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Re: antibiotics for back pain

A recent study into the use of antibiotics as a cure for back pain was completed in Denmark and published in the European Spine Journal in early May. A press conference was held to publicise the findings and newspapers widely reported the research. The articles claimed that 40% of back pain could be cured by antibiotics, there was even mention that the research could be worthy of a Nobel Prize. As an Alexander teacher with a particular interest in back pain, I was interested to take a closer look at the findings.

Firstly the BMJ take (14 May 2013):

The trial was a randomised double blind controlled trial of 162 patients with a history of at least six months of low back pain and previous disc herniation that was visible with magnetic resonance imaging (MRI).

A few news reports urged caution. The Canadian Globe and Mail quoted a physician who said that there were “dozens of causes of back pain” that would not respond to antibiotics. The Independent reported from the press conference: “The examination can only be carried out by a practitioner trained to recognise the changes and distinguish pain caused by infection from that due to other causes.”

Martin Underwood, professor of primary care research at Warwick Medical School and who has chaired National Institute for Health Care Excellence (NICE) guidelines on low back pain, told the BMJ, “These are promising preliminary findings, but it is too soon to start changing practice on their basis until they have been replicated in other studies and in other populations.” He went on, “These findings are only relevant to a small minority of people with chronic back pain who have both degenerative changes and evidence of modic changes.”

From BMJ responses: G Lorimer Moseley – Clinical Scientist – University of South Australia - replies

I believe that chronic back pain is a multifactorial problem

. I believe that persistent pain is associated with changes in sensitivity throughout the nociceptive neuraxis, and with multiple system dysfunction. I believe that persistent pain is evidence that the brain still concludes that a body part needs protecting and working out why this is the case can be very very difficult. I believe the evidence in support of my position is very compelling. It is difficult for people in pain to accept this position because it implies that the journey to recovery will necessarily be a long and difficult one, rather than a short and easy one.

This is not the first study to claim a simple cure for back pain – a recent example is that of an RCT of injecting blue dye into the disc, which had better outcomes than the antibiotic study, and was accompanied by an editorial raising the possibility that is was a ‘cure’1, but it didn’t get anything close to the hype that the antibiotic paper did (perhaps including ‘Nobel’ in the media release was the key). We must remember that patients probably don’t hear the qualifying statements that put the idea of ‘cure’ into context – they just have a new reason to hang on to an outdated model of their chronic pain.

From Rheumatology Update:

A widely publicised study which claimed antibiotics could relieve up to 40% of lower back pain failed to disclose its authors’ potential conflicts of interest, it has emerged.

Three authors did not state they serve on the board of a UK company that receives money to certify doctors in antibiotic therapy.

The publicly-listed Modic Antibiotic Spine Therapy Academy, or MAST Academy, charges £200 ($310) to certify doctors in how to identify and treat modic back pain with antibiotics. Clinicians can alternatively take an online course for £100 ($155).

The authors claimed that the cause of up to 40% of lower-back pain was a common infection in the vertebrae that could be cured by antibiotics.

The randomised double-blind trial concluded that 100 days of amoxicillin with clavulanic acid reduced disability and pain compared to a placebo in 162 patients with chronic lower back pain associated with vertebral bone edema.

Dr Michael Vagg, a pain specialist at Deakin University, told Fairfax Media that while the link between bacterial infections and some back pain was plausible, the authors had not shown that the infection in question was the cause of the patients’ pain.

“They don’t have the science to entitle them to make the sort of claims they’re making,

” he said.

It would seem that the newspapers were guilty of hype and some of the writers were guilty of a lack of serious scientific investigation. We know that back pain can be attributed to a number of causes and the most common cause is muscle spasm. Disc related injuries are less common. In our work as Alexander Teachers we work with correcting misuse – a term which covers how we use our bodies in all our daily activities and includes posture, movement and breathing. Our own MRC sponsored trial showed that the incidence of back pain could be reduced by 86% by having Alexander lessons.

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