Of the 291 conditions studied in the Global Burden of Disease 2010 Study, low back pain (LBP) rates highest in terms of years lost to disability (YLD) and sixth in terms of overall burden. Because LBP has no mortality, YLD are the same as disability adjusted life years (DALYs). With a 9.4% global prevalence (95% CI 9.0–9.8), LBP causes more global disability than any other condition.
Prognosis
For a proportion of back pain patients the prognosis can be bleak. Once you take time off work for back pain you have with different medical and benefit systems a 1–10% risk of not returning to work for at least a year. Not working for 4–6 weeks leads to a 20% probability of long-term disability and not working for 6 months reduces the possibility of returning to previous work to 50%. Once the patient loses their job or has been off work for 1–2 years, a return to work is unlikely [
9].
Almost two-thirds of newly identified CLBP patients do not recover within 12 months [
10,
11]. For those with longer term pain, the figure has been reported at 80% [
12] including mixed primary care populations [
13], with 60–80% of those who consult health care providers still reporting pain 12 months later [
14‐
16].
Cognitive factors appear instrumental in return to work rates for workers with subacute LBP; additionally, and perhaps paradoxically, going to physiotherapy has been found to reduce the chances of returning to work [
17].
Treatments
Forty-eight systematic reviews, meta-analyses and guidelines [
18‐
66] on non-pharmacological CLBP treatments, plus a special issue of
Spine Journal [
67], revealed no treatment that consistently provides superior results for the treatment of CLBP. Overall positive recommendations exist for exercise therapy, massage, various forms of physiotherapy, cognitive behavioural therapy and, in particular, a multi-disciplinary approach. The standard treatment, physiotherapy, tends to be no better or worse than many other treatments. Therefore, there is no gold standard treatment for CLBP, and the search for an effective treatment continues. This is shown in the recently (November 2016) updated UK NICE clinical guidelines [
65] for chronic LBP, summarised in the
BMJ [
68]. No treatment is recommended for CLBP, except for radiofrequency denervation under limited circumstances.
The present study
This randomised controlled trial with treatment and control groups treated in parallel has undergone a full ethical review by the University of Queensland’s contractor, Bellberry Pty Ltd (HREC approval number EC00444).
Many scientific articles have made urgent pleas for further investigations, especially randomised controlled trials, of treatments for CLBP [
1,
9,
18,
24,
69,
70].
To quote the most downloaded paper in the history of
PLoS Med [
71], “[M]ost new discoveries will continue to stem from hypothesis-generating research with low or very low pre-study odds.” Hence, it may be worthwhile to investigate new treatments that are currently not given by registered medical professionals.
Such treatments are usually referred to as complementary and alternative medicine (CAM), an ill-defined group of treatments [
72‐
74] with the difference between “complementary” and “alternative” rarely, if ever, defined. For the purposes of this article, complementary treatments are defined as working in conjunction with and in support of medical professionals, and patients are not expected to reduce their frequency of medical doctor visits; in contrast, alternative treatments aim, at least in part, to replace the work of registered medical professionals.
One approach may be to target the connective tissue (including fascia) because this represents a substantial part of the body [
75] and is important in enabling physical motion [
76,
77] and considered to be involved in back pain [9, p. 159, 164–6, 171–2], with fascia having rich innervation, nocireceptors and being involved in load transfer [9, p. 155, 164–5, 198]. Therefore, finding a way to treat the connective tissue may influence acute and perhaps even chronic back pain. The authors are unaware of any current treatment for LBP that specifically targets the connective tissue.
A new complementary-to-medicine technique that concentrates on treating the connective tissue was developed by Serge Benhayon in 1999 and currently has about 30 practitioners. This technique is called Esoteric Connective Tissue Therapy (ECTT) and is a gentle, hands-on treatment that claims to work by allowing connective tissue in the body to soften and return to its fluid and flexible state, which in turn decreases the compression effects on the body from tight, hard and scarred areas of injured and diseased connective tissue, thereby possibly enabling the affected body parts to resume normal, pain-free movement.
