Clean teeth, bad back? Antibiotics for chronic low back pain.

It is unsurprising that there are few-to-no impressively effective treatments for chronic non-specific low back pain. The clue is in the “diagnostic” label. Non-specific low back pain represents the vast majority of cases for whom our traditional diagnoses don’t explain a great deal. If we can’t put our finger on what is causing it, we are likely to be donkeys at treating it.

There is much discussion and debate about why things are this way. Some argue that, at least in chronic persistent cases, the reason that imaging findings correlate poorly with symptoms and outcome is because these factors are no longer driving the symptoms. Rather, features such as central sensitization and a complex interaction of psychosocial factors drive the syndrome, causing on-going pain and disability in the absence of a continuing cause in the spinal tissues. Others that our imaging technologies and research designs simply lack the sophistication to finger the real culprit in the tissues. We’ve covered this ground before (see here).  Playing out in the middle of this conceptual minefield for a while now have been Modic changes.

Modic changes are found on spinal MRI scans around the borders of the disc and vertebral body. They seem easy to spot and, unlike most MRI findings in the spine, do seem to be consistently associated with the presence of non-specific low back pain and may have some prognostic influence. They are understood to represent bone oedema (swelling) and it is suggested that the cause might be infection with bacteria that normally live in your mouth. Curiously the obvious pathway for these bacteria to your disc is via the bloodstream, most likely via brushing your teeth.  This suggestion is lent weight by the finding of such bacteria, particularly the delightful sounding Proprionibacterium acnes (p acnes), more frequently in the nuclear material of patients with disc herniations who then went on to develop new Modic changes in adjacent vertebrae. Could it really be so simple – that for this group of patients antibiotics might offer an answer?

A trial just published in the European Spine Journal sought to test this. Following from some promising uncontrolled exploratory findings they took a group of patients with chronic back pain, who had had a finding of disc herniation on MRI within the preceding 6 to 24 months and gave them a repeat MRI. It is worth noting that these were not all non-specific cases, they included patients with or without neuropathic pain and some who had undergone spinal surgery. Those who demonstrated new Modic (Type I – the smallest type) changes adjacent to that disc were recruited and randomised to a 100-day course of high-dose oral antibiotic therapy or placebo and followed for a year. The design was nice and tight: good randomisation, allocation concealment and blinding of all the key players.

The findings are, at first glance, remarkable. Statistically significant improvements seen at the end of treatment, but further, larger and clinically important improvements were observed at one year.  This was as predicted – at 100 days the underlying infection may have gone but at one year there has been time for substantial biological repair. The results show a 45% reduction in back pain at one year versus no reduction in the placebo group, and a 53% improvement in disability versus a 7% reduction in the placebo group. More surprisingly they found a 68% reduction in leg pain versus a slight increase in the placebo group. For chronic back pain these are genuinely eye-catching numbers and were accompanied with improvements in Modic changes on MRI. There was a price though, adverse events, mostly gastro-enterological and varying in severity were much more prevalent in the group taking antibiotics.

There are, in my view, reasons to be cautious here. The approach taken to the analysis seems a little basic. Worse the analysis does not appear to have employed a genuine “intention to treat” approach, or, if it did, it is not clear how. This is important as it helps to prevent uneven drop-out of participants during the trial from artificially inflating the effects. 14% of participants dropped out of the active arm compared to 7% in the placebo arm. This probably doesn’t catastrophically undermine the results of the trial but it offers a path by which the size might have been exaggerated. I find this a shame because it is so easy (and standard practice) to fix and its absence muddies the waters of what is otherwise an exciting finding. Finally there is an almost total lack of a response in the placebo group suggesting no impact of placebo effects, natural recovery or regression to the mean. Which is odd.

