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Antibiotics for Low Back Pain

Low back pain is a particularly frustrating condition that is common, poorly understood, and difficult to treat. Could a long course of antibiotics be the answer for some patients? A recent study from Denmark suggests that it might be:  “Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy” by Albert, Sorensen, Christensen and Manniche.  Is this a crazy idea like long-term antibiotics for “chronic Lyme disease” or will it pan out like antibiotic eradication of H. pylori in patients with ulcers? Time will tell. This was a rigorous, well-done study, but we can never rely on the results of a single study until it is replicated or confirmed elsewhere.

Background
Modic type 1 changes represent edema in the bone and can be seen only on MRI.  They are present in 6% of the general population and 35-40% of the low back pain population. Infection is one of the hypothetical causes of bone edema, and several studies have found bacteria in material removed during disc surgery. Low virulence anaerobic organisms (Proprionibacterium acnes and Corynebacterium propinquum) were found in 53% of patients in one study. Another study found bacteria in 37% of disc material from patients with herniated discs and 0% of disc material from patients with other spinal disorders. It is thought that these skin and mouth organisms spread to the disc during normal bacteremias as a result of neovascularization associated with disc disease; the Modic changes may be a side effect manifested in the adjacent bone rather than a bone infection per se.

An uncontrolled pilot study of 32 patients had shown promising results with antibiotic treatment. This new double blind study confirmed those preliminary results.

Study Methods
Subjects were 162 chronic back pain patients recruited from spine centers. They had to have MRI-confirmed disc herniation within the previous 6-24 months, with Modic type 1 changes on MRI. Subjects had had either conservative or surgical treatment; patients with and without sciatica and neuropathic pain were included. Randomization and blinding were rigorous. The placebo was a calcium carbonate pill indistinguishable from the active treatment. The antibiotic, amoxicillin-clavulanate (500mg/125mg), was given 3 times a day for 100 days, consistent with the recommendations of infectious disease experts based on bacterial culture results of previous studies. There were 4 treatment groups: single and double dose antibiotics, single and double dose placebos. MRIs, symptom questionnaires, clinical exams, and blood tests were done at baseline, at end of treatment, and at a 12-month follow-up.

Results
The antibiotic group improved on the primary outcome measures of disease-specific disability and lumbar pain, and also on the secondary outcome measures of global perceived effect, leg pain, hours of LBP during the last 4 weeks, the EQ-5D Thermometer (a measure of quality-adjusted health status), days with sick leave, bothersomeness, constant pain, MRI Modic grading, and physical exam measures (i.e. pain with Valsalva maneuver). Improvement in all these factors was clinically as well as statistically significant at p levels from .05 to .0001. Pain relief was gradual, beginning at 6-8 weeks and sometimes continuing long after the end of the treatment period.  On MRI there was a significant decrease in the volume of Modic-1 findings in the antibiotic group but no reduction in the placebo group. Side effects (mostly gastrointestinal) were reported by 65% in the antibiotic group and 23% in the placebo group. There were 13 dropouts in the antibiotic group (only 4 of these were due to side effects) and 5 in the placebo group (due to no shows and new disc herniations). There was a trend towards a dose-response relationship with double-dose antibiotics being more effective (not statistically significant).

Discussion
The authors point out that the improvements in this group of traditionally resistant chronic low back pain patients with this protocol were substantially greater than those described with other treatments. They felt the course of improvement was consistent with slow resolution of anaerobic infection in poorly vascularized tissue followed by gradual healing. They stressed that their findings applied only to this specific group of patients with disc herniation and Modic-1 changes on MRI, not to all patients with back pain. They also stressed that high-dose long-term antibiotics should not be prescribed without careful consideration because of the risks to individuals and to the community (antibiotic resistance).

Conclusion
This study is encouraging but far from definitive. It might justify antibiotics for patients with chronic low back pain and Modic-1 MRI changes following a herniated disc when they have failed to respond to all other treatment options. This was a well-designed study, carefully carried out, with a credible rationale, impressive results, and a cautious interpretation. This is how science should be done.

The authors cautioned:

We rely on our fellow colleagues to use clear evidence-based criteria and to avoid excessive antibiotic use.

Back pain is a frustrating problem, and patients who learn about these results may ask for a trial of antibiotics even if they don’t fit the criteria of the study. That would not be justified and might be expected to do more harm than good. Chronic low back pain is a mixed bag with various etiologies, and it must be stressed that this study addressed only one very limited sub-group of back pain patients. That said, it is a ray of hope for those patients, and I hope it will be confirmed.

Posted in: Clinical Trials, Pharmaceuticals

Leave a Comment (96) ↓

96 thoughts on “Antibiotics for Low Back Pain

  1. Amoxicillin for spinal disc herniation? Great way to get clostridium difficile diarrhea. And dysbiosis. And breed an army of amoxicillin-resistant superbugs.

    I am with skeptics on this one..

  2. MarcusGP says:

    I must admit I have slightly ambivalent relationship to this article. On the one hand it is very promising, and very well written (the caveats and cautions really show integrity), on the other my nearly complete paper on chronic and sub acute low back pain will need some revisions. ^^

  3. WilliamLawrenceUtridge says:

    I am with skeptics on this one..

    No you’re not. The “skeptics” (in this case, Dr. Hall) are saying it is a potentially useful treatment that needs replication. You’re a reality-denying CAMster.

  4. Scott says:

    Well, he IS right to be concerned about those effects. The authors and Dr. Hall are, too. And it was my first thought on reading the title.

    The more nuanced position of, “this is a concern, but doesn’t necessarily invalidate the idea” seems beyond him, though.

  5. goodnightirene says:

    “I am with skeptics on this one.”

    No you’re not. You just want to pick and choose what to accept and pretend to be a skeptic whenever you decide to “believe” in something that appears to confirm one of your beliefs.

    You have absolutely no clue how this post demonstrates the validity of the scientific method.

    This is the last time I feed the troll.

  6. @WLU
    The issue is, how do you establish that back pain episode is caused by a bacterial infection? You wouldnt want to dispense amoxicillin at every episode of back pain, it would quickly become as useless as penicillin with multiple pathogen strains being resistant to it.

  7. mousethatroared says:

    Well this is not something I wouldn’t have guessed was a possibility. Bacteria and antibiotics are weird, eh?

