’s response to her ECTT treatment program was, via participant 2:

“She was just moving so well again and so appreciative of what the ECTT treatment for her chronic back pain had brought her, because it had given her life back – she had no pain at all and her function had returned and she returned to how she’d been about 15 years previously.”

Clinically it is more difficult to treat and reduce CLBP with associated leg pain when it has been present for many years. Participant 4 described a case of a medical specialist they were treating for severe low back and leg pain:

“Just to share about a patient I treated 5 years ago, with Esoteric Connective Tissue Therapy, she was a consultant at a medical teaching hospital and she’d had 10 years of severe back pain, very, very, very debilitating and she had leg pain as well, referred leg pain. She had tried many different forms of physiotherapy before she came to see me, she had 6 sessions, after the 6 sessions she was pain free. I called her recently as a review and she has been completely pain free with all her daily activities, she has become a golf professional and she has 2/10 pain after playing 2 hours of golf, which goes away easily when she does her back stretches.” (2/10 is a number estimate from the standard numerical pain scale used in medicine and allied medicine – 0 being no pain and 10 being excruciating pain).

Theme 3

ECTT places less strain on the practitioners’ bodies.

Another important theme was how supportive ECTT was for the physiotherapists as they treated their clients with CLBP, with some participants comparing the effects on their bodies from using ECTT with more standard forceful manual therapies.

Participant 1 shared that over the many years of working with manual therapies they had numerous painful musculoskeletal conditions, such as low back pain, thumb and wrist pain and neck and shoulder pain, participant 1 stated: “Over 22 years I think I’ve seen a lot of patients on a really practical level, in terms of a level of physical strain that ECTT actually puts on your body and if you can get the same result, if not a better result, with less stress and strain on my body as a practitioner and on the patient’s body, then as far as I'm concerned that’s a win/win, yes the stress and strain on my body physically is far reduced.”

Participant 2 expanded on the nature of ECTT’s support: “And it's a rhythm that can be felt between the patient and the practitioner. It is very invigorating, it's just not exhausting at all to give it helps me to reconnect back to myself, when I have a day of doing ECTT treatments - I am totally energised at the end of the day.”

A few of the physiotherapists felt that using ECTT had increased their awareness of the way they move and do daily activities in terms of the quality of their movements, this is shown in Participant 5’s statement: “In understanding the treatment it's like you apply it, or you do it with somebody, but at the same time you receive it when I give it, my own connective tissue gets in another flow, I would say. And I apply actually this treatment every day in my life. If there is a need to give another treatment, like a more physical technique, I do it with the same flow and connection to my connective tissue, as what I do when I give Esoteric Connective Tissue Therapy itself.”

Theme 4

ECTT is perceived as cost effective Participants were asked about the cost effectiveness of ECTT and there was a general agreement amongst the group that ECTT is cost effective. Participant 1 summed up many responses with: “When all that’s been shared is considered, not only has the person not got pain and their future is so much more, their function is restored and everything, they're obviously not doing that cycle of returning for treatment. So, it's pretty obvious really that ECTT is more cost effective.” Participant 6 was more specific as to where the reduction in medical costs was: “If and when patients can avoid an operation or yes, another medical treatment, or with reducing pain, definitely ECTT is cost effective.”

Then participant 1 expanded on the above statement and the question of cost effectiveness: “Chronic back pain is a huge burden in cost onto our economies in terms of lost days off work, or people off work, or people on modified duties and some of the changes that I've observed with ECTT in terms of people being able to function on a whole different level in their day-today lives and return back to work and as we said, better sleep so I would say there’d be a cost saving there as well, for sure.”

Discussion

This study was the first to explore the experiences of physiotherapists using ECTT to treat their patients with chronic low back pain. The experiences of the UK and Australian physiotherapists in applying ECTT treatments to their CLBP patients were positive and very similar to the experiences of the German physiotherapists, even though they had different approaches to manual therapy with their clinical experiences. Most of the physiotherapists stated that many of their patients with CLBP had a hypersensitivity to touch and pressure with what seemed to be anxiety or fear in case they had increased pain levels from the treatment they were about to receive.