What these results don’t do is offer us a solution to the broad problem CNSLBP. The group in this trial were, quite correctly, very carefully selected by the probability that Modic changes might explain their pain. This type of selection is likely to have preferentially recruited many patients who we would not consider to be “non-specific”.  But they do seem to suggest that a proportion of cases could be chipped away from the non-specificity mountain and be offered a substantially effective treatment. Before we jump on that bandwagon with both feet, let’s have a big, multi-centre trial with a nice, tight approach to data analysis. In the meantime it’s interesting to ponder whether population- level leaps forward in oral hygiene may have surreptitiously fed an explosion in disabling chronic low back pain.

Neil O’Connell

Neil OConnell 150 Clean teeth, bad back? Antibiotics for chronic low back pain.As well as writing for Body in Mind, Dr Neil O’Connell, (PhD, not MD) is a researcher in the Centre for Research in Rehabilitation, Brunel University, West London, UK. He divides his time between research and training new physiotherapists and previously worked extensively as a musculoskeletal physiotherapist.

He also tweets! @NeilOConnell

Neil’s main research interests are chronic low back pain and chronic pain more broadly with a focus on evidence based practice. He has conducted numerous systematic reviews including some for the Cochrane Collaboration. He also makes a mean Yorkshire pudding despite being a child of Essex.

Link to Neil’s published research here. Downloadable PDFs here

References

Jensen TS, Karppinen J, Sorensen JS, Niinimäki J, & Leboeuf-Yde C (2008). Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain. Eur Spine J, 17 (11), 1407-22 PMID: 18787845

Jensen RK, Leboeuf-Yde C, Wedderkopp N, Sorensen JS, Jensen TS, & Manniche C (2012). Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI. Eur Spine J, 21 (11), 2271-9 PMID: 22526703

Albert HB, Lambert P, Rollason J, Sorensen JS, Worthington T, Pedersen MB, Nørgaard HS, Vernallis A, Busch F, Manniche C, & Elliott T (2013). Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? Eur Spine J PMID: 23397187

Albert HB, Sorensen JS, Christensen BS, & Manniche C (2013). 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. Euro Spine J PMID: 23404353

Albert HB, Manniche C, Sorensen JS, & Deleuran BW (2008). Antibiotic treatment in patients with low-back pain associated with Modic changes Type 1 (bone oedema): a pilot study. Br J Sports Med, 42 (12), 969-73 PMID: 18718972

Comments

  1. Magdalena Portmann says:

    Dear Neil,

    I found your article very interesting, and like in particular the point you ponder at the end of the article. Enjoyable reading!

    You say that “there are few-to-no impressively effective treatments for chronic non-specific low back pain. ” I hope you won’t be offended if I send you to the link to a randomised factorial trial for patients with recurrent and chronic back pain of GP exercise prescription, the Alexander Technique and massage (ATEAM trial). If you already know about this, I apologise.
    http://www.stat.org.uk/pages/ateam.htm

    Best wishes,

    Magdalena

    [Reply]

    Neil O'Connell Reply:

    Thanks for your comment Magdalena,

    I think it would be a stretch to interpret the primary outcome results in that trial as dramatic. The results are interesting but for example a difference of around 1 point on the RMDQ is not particularly substantial. That is not to say the trial doesn’t show an effect for AT but it is a fairly moderate one.

    Best

    Neil

    [Reply]

    Neil O'Connell Reply:

    I should add that I am referring to the comparison of AT with exercise there.

    [Reply]

    Mrs Pamela Orritt Reply:

    Dear Neil,I have stumbled across this article today after truly being convinced that the very occasional time that I have to take Amoxicillin 500 mg (at the moment for a Dental reason)that my chronic but minor low back stiffness pain and just troublesome feelings,completely dissapear,this is my 3rd time of finding this happen,and as I feel so well I tried to find an article that might refer to this fact and only had a few mins,I am 57yrs well and average weight leading a full and active lifestyle,I find this intriguing,regards from Pam Orritt

    [Reply]