  8. mousethatroared says:

    FastBuckArtist ” The issue is, how do you establish that back pain episode is caused by a bacterial infection? ”

    That’s covered in the article.

  9. @mousethatroared
    Whats covered in the study is they examined extracted disc material during spinal surgery operations and found bacteria in some of them. Interesting, but you wouldnt do this as routine diagnosis.

    This is all quite suprising. With so many patients suffering from chronic back pain, and taking antibiotics for other conditions (respiratory tract, UTI, GI) you’d think somebody would have noticed in the previous 60 years that low back pain gets better when abx are taken..

  10. mousethatroared says:

    FBA – I was referring to the participants in the study group “Subjects were 162 chronic back pain patients recruited from spine centers. They had to have MRI-confirmed disc herniation within the previous 6-24 months, with Modic type 1 changes on MRI. Subjects had had either conservative or surgical treatment; patients with and without sciatica and neuropathic pain were included.”

    bold mine

    Also see HH’s conclusion “It might justify antibiotics for patients with chronic low back pain and Modic-1 MRI changes following a herniated disc when they have failed to respond to all other treatment options. ”

    So, that’s not just any “episode of back pain”.

  11. mousethatroared says:

    “This is all quite suprising. With so many patients suffering from chronic back pain, and taking antibiotics for other conditions (respiratory tract, UTI, GI) you’d think somebody would have noticed in the previous 60 years that low back pain gets better when abx are taken..”

    One could say the same thing for H. Pylori

  12. Mark Crislip says:

    I have yet to read the originals, but there are issues that bug me

    P. acnes is almost always associated with prosthetic material. I have never seen it in normal tissue that I can remember. Anaerobes do not grow in tissues as a rule but damaged discs are at risk http://www.ncbi.nlm.nih.gov/pubmed/15759942

    And P. acnes is an extremely common contamination in specimens: it is not killed either by topical or IV antibiotics used preventatively in the OR

    And, living mostly in hair follicles, it is not the common organism seen in transient bacteremias, although most of the studies look at dental bacteremias. http://www.ncbi.nlm.nih.gov/pubmed/18541739

    However many of the bugs we get bacteremic with are not culturable , they only can be found with 16S ribosome assays, and the MRI’s in the study that improve look like discitis. And if you want to find P. acnes you often have to hold the cultures longer than the standard 5 days

    It is not unusual for transient bacteremias to go to the disc and cause infection; I see 3 or 4 a year easy, so while I am skeptical about the microbiology, I am not about some back pain being due to infection.

    It would be nice to repeat the study doing molecular techniques to confirm the microbiology

    I am more skeptical about the potential microbiology and less about some responding to antibiotics.

    It is intriguing. But then all disease are either genetic, wear and tear or infection and only the last are interesting.

    If I get a clinical history of slowly progressing back back pain with those MRI changes, I would likely treat them for discitis. There are no cases I could find of bacteremia specifically seeding a disc with prior herniation since I had a recent case due to (presumptively) group B strep. Some of the gamut of P acnes infections and discitis can be found by searching my ID blog over at medscape. http://boards.medscape.com/.29f3af03/

    Eventually I have to hunt down the original references

  13. Mark Crislip says:

    BTW

    Don’t presume that untreated that infected discs will not improve on its own. They do. Just not as often and not as rapidly as treated with abx and it depends on the infecting organism.

  14. @Mark Crislip

    It is not unusual for transient bacteremias to go to the disc and cause infection; I see 3 or 4 a year easy, so while I am skeptical about the microbiology, I am not about some back pain being due to infection.

    How did you diagnose this infection, taking a disc sample during spinal surgery? And how are you treating it at the moment?

    I am concerned if this study is validated, it will lead to mass abuse of amoxiclav – in the study they took it for 100 days, which is a really long time already, and had double the amount of abx diarrea over control group. Since the antibiotic treatment doesnt cure the underlying problem (slipped disc) I imagine the bacteria would return to recolonise the disc right after interruption of the antibiotic intake.

  15. Just to add one more thing – lower back pain in most cases is a transient symptom, self-resolving in most cases, around 80% disappears within 90 days. Considering the study went on for 100 days ( a really long time to be on amoxiclav ) it makes you wonder if this experiment could be better designed.

  16. windriven says:

    @FBA

    I don’t mean this quite as pejorative as it sounds but are you at all scientifically literate?

    You asked, “[H]ow do you establish that back pain episode is caused by a bacterial infection?”

    The researchers conjectured that some LBP was caused by bacterial infection. This conjecture flowed from the observation that bacteria could often be cultured in material removed during surgery in cases that included osteoedema. This led to the hypothesis that, if the disease had a bacterial etiology, a course of appropriate antibiotics might be expected to lead to improvement. They carefully selected a subset of LBP sufferers who met the osteoedema requirement, used a plausible placebo and blinded the patients and clinicians.

    A hypothesis is by its nature predictive and hence disprovable. Had there been no significant difference in outcomes between the Tx group and the placebo group the hypothesis would have been at least narrowly disproved. As it happened there was a significant difference in outcomes. Had there been no infection or if any existing infection was in no way causative of LBP, one would not expect the difference. This suggests that the hypothesis may have merit.

    The authors of the study were careful in their wording and noted that other researchers needed to replicate their results. There was no claim that this therapy should be considered a legitimate therapy for LBP in general, only for the subset presenting with Modic type I changes in their vertebrae.

    This is how science is done. It is not enough to have a conjecture, an untested hypothesis or a handful a anecdotes. Those are the hallmarks of quackery.

  17. @windriven

    You didnt understand my question at all.
    I wasnt asking how the study authors figured out there is an infection. That much is explained in the study, samples were taken during surgery.
    The question I was asking is how does one diagnose this P. acne infection in a clinical patient, someone who presents with a herniated disc. For this treatment to be useful, the condition needs to be diagnosable.

  18. windriven says:

    @FBA

    “the condition needs to be diagnosable”

    That was clearly explained in the article. The hypothesis is that LBP presenting with vertabral osteoedema (which can be confirmed with MRI) may have an infectious etiology susceptible to treatment with antibiotics.