They specified the importance of their patients being relaxed as they received any form of manual therapy and they stated that ECTT was very effective in relaxing their patients allowing for a greater benefit from the treatment. These physiotherapists explained that it was very beneficial for their CLBP patients to be relaxed while they were receiving ECTT to ease their chronic tension in their connective tissue which helped ease their pain levels and improved their overall function.

This study provides insights into the need for relaxing, gentle manual therapy treatments for people with CLBP, with the experiences of these physiotherapists suggesting that ECTT is the therapy that is needed. They all agreed that their patients did not have any major adverse effects from their ECTT treatments. The minor effects included mild dragging aches in the problem area, occasional dizziness and body fatigue, all of these effects were completely gone after 1-3 days post treatment.

Most of the physiotherapists in this group expressed their appreciation of how ECTT treats the CT of the whole body, not just the back pain area of their CLBP patients. Furthermore they added that in feeling the quality of the energetic and fluid flow in the CT of their patients, initially the tension and stiffness in a hip or knee becomes more apparent than the low back and as that stiffness resolves this helps the chronic tension and pain of the patient’s lower back as well.

There was a consensus amongst the physiotherapists that the benefits of ECTT for their CLBP patents lasted longer than other manual therapies they had used in the past. Four participants specified that ECTT was particularly effective in the correction of imbalances of the pelvis. They found - from their patient feedback that the corrections from the ECTT treatments had lasted longer than other techniques used on the pelvic joints, with some of their patients having pain reduction and improved function that lasted 6 months and even 12 months in some cases.

Over the last 20 years of research globally on various forms of manual therapy for people with CLBP, there has been no definitive treatment protocol found. More specifically there have been no studies on solely treating connective tissue and very few showing benefits lasting longer than 6 months [3].

In the focus group discussion, there was also a consensus with the participants of the benefits of using ECTT not just for their patients but also for themselves as the physiotherapists, in that it was far less of a strain on their bodies. Many stated that after a day of treating patients with ECTT they felt relaxed and revitalised without the fatigue that can occur when they treat with more strenuous manual therapies. All the physiotherapists agreed that from treating with ECTT they were more aware of the energetic flow in their own CT and this supported them to be aware of their quality of movements. In moving and doing daily activities more smoothly, like the gentle movements of the ECTT techniques, they were less tired or fatigued from those daily activities.

When using ECTT on their CLBP patients many of the physiotherapists stated there was not only long-term benefits for their patients, but their patients also had less treatments overall compared to other manual therapies they had used. One physiotherapist stated their patients had less extensive medical interventions and most had returned to work which meant overall less cost of treatment, less cost burden on the medical system and society and that ECTT was more cost effective for their patients.

The qualitative nature of the focus group and the modest sample size limits the generalizability of the findings of this study. This focus group brought together a number of trained physiotherapists who routinely apply ECTT to patients with CLBP and are rarely provided with an opportunity to offer their insights and experiences on the research topic.

The positive benefits of ECTT for their patients with CLBP that these physiotherapists have experienced with the research that has shown thickened CT in areas of the back pain in CLBP [5] suggests more specific research is needed on any quantitative long term benefits of ECTT for people with CLBP.

Conclusion

In summary the physiotherapists in this focus group stated that ECTT is gentle holistic hands on healing modality focussing on the CT of the entire body, their experiences with this modality in treating patients with CLBP were:

• ECTT is associated with long term lasting benefits in the CLBP patients‘ pain levels and function

• ECTT is less stress and strain on their bodies as well as supporting a greater level of vitality and

• There is generally less treatment required for their CLBP patients when using ECTT which makes it more cost effective than other manual therapies.

This anecdotal evidence is a positive first step in formally researching the benefits of ECTT treatment for people with CLBP. Further qualitative research is needed to explore the physical and emotional experiences of CLBP patients receiving ECTT treatments and a randomised control trial of CLBP patients receiving ECTT treatments compared with standard physiotherapy treatment. This would assess more objectively and quantitatively the possible greater short-term and long-term benefits in terms of pain, emotional health and physiological health for patients with chronic low back pain receiving ECTT compared with the standard physiotherapy treatment.

This may pave the way for medical practitioners, allied health practitioners and body workers to be educated on a new therapeutic modality that may change the future course of treatment for the recovery of chronic low back pain and its associated emotional and physiological disorders.

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