ECTT description
Descriptions of ECTT and anecdotal references are available [
78‐
82]. The treatment consists of small circular motions, primarily with a diameter of 2–3.5 cm, to the legs, arms and head, with the motions to the head being even smaller. Further actions involve techniques for gently holding the hip, knee, ankle, back and spine, allowing the body to adjust (align). There is some evidence that connective tissue undergoes changes in patients with CLBP [
83]; hence, there is a possible mechanism to explain the effects of treatment of the connective tissue on non-specific CLBP.
ECTT and other modalities, such as Esoteric Chakra-puncture, Esoteric Massage, Esoteric Healing and the women-practitioners-only Esoteric Breast Massage, are all derived from the same underlying understanding that energy, a word which here includes consciousness, has a strong influence on humans. This is considered a truism in many alternative treatments [
84], but clearly there is no scientific consensus or even much, if any, scientific evidence that there are other influences on well-being in addition to the physical and the psychological.
However, theoretically speaking, if there are such influences, and if providers were to cultivate awareness and understanding of these influences, it should be possible to design treatment modalities that work substantially better than existing modalities by addressing these important and heretofore unexamined influences as a complement to the exemplary work that is done by conventional medicine.
In the experience of its practitioners, ECTT works best when done in conjunction with the patient consulting their GP and medical specialists for any diagnostic, pharmacological or surgical interventions that could be necessary, because ECTT is not a substitute for any of these interventions but a complementary intervention.
One corollary of taking into account what ECTT practitioners refer to as energy is that ECTT practitioners consider the well-being of the practitioner to be of high importance. As a result, practitioners are required to abide by a stringent code of ethics and conduct [
85] that includes the following:
“… [D]uring the life of the student/practitioner as a practising individual he and she will abstain unequivocally from pornography, the use of alcohol, recreational or illicit drugs (including all forms of cannabis, ayahuasca and or alike [sic]), nicotine (cigarettes, cigars, pipe or alike) and/or any other substance that will obscure and/or alter in any way their conscious presence and centredness.”
Although the code is unorthodox in the categorical and specific nature of its prescriptive rules, similarities exist in mainstream medicine, for example in the CatholicCare Sydney code of conduct [
86].
From 2006 to 2009, KG-T, a registered physiotherapist who is also ECTT-qualified, conducted an unpublished non-comparative, single-arm phase I/II study of the effect of ECTT for chronic pain, with participants receiving an ECTT session once a week for 6 weeks. After five sessions, 45 out of 51 participants reported improved pain levels on the 100-mm Visual Analogue Pain Scale (VAS) [
87‐
89] for pain; three participants had no change and three participants deteriorated. The average pain level moved from 40.2 mm to 17.7 mm after five treatments; after 6 months to 22.2 mm and after 7–9 years in 2016 to 18.6 mm (standard deviations from 16.8 to 21.6 mm).
This 2006–2009 ECTT study by KG-T received Southern Cross University ethical approval as a long-term follow-up study (Approval Number ECN-16-026).
The biggest improvement in the previous ECTT trial was from a VAS score of 80 mm to 0 mm. The worst performances were two increases in pain scores – from a score of 30 mm to 50 mm and from a score of 50 mm to 70 mm. The improvements in this study could be due to many influences, including the placebo effect, regression to the mean or other reasons. However, the result, if it turns out to be representative, would be among the more promising outcomes available, especially in light of the low-intensity nature of the intervention.
Because the previous study is a single-arm phase I/II study evaluating safety and efficacy, the next step is to perform a randomised controlled phase III study comparing ECTT with standard therapy.
SM and another practitioner of ECTT with 8 years of experience each in ECTT have been voluntarily offering ECTT treatments at two hospitals (Pacific Hospital, Hoi An and Pacific Hospital, Tam Ky) in central Vietnam, near Da Nang, over the last 4 years, and the administrator of both hospitals has indicated his willingness to provide the facilities and resources for a randomised controlled trial comparing ECTT with the standard physiotherapeutic hospital treatment of CLBP.