  19. @windriven
    “May Have” is not a diagnosis

  20. windriven says:

    @FBA

    And this is not a treatment. That is the entire point. This is an interesting hypothesis that is being investigated and may lead to a treatment.

    This is the point I was trying to make above. Science done properly does not ejaculate prematurely.

  21. pmoran says:

    I’m puzzled, but perhaps merely ill-informed regarding recent bacteriological discoveries.

    Are these organisms difficult to culture? Why do we not find them elsewhere, for example on blood culture? Or do we now, Mark Crislip??

    It is also weird that these organism of apparently very low virulence should be found at such a high rate in any group of patients, without there being at least some examples of infection with more virulent organisms commonly associated with bacteraemia such as S. Aureus. Or is this a sufficiently anaerobic environment to inhibit these other bugs (and if so why should that be)?

    Lovely exposition, by the way, Harriet.

  22. goodnightirene says:

    @Mark Crislip

    Thank you Dr. Crislip! While reading the post, I kept thinking, “what will Dr. C have to say?” I was going to focus my comment on asking your opinion, but got distracted by the quack.

    @windriven

    FBA isn’t here to understand anything, but rather to express feigned interest (isn’t there a word for that in interwebspeak?). Or maybe I’m just too rude these days, but that’s because I haven’t found a pill for my pain in the ass.

  23. WilliamLawrenceUtridge says:

    The issue is, how do you establish that back pain episode is caused by a bacterial infection? You wouldnt want to dispense amoxicillin at every episode of back pain, it would quickly become as useless as penicillin with multiple pathogen strains being resistant to it.

    Gee, if only the article somehow discussed the value of carefully selecting patients. If only Dr. Hall raised this in the article, perhaps by saying something like “They stressed that their findings applied only to this specific group of patients with disc herniation and Modic-1 changes on MRI, not to all patients with back pain. They also stressed that high-dose long-term antibiotics should not be prescribed without careful consideration because of the risks to individuals and to the community (antibiotic resistance).”

    Oh, hold on, that’s a direct quote of Dr. Hall’s post. Do you even read these? It’s hard not to call you an idiot at this point. Fortunately “troll” is equivalent. Troll.

    I am concerned if this study is validated, it will lead to mass abuse of amoxiclav – in the study they took it for 100 days, which is a really long time already, and had double the amount of abx diarrea over control group. Since the antibiotic treatment doesnt cure the underlying problem (slipped disc) I imagine the bacteria would return to recolonise the disc right after interruption of the antibiotic intake.

    Fortunately antibiotics aren’t available over the counter so doctors will act as gatekeepers. Fortunately as well, this is the first of several studies on this hypothesis, so we can work on refining things over the years.

  24. Mark Crislip says:

    P. acnes is not hard to grow, just slow to grow. If you are worried ask the lab to hold the specimen for 2 weeks and it grow day 8 or so. I see the bug in all sorts of post op infections associated with hardware, never yet in a blood culture. Most anaerobes are not tolerant of O2 and die quickly. The blood has lot of oxygen in it.

    If you want a clinical flavor with all sorts of spelling and grammer mistakes:

    http://boards.medscape.com/forums?128@136.9jcRac65gub@.29f67951!comment=1
    http://boards.medscape.com/forums?128@136.9jcRac65gub@.29f7ba4f!comment=1
    http://boards.medscape.com/forums?128@136.9jcRac65gub@.2a0889c2!comment=1
    http://boards.medscape.com/forums?128@136.9jcRac65gub@.2a2ea376!comment=1
    http://boards.medscape.com/forums?128@136.9jcRac65gub@.2a577c78!comment=1

    But you have to be a member

  25. ConspicuousCarl says:

    Why should FBA, a homeopath apparently, even care about antibiotic resistance? If his mookie stink were real, we wouldn’t need antibiotics. The fake concern over difficult diagnosis is equally ridiculous for someone of his repute.

    Sayeth the swindler,
    “Since the antibiotic treatment doesnt cure the underlying problem
    (slipped disc) I imagine the bacteria would return to recolonise the
    disc right after interruption of the antibiotic intake.”

    You imagined, and yet the test group continued to IMPROVE for 265 days after the end of treatment?

  26. ConspicuousCarl says:

    Dr. Hall or Crislip,

    If either of you have the full paper, is the improvement well spread across all test patients, or was it clumped with some of them accounting for most of the change? It would also be interesting if there is enough info to see if the improvement level corresponds to any differences in severity of whatever initial criteria (sounds like some kind of swelling?) was seen in the MRI.

  27. Harriet Hall says:

    @Carl,
    Good questions. Unfortunately my computer had a psychotic break and is in the Apple hospital awaiting a video card transplant, and I can’t get at my copy of the article until I get the computer back. I’ll try to remember to look this up and get back to you.

  28. mattyp says:

    I read this with cautious excitement. I agree with Harriet in that it is a well designed study and the study itself offers caution.

    I notice some of my colleagues are trying to say it’s a “swing and a miss” for medicine (yeah, I know, right). I think it could be a useful therapy for a subgroup of patients that don’t respond to previous therapies.

    It demands replication. I await with interest. :-)

    I can get the original to you if you like, Carl.

  29. Badly Shaved Monkey says:

    Um, FBA, if you shoot from the hip you foot is a highly likely target;

    I wasnt asking how the study authors figured out there is an infection. That much is explained in the study, samples were taken during surgery.

    Look back at what Dr Hall wrote and find these words “patients in one study. Another study”. Bacteria were recovered from disc material in different patients who were undergoing surgery. The patients in the double-blind medical study that is being discussed were not undergoing surgery. That’s kinda the whole point. They were diagnosed from clinical features including MRI findings. The study then tested whether, acting on those findings and based on previous information that these findings may be associated with bacterial infection, antibiotics effectively treat those patients.

    A valid point is whether a long antibiotic course is better that surgery in that group of patients. You can treat infection with antibiotics. You can also cut out a nidus of infection at surgery. What is actually needed in due course would be a trial comparing outcomes and complications of patients undergoing surgery vs an antibiotic course and also a long-term follow-up is required. Maybe cutting out infection works better in the long-term because bacterial infections can recrudesce when the vulnerable site remains. A comparison would be infection associated with an orthopaedic implant. Maybe infection can be controlled with antibiotics, but maybe the problem will only truly go away permanently if the implant is removed. These are valid questions that need to be answered at some point.

  30. elburto says:

    @BadlyShavedMonkey -

    At this point I’m convinced it’s a bot. It’s reacting to key words in the post without being able to to parse meaning from them. Every “skeptical” question it asks/statement it makes* is covered right there in Dr Hall’s (not very long) post

    Perhaps it’s a thousand monkeys with a thousand keyboards, but whatever it is it apparently cannot read for meaning, only for trigger words. Anyone remember the ThingyBot? (based on a notorious SBM/scienceblogs troll) Just like that.

    *For example:

    “[H]ow do you establish that back pain episode is caused by a bacterial infection?”

    Wow.

    ” [L]ower back pain in most cases is a transient symptom, self-resolving in most cases”

    Which is why the study’s participants had chronic, unresolved LBP, and weren’t selected from people visiting an urgent care centre, complaining of LBP

    ” You wouldnt want to dispense amoxicillin at every episode of back pain”

    Gee thanks for the heads up C. Everett Loopy. Good job nobody was advocating that.

  31. BillyJoe7 says:

    Why is anyone still bothering to respond to that individual.
    Every question he asked was already answered in Harriet very clear and concise post.
    Every statement he made was either irrelevant or wrong.
    And despite being responded to and corrected, not a single admission of error has been made by that individual.

    I say to hell with him.

  32. windriven says:

    @BillyJoe et al

    “Why is anyone still bothering to respond to that individual.”

    Amen. A number of us spent a good deal of time trying to have a meaningful dialogue with him. But as you suggest, there was never any indication that anything was getting through. Ignorance that refractory is either stupidity unrecognized or naked trolling. Either way it is a waste of time. I’m done with him.

  33. mousethatroared says:

    BillyJoe “Why is anyone still bothering to respond to that individual.”

    Aside from the perverse satisfaction of being able to quote directly from an article to show that they clearly didn’t read it?

    I was just having a “Someone said something wrong on the internet” moment.

  34. @Badly Shaved

    I see now, indeed I missed the “another study” part, must have skimmed it quickly.
    I am still unclear why they had to keep them on amoxiclav for so long. Was a shorter course not effective?

    1. Harriet Hall says:

      @FastBuckArtist,
      “I am still unclear why they had to keep them on amoxiclav for so long”

      Apparently you missed or misunderstood what my article clearly explained: “The antibiotic, amoxicillin-clavulanate (500mg/125mg), was given 3 times a day for 100 days, consistent with the recommendations of infectious disease experts based on bacterial culture results of previous studies.” Experts in infectious disease judged that a shorter course would be less likely to be effective, based on currently available medical evidence. There is no way to know whether a shorter course was effective, since it was not tested. That might be a subject for future investigations.

  35. @Harriet

    Experts in infectious disease judged that a shorter course would be less likely to be effective, based on currently available medical evidence.

    Where might we find this evidence? I see that the common antibiotic course for post operative discitis is 6 weeks, which is already a long time to be on broad spectrum abx like amoxiclav.

    BTW, the reason I am interested, I dont do any spinal surgery, but people come in after surgery with gastrointestinal problems and ask if they can get off the drugs earlier.

  36. Harriet Hall says:

    @FastBuckArtist,

    “Where might we find this evidence?”

    I don’t know. I’m not an expert in infectious disease. While there is evidence about treating various infections, I don’t think there is any evidence that would apply to this particular situation, so it is reasonable to fall back on “expert opinion” based on their knowledge and experience in treating other infections. Not as good as solid evidence-based recommendations, but the best we can do under the circumstances. I trust them to know their area of expertise better than I could hope to do, and I wouldn’t presume to second-guess them based on a single fact like recommendations for post operative discitis.

  37. weing says:

    “BTW, the reason I am interested, I dont do any spinal surgery, but people come in after surgery with gastrointestinal problems and ask if they can get off the drugs earlier.”

    Tell them to ask the doctor that prescribed the meds.

  38. @weing

    Tell them to ask the doctor that prescribed the meds.

    They’ve already done that before they came to see me.
    Do you send your patients who are on naturopathic meds back to the doctor who prescribed them as well? :)

  39. weing says:

    @FBA
    Interesting. So, I presume they were told no. Just for hypotheticals. If you tell them to stop the meds, and they get a rip-roaring discitis and abscess and end up paralyzed from the waist down, who do they get to sue?

  40. @weing

    Interesting. So, I presume they were told no.

    Usually, the MD just didnt take their side effects seriously. Or didnt want to. Or didnt listen to their concerns at all. Due to malpractice fears you have alluded to, often the MD is afraid to have any kind of opinion and simply follows the protocols written by pharmaceutical sales reps, and published by the national college of infectious disease:
    - patient shows up with urinary tract infection? Give them Bactrim for 3 days
    - still sick? give them Cipro for 7 days
    - still have some symptoms? give them levofloxacin for 7 days.
    - more problems? refer to ID specialist
    - If you followed the script to the letter, we absolve you of any legal liability! Done!

    When patients get fed up with talking to drug-dispensing protocol robots, they come to an alternative practitioner who actually listens to what they have to say and treats their concerns seriously.

  41. windriven says:

    @weing

    Amazing. Fast Buckie strings together a whole lot of words but never quite manages to answer your question. He sidesteps both the legal and the ethical consequences of playing doctor. But of course consequences don’t matter because hereally cares while MDs are just in it for the money.

  42. weing says:

    @windriven,

    Amazing indeed. He still hasn’t answered my question. I have no idea what he is ranting about. It seems, in FBAs world, bacteria that are resistant to courses of Bactrim and Fluoroquinolones don’t cause sepsis if left untreated and are sensitive to listening.

  43. @weing

    You havent answered my question either. Do you return patients who are on natural medications back to the ND who prescribed them?

    I said nothing about bacteria being sensitive to listening.

  44. BillyJoe7 says:

    Now that person is asking a rhetorical question and actually expecting someone to reply!

  45. WilliamLawrenceUtridge says:

    But of course consequences don’t matter because he really cares while MDs are just in it for the money.

    I wonder if he only accepts barter for goats milk, or simply does it for the satisfaction. Because clearly, he wouldn’t accept money like some sort of greedy doctor or pharmaceutical company. I bet he distills the vitamins out of dandelion leaves and deer placenta, so he doesn’t have to buy them from a supplement manufacturer (most of whom are profit-centres for Big Pharma). Otherwise, troll would be a massive hypocrite.

  46. BillyJoe7 says:

    …and completely misses a joke with a message that is actually important for him to grasp.
    There is no hope.

  47. weing says:

    “Do you return patients who are on natural medications back to the ND who prescribed them?”

    I tell patients that they are free to see quacks at their own risk.

  48. @weing

    If you tell them to stop the meds, and they get a rip-roaring discitis and abscess and end up paralyzed from the waist down, who do they get to sue?

    I dont tell them to stop the meds. I tell them what the consequences of using the drugs are, and what are the rehabilitation options. Nobody gets sued.

  49. ixkmanxi says:

    I am a health 32 year old male. I had chronic dull lower back pain for 16 months. It bothered me every day and started effecting my daily life. After 4 doctors, blood test, anti inflammatories, x-ray, and MRI, I was told I had a damaged L5 and the rest of my life would consist of avoiding flare ups and pain management. As I stated, I am healthy and in great shape. I can run 5 miles in 30 min and eat very healthy. Living with pain management made no sense. Time passed and because I do run, occasionally I get ingrown toenails. One of these got really infected so I went to a podiatrist. He removed the toenail and prescribed an antibiotic to eliminate the infection. I took an antibiotic for 10 days and cured both my infected toenail and my lower back pain……….. Who wants to argue with proof now?

  50. @ixkman: Thanks for the testimonial. What antibiotic did you take for the toenail infection?

  51. Badly Shaved Monkey says:

    @ixkmanxion

    It’s certainly an interesting story, but as advocates of SBM we need to keep discipline and note that your recovery may still not be causally related to the antibiotic. That’s why controlled trials are done, to remove coincidental changes from consideration.

    And similarly, FBA, one case and one antibiotic given for one duration gives the basis for a testable hypothesis not for the drawing of causal inferences.

    And while I’m addressing some loose ends;

    “Do you return patients who are on natural medications back to the ND who prescribed them?”

    As a vet we do get some of this and my approach would depend on the circumstances, but given that essentially no “natural medications” have any therapeutic benefit little is gained by referring clients back to the muppets who misled them. Generally, I think if a client perceives there to be problems of some sort with a “natural medication” I think that is the ideal opportunity to gently dissuade them from pursuing that line any further.

  52. BillyJoe7 says:

    I thought ixkmanxi’s comment was tongue in cheek.
    Oh well…

  53. ixkmanxi says:

    This all took place in February of this year. I took a 10 day course of sulfameth trimethoprim 800/160. Generic form of Bactrim.

  54. vance says:

    Lets not forget the anti-inflammatory effects of antibiotics in general.

    I have experienced relief of back pain when treated for other infections with antibiotics. So this begets the question, what is it, the killing off of bacteria or the anti-inflammatory effects of antibiotics in general?

  55. vance says:

    @ixkmanxi

    Could the abstinence from running while he toenail surgery healed have givinen enough rest to relieve the back pain?

  56. ixkmanxi says:

    Didnt run for 4 days due to toenail…. I have taken 2 weeks off for back pain alone in the past with no back pain relief.

  57. jhawk says:

    Harriet,

    So what you are saying in this post is that chiropractors should have antibiotic prescription rights!! (sarcasm everyone, sarcasm!)

    Pretty cool study, hopefully it can be replicated.

    Did the study mention what and how long the conservative treatment was that was ineffective?

  58. BillyJoe7 says:

    ixkmanxi,

    I’m sorry that you think your anecdote is proof of anything. I really did think that comment at the end of your post was tongue in cheek. This is probably the first and most important lesson in science based medicine: you can generate hypotheses from anecdotes and then design trials to test these hypotheses, but the anecdotes themselves are not proof of anything. Not understanding this is the basis of most CAM treatments and its the reason most CAM treatments don’t work. Most things that you intuitively think are true are not true. So stop fooling yourself and run that trial. Better still, read about scientists who have evaluated the trials that have been done.

  59. BillyJoe7 says:

    Personally, I don’t use any treatments that aren’t at least scientifically plausible and then only if there are no evidence based treatments available. Otherwise it’s just like playing the lottery – a complete waste of time and money considering that the life time odds of winning are close to zero.

  60. daedalus2u says:

    BJ, an anecdote is not proof positive (or proof negative) for anything. But a positive anecdote is still positive evidence, albeit positive evidence of low statistical power. An anecdote of resolution of low back pain following a course of antibiotics provides no evidence whatsoever that antibiotics do not resolve low back pain. An anecdote of antibiotics being associated with resolution of low back pain can only increase the Bayesian posterior plausibility of the intervention, it cannot decrease it.

    There could be multiple reasons for resolution of symptoms. Physiology is really complicated, non-linear and all of the systems are coupled together at the level of noise. Physiology is so sensitive, that sometimes just thinking about it can cause changes. That is a lot of how the placebo effect works, people are induced to think they are getting better, and so they feel they do get better. Sometimes that “getting better” is just an illusion, but sometimes it is not.

    Antibiotics could be having effects even if low back pain is not due to an infection. Essentially every condition that is associated with any type of pain has some degree of inflammation. Like every other physiological state, a state of inflammation is regulated by physiology. The regulation of inflammation is complicated. There are a zillion pro-inflammatory and anti-inflammatory agents, in each tissue compartment.

    One thing that antibiotics do is kill bacteria that are sensitive to that particular antibiotic. Those bacteria then lyse and spill their cytoplasm wherever they are. Physiology responds to bacterial cell contents by releasing pro-inflammatory cytokines (the Jarisch-Herxheimer reaction). Physiology responds to pro-inflammatory cytokines by releasing anti-inflammatory cytokines. There are always lots of susceptible bacteria in the gut. So the effects of a particular antibiotic could be mediated through direct effects of the antibiotic on susceptible bacteria, through the effects of the pro-inflammatory cytokines produced through the Jarisch-Herxheimer reaction, or to the anti-inflammatory rebound from the pro-inflammatory reaction.

    Depending on what is the cause of the low back pain, a particular type of antibiotic may or may not be effective. If the “cause” is self-sustaining inflammation, perhaps the presence of sufficient susceptible bacteria in the gut is necessary for a sufficient pro- and then anti-inflammatory reaction to “reset” the state of inflammation of that tissue compartment. But if that is the mechanism, then taking an anti-inflammatory may prevent the resolution.

  61. Harriet Hall says:

    ixkmanxi’s anecdote is inconsistent with the study, which reported slow improvement over far longer than 10 days.

    Anecdotes are helpful guides to things that might be worth studying, but they only show apparent associations, not actual correlations, much less causation. They are subject to the post hoc ergo propter hoc fallacy. They may represent simple coincidence with fluctuations in the natural course of a disease.

    My favorite example was a friend who tried several conventional treatments for low back pain and finally decided to try a chiropractor as a last resort. He called on a Friday and was given an appointment for Monday. On Saturday his back pain vanished never to return. If he had seen the chiropractor on Friday, he would have believed forever after that the chiropractor had cured him.

    Or maybe you think his experience proves that the act of phoning a chiropractor’s office is an effective treatment for back pain. Should we do a controlled study to test that? :-)

  62. ixkmanxi says:

    Billyjoe7 you have the right to draw your own conclusions. With that said, thats all you have. I on the other hand have a personal experience I was sharing with the group. At the end of the day I don’t really care if you (Billyjoe7) benefit at all by my posts. Hey, its my back that is no longer hurting and thats good enough for me. Maybe you will be one of the fortunate people never to experience lower back pain however, if you do experience lower back pain and decide to post about your first hand encounter, I will not be the guy in the forum to discredit you just for the hell of it to make myself feel bigger or better. Nope thats not me. I will be the guy moving on enjoying life without chronic lower back pain.

  63. fasty23 says:

    Can I ask a question about the injectionton antibiotic to disk area?

  64. BillyJoe7 says:

    d2u,

    I can’t see anything in my posts that you actually disagree with. And vice versa.
    ….unless you think I should try a ten day course of Bactrim next time I get back pain on the basis of plausibility and a single anecdote.

  65. BillyJoe7 says:

    ixkmanix,

    Hmmm…I really did have you figured wrong hey?
    I was just trying to do you a favour, but it seems your biases won’t allow you to learn something new.
    In short, that personal experience = anecdote =/= proof.
    Take it or leave it at this point of the discussion, though I do have to wonder why you’re hanging around on a science based medicine blog.

    And, in fact, I have had an episode of severe back pain and I have already shared it a couple of times with the posters here. And I did so in a context similar to the present discussion, to demonstrate how personal experience (ie anecdote) is not proof of anything.
    My anecdote had the same message as Harriet Hall’s anecdote above, so I won’t repeat mine here.

  66. FibroLogic says:

    Just skimming through the comments it doesn’t look like anyone else has picked up that the authors of these studies have a significant undeclared conflict of interest. It appears that Albert, Sorenson, and Manniche are all part of a “MAST Academy” that is involved in promoting the use of antibiotics as a treatment for lower back pain.

    I found this out via this website: http://ferretfancier.blogspot.co.uk/2013/05/antibiotics-for-back-pain-conflicts-of.html
    Quote from the above website:
    “3 of the 4 authors are involved with a private company that appears designed to make money out of patients and clinicians in diagnosing and treating back pain with antibiotics. Indeed these 3 authors are all MAST ‘Academy’ members. The first major problem I have with their study is the fact that they declared to the journal that they had ‘no competing interests’. This appears dubious at best.”

    “MAST” stands for “Modic Antibiotic Spine Therapy”, which appears to be an organisation (company?) that promotes the use of antibiotics for lower back pain where modic changes are present. According to their website, the MAST Academy are:
    “The MAST Academy is comprised of leading international researchers and clinicians with vast experience in this field. Members of the MAST Medical Academy are; Dr Hanne Albert PhD, Professor Claus Manniche, MD PhD, Dr Joan Sørensen, Consultant Radiologist, Mr Peter Hamlyn, Consultant Neurospinal Surgeon, Dr Alan Jordan PhD. This group is responsible for the teaching and examinations related to becoming a MAST certified practitioner as well as informing the general public about Modic and its ramifications in an ethical and responsible manner.”

    The MAST website is here: http://mastmedical.com/frontpage_en/

    I can’t access the full articles online to double check if they have actually disclosed this conflict of interest somewhere. The abstract info I was able to get online simply listed author affiliations for the 3 authors in question as:
    “Research Department, Spine Centre of Southern Denmark, Institute of Regional Health Services Research, Lillebaelt Hospital, University of Southern Denmark, Middelfart, Denmark”

    I did manage to find the Conflict of Interest declaration form for the European Spine Journal, which states:
    “It is the policy of the European Spine Journal to ensure balance, independence, objectivity, and
    scientific rigor in the journal. All authors are expected to disclose to the readers any real or apparent
    conflict(s) of interest that may have a direct bearing on the subject matter of the article. This
    pertains to relationships with pharmaceutical companies, biomedical device manufacturers or other
    corporations whose products or services may be related to the subject matter of the article or who
    have sponsored the study.”

    I haven’t looked much deeper into this, but it raises a lot of red flags with regards to the integrity of the research if this clear conflict of interest hasn’t been disclosed.

  67. @FibroLogic

    It’s rare for study authors to have truly no conflict of interest.. either they are from the company trialling the drug (direct conflict of interest) or working in some related medical field or otherwise financially entangled with the results.

    I am bracing for an influx of patients with GI disorders. Have no doubt all the patients with chronic back pain have started popping generic amoxicillin the day after they read the news.

  68. BillyJoe7 says:

    … Only if they had the reading comprehension of our resident fast buckling cam artist.
    The case of the missing Clavulanate.

  69. John Ware says:

    Fastbuckartist says: “I am bracing for an influx of patients with GI disorders. Have no doubt all the patients with chronic back pain have started popping generic amoxicillin the day after they read the news.”

    Based on what I’ve read from you so far, I’m quite certain that your strong tendency towards confirmation bias will ensure that the above statement comes true in your world.

    I’m not sure what “brand” of health care you claim to provide, but your cynicism towards traditional, allopathic medicine is remarkable. I have to wonder if you direct the same level of “skepticism” at all the whacked out crap that comes out of the CAM industry by, dare I say, the legions of fast-buck artists that populate it.

    Having said that, I am concerned that this study will significantly increase the already burgeoning over-use of MRI for patients with persistent low back pain.

  70. @John Ware

    I have to wonder if you direct the same level of “skepticism” at all the whacked out crap that comes out of the CAM industry by, dare I say, the legions of fast-buck artists that populate it.

    You’d be surprised, I am considered a skeptic by the altmed practitioners :)

    - My peers are not impressed with my support for FDA for example, they believe its a thoroughly corrupt organisation that should be shut down completely. I see it as a necessary agency that has its faults but does an important job.
    - I get called a pharma shill for recommending antibiotics over natural antibacterials for certain infections.
    - I get even more grief from naturopaths for recommending invasive surgical procedures where they are needed.
    - I get attacked over my support for licensing and certification of alternative medical professionals. From both sides mind you, the fanatical allopaths oppose any kind of altmed practice, and the libertarian minded alties oppose any kind of licensing for medicine in general.

    Its not easy to be an Integrative Doc, you are a target for cultist fanatics on all sides.

  71. John Ware says:

    @FBA

    So, it sounds like you get razzed by loons for complaining about the color of the walls on the mothership.

    For the record, I oppose “altmed practice” and “integrative medicine” because they are just New Age terms for pseudo- and anti-scientific quackery. (And please don’t wreck this thread by trying to convince me otherwise.)

    I see lots wrong with modern health care delivery systems, but I’m not going to blame these shortcomings on some paranoid perception of the scientific method- otherwise referred to as “ignorance”.

  72. fasty23 says:

    Hi
    I had chronic backache for a long time. Last time I got backache 2 months ago again, I tried so many ways to treatment but they were not successful (I didn’t have time for long time resting).
    So I started antibiotic 2 days ago. Unfortunately I just have antibiotic for 5 days, I try to find more. ( I know that was stupid decide “start antibiotic period without enough antibiotic. But I hope i find it).
    I will comment the result here.
    Regards

  73. See, the study is barely out, and people are popping antibiotics for their backpain already.

    @fasty23

    Fasty, have you tried physiotherapy and bodywork? In my practice, most people found lasting relief from backpain by doing the right exercises to strengthen their back muscles. The antibiotics may kill the infection, but you also need to address the cause of the damage, structural imbalance causing high load on your lumbar spine.

  74. WilliamLawrenceUtridge says:

    @fasty23

    Keep this up and all you’re really doing is breeding antibiotic-resistant bacteria, which will ensure that even if they are the cause of your backache, you won’t be able to treat them.

    It is truly, truly unfortunate that we don’t have a better treatment for back pain. It is truly, truly unfortunate that we don’t have a way of speeding the necessary clinical trials to test whether this is actually an effective form of treatment. I wish “we must be patient” wasn’t such a depressing necessity, and I wish that biology were easily, safely and reliably fixed. Sadly none of this is true and we basically have to wait.

    Sorry about that.

  75. madmidgitz says:

    You know FBA showed up just after jake the creationist troll ran away(or got banned?)
    Could FBA just be jake with a little higher sofisticated method of trolling?

    May the creator touch you with his noodly appendages
    And may pesto be upon you
    r’Amen

  76. madmidgitz says:

    FBA could give a course to jake from AOA(a diferrent one from creationist jake) on how to play the “im really a skeptic but why dont we use s’CAM methods” troll

    r’Amen

  77. John Ware says:

    FBA says: “Fasty, have you tried physiotherapy and bodywork? In my practice, most people found lasting relief from backpain by doing the right exercises to strengthen their back muscles. The antibiotics may kill the infection, but you also need to address the cause of the damage, structural imbalance causing high load on your lumbar spine.”

    Alright, now you’re in my wheelhouse- I’m a PT- and it’s clear that you have no idea what you’re talking about. I’ve been practicing PT for over 18 years and I’ve never performed “bodywork” on anyone. Why would you lump these together as if they’re a package of some sort?

    There is NO relationship between back muscle strength and pain. Period.

    The idea that there is an identifiable structural “cause” of most persistent low back pain is misguided at best. This is not to mention the blatant hypocrisy of your suggesting that there is, but then when a study comes out proposing a treatment to address a specific cause related to a structural pathology (Modic changes), you begin your best impression of Chicken Little. You’re just another one of those anti-medical-establishmentarians, like all the rest of the CAM’ers. You’re knee-jerk and predictably so.

    If you’d read any of the epidemiological studies on chronic low back pain (pariticularly the twin spine studies) you’d know that occupations with “high loads” do not predict incidence of chronic low back pain. And what in the name of Hades is “structural imbalance”?

    I wish I could say that I appreciate the endorsement, but I don’t want to have anything to do with the inaccuracies and ignorance that come along with it.

    Please stay out of my wheelhouse.

  78. @John Ware

    WHAT are you ranting about now? You have to be trolling me, there is no way a real physiotherapist doesnt understand the role of core muscle strengthening in prevention of back pain. Its what a PT does every working day.

    Please find out what a physiotherapist actually does before you pretend to be one. You are on a medical website not youtube comments section.

  79. WilliamLawrenceUtridge says:

    I find it amusing that a naturopathic troll is citing a physiotherapist. I find it amusing and indicative that a naturopathic troll is citing a physiotherapist as if it represented the entire profession. I find it hugely amusing and indicative that the naturopathic troll bundles physiotherapy and bodywork together, without defining which kind of bodywork (vanilla variant of massage? Crazy irrational nutter variant of massage that thinks memories are stored in the body? Variant of therapeutic touch? Just another word for exercise?). So in this one post we have a) parasitism on science, b) straw man and c) bait-and-switch with a couple easily-relocated goalposts built in. A quackery trifecta!

    Yep, low back pain is complicated and if anyone claims they’ve got the answer, they’re lying, deluded or both.

  80. mousethatroared says:

    WLU “Yep, low back pain is complicated and if anyone claims they’ve got the answer, they’re lying, deluded or both.”

    “I boast nothing, but plainly say, we all labor against our own cure, for death is the cure of all diseases. ”

    - SIR THOMAS BROWNE, Religio Medici

  81. mousethatroared says:

    Oh, that was rather grim. Sorry…

  82. John Ware says:

    I am exactly who I say I am (https://alliedhealth.lsuhsc.edu/physicaltherapy/Ware.aspx)- not some anonymous internet troll who pretends to be a “doctor” by preying on innocent and often desperate individuals with a health malady.

    Princeton, for all of its high academic standards, doesn’t even have a Physical Therapy school. So, your attempted argument from authority is seriously lacking in the authority department.

    If you’re interested in a truly authoritative, well-informed and well-referenced review of the concept of “core stability”, I suggest you take a look at this piece by Professor Eyal Lederman: http://www.cpdo.net/myth_of_core_stability.doc

  83. @ John Ware

    I wonder if you actually read that paper by Lederman or you just threw it in here to appear like you know something without reading it.

    Lederman acknowledges core strengthening exercises improve back pain prevention and cited 5 studies to back it up. The “myth” he refers to is that specific core-muscle training is better than broad-scope overall body training. There are indeed recent studies that challenge the idea of focus on core muscles is better than focus on full-body exercise, which is hardly a discovery as full-body exercise also strengthens core muscles. Duh!

    Thanks for hijacking the thread, showing rude manners, condescending attitude, and intolerance to any view different of your own, you fit in perfectly with the allopathic cult. The other cultists will approve of your zeal.

  84. WilliamLawrenceUtridge says:

    @MTR

    Touche, I chuckled.

    @FBA

    AHAHAHAHAHA you trolling hypocrite.

  85. John Ware says:

    So, now “core stability” is something else? There go the goalposts further into the fog of sloppy reasoning yet again.

    FBA has impugned my integrity twice now in this thread. That is my limit.

    I’m surprised that the administrators here at SBM allow a peddler of quackery such a long leash.

  86. fasty23 says:

    Hi
    This is the fifth day of using antibiotic, interesting! I feel better.
    I know the Hazards of using antibiotics, I know people shouldn’t use antibiotic without prescription …
    But I was frustrated from long time backache, I tried so many methods, but when the backache came back the only way reduced my back pain, was resting for long term (30 days) and after that I should use multiple methods and reduce my activity, never my backache finished completely.
    This is the first time my backache cure so fast without resting. It’s look like miracles.
    One of the reasons that made me this decision is I’ve noticed 3 of my friends had surgery for their back pain had chronic wound in their skin. And me too I didn’t care my skin alot; my gums had bleeding sometimes, my thumb nail wounded my feet, i had some boil in my skin and i used to pick at that boil. It shows Propionibacterium was rampant in my blood, because of that back pain disappear nevertheless all methods for backache.
    Sorry for interference to physician’s word.
    I’m happy now after 2 months, my juvenile will come back :) and I will do sport again :)

  87. fasty23 says:

    Correction:
    because of that, back pain was NOT disappear nevertheless all methods for backache.

  88. WilliamLawrenceUtridge says:

    @John Ware

    Dr. Gorski has repeatedly stated that he is a very strong supporter of freedom of speech, thus most trolls are given extremely long latitudes on this blog. FBA is far from the worst we’ve seen (everyone remember RusticHealthy? And you can hear the groans from space…)

    Fasty, it’s not that we’re not unsympathetic or helpful – it’s just that I doubt anyone here will be convinced or care about your n=1 trial. Single subject studies tell us nothing that is scientifically useful (and given the peculiarly variable nature of back pain, as well as the notorious susceptiblity of pain to placebo effects, for this specific topic the problem is especially acute). Not to mention the original study gave antibiotics for 100 days, not a week. Even if you are a candidate for this treatment, even if your back pain is caused by bacteria – your n=1 trial may have done little except guarantee you can’t benefit from it.

    It would be nice if science could move faster. But no doubt, even as we speak multiple replications are in progress.

  89. John Ware says:

    William,
    I’m all for these CAM loons making fools of themselves on blogs like this by showing the world how miserably inept they are at sound reasoning. Your identification of the “CAM-trifecta” is a brilliant example of that.

    But, when they accuse others of misrepresenting their credentials (for cryin out loud- this is my real name!) and posting references that they haven’t read, then I think it crosses from the realm of CAM-loonery to CAM-hostility. It’s a fine line, and in my experience, the more persistent CAMers invariable resort to it.

    How could any rational human being who peddles something like homeopathy NOT have a deep-seated antipathy for humanity.

  90. fasty23 says:

    Dear WilliamLawrenceUtridge
    I don’t know about n=1 trial benefit and I don’t follow any benefit. The most important thing is curing my back pain.
    I have to mention I don’t have only back pain, I have numbness and pain in my feet this ( these symptoms are curing). I am familiar with placebo effects, and I know antibiotic couldn’t effect in just 5 days at joints. I expected I would see the effect after at least 50 days, but it happened., wired!!! . Meanwhile I combined other methods for curing back pain with using antibiotic for better result.
    I owe them for this discovery.

  91. WilliamLawrenceUtridge says:

    Yes, Fasty, you are feeling better now. But if you are using several methods for curing back pain at once, you can never know what actually cured you. Was it the antibiotics? The exercises you may be doing? Or the oregano in the spaghetti you had for dinner last night? And are you truly cured? How long have you been taking the vitamins? How long have you been without back pain? How long were you in pain versus how long were your pain-free periods?

    Understanding placebo effects isn’t the same thing as being immune to them.

    I do hope it’s a genuine, permanent cure. In fact, I encourage you to come back to SBM every couple months to note how you’re doing, to see if your improvements are persisting. It’s a less formal version of the careful record-keeping you need to do good research.

  92. vadaisy says:

    It would be interesting to learn if people who have had artificial joint implants are more susceptible to this type of arthritis. If, for example, an infection within the implant area could spread to the spine and cause worsening arthritis. Would this type of infection always be readily apparent in basic blood work?

    1. Harriet Hall says:

      You have misunderstood. This study was about patients with herniated discs who had bone edema. It has nothing to do with arthritis.

  93. vadaisy says:

    Thank you for clairifying that. I was likely thrown off by the mention of Lyme disease, and began thinking about arthritis. I’ve always assumed that most people with any type of degenerative disc disease have it due to some type of arthritis, and had never heard of bone edema prior to reading this article. Thank you so much for the helpful information.

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