  2. Matt Erb says:

    Very interesting, great review, thanks. I wonder, if this holds true in future studies and represents legitimate causal factors, what sort of other treatment options might arise instead of massive lengthy doses of antibiotics. Personally, I would have to be in pretty severe and constant pain to consider that as an intervention as wiping out the numerous beneficial bacteria in the body over such a long period of time does not seem particularly wise to my liking. I wonder if there would be any natural treatment approaches harnessing the power of immunological and anti-inflammatory activity (such as target specific guided mental imagery) combined with nutritional, herbal or other remedies carrying anti-bacterial properties, and/or the development of some type of localized modality application with the potential to “irradiate” (sorry, not sure what other word to use) the region, etc. that would be smarter and safer than antibiotics? Just thinking out loud here. I also wonder, if this is the cause, why are these bacteria settling into lumbar vertebra and producing non-specific LBP – what about thoracic, cervical, and other bones? What “weakness” exists here that the bacteria “like”/are “drawn to”?

    [Reply]

    Neil O'Connell Reply:

    Hi Matt,

    I agree that this kind of treatment is not to be taken lightly. The risk of complications extend beyond the individual too in terms of the current antibiotic overuse crisis. I am not convinced that any of your suggested alternatives are likely to have any impact, if this infection model is true.

    The bacteria have been found in lumbar discs as that is where researchers have gone looking for them I guess. Perhaps the vulnerability of lumbar discs and their subsequent vascularisation is also relevant.

    [Reply]

    John Palmer Reply:

    Lots of these comments are based on the research of the drug and the possible side effects of long time exposure to these drugs. I know this is the platorm for exactly that but from a back pain sufferer who has had 2 microdiscectomies on L4/5………..give me the drugs now! Its soul distroying having the pain every minute of every day. I am back to work (paramedic in the UK) but every day use of pain relief also has effects that are not too nice and may also be life threatening. I would happily give you 10yrs of my life in exchange to be pain free for 20. The meds that so many of us sufferers are taking daily do not make us pain free but in my case just get me off my face for a bit to stop caring about it. Its not a great feeling being knackered at 42.

    [Reply]

  3. stuart miller says:

    Neil,
    I really appreciated the article (impressive results) and the review of modic changes in the L spine but I fail to see your ‘obvious’ conclusions as to the mode of transmission of the bacteria (ie brushing your teeth). If you were being facetious, I missed it. Referring to the BMJ 2010, there is a causal link with POOR oral hygiene and cardiovascular disease, possibly due to systemic inflammation. The people that brushed their teeth more regularly had reduced risk. In terms of the chronic back pain studies, Amoxicillin was used in some studies (with modic changes) due to thought that it had more antibiotic effect (vs anti-inflammatory effect like many antibiotics especially tetracycline derivatives). Did they resample the concentrations of p acnes (again a bacteria that lies on skin, sebaceous glands primarily) after the antibiotic treatment (I realize there were higher concentrations initially) ? I may have missed this from the study. The other thing that amoxicillin helps treat is H pylori and one would think that treating bacteria that function better in stressed environment in gut may have also helped situation. I don’t know if some of these patients had ulcers but I would envision a higher level of stress. Please advise. Thanks.

    [Reply]

    Neil O'Connell Reply:

    Thanks Stuart,

    The “obvious” pathway was suggested by the trial authors in the report and I confess to taking it at face value. In terms of retesting I will check when I have the paper at the office next week. Interesting ideas re the gut, would be open to evidence to that effect.

    [Reply]

  4. Anonymous says:

    Neil, respectfully I disagree with your comment that such suggestions would have little clinical relevance. Evidence based mind-body medicine has substantial implications for systemic immune function, as does food as medicine as well as herbal properties that can be as powerful as any antibiotic when used appropriately. The lack of recognition of this is a major deficit in the prevailing biomedical model. I would also add that I feel it is far too simplistic to suggest that dental hygiene mechanisms/practices are responsible. Correlation does imply causation. There must be broader deficits in systemic or local immune system function happening for the bacteria to “sneak past and take hold”. The biology of environmental, physical, nutritional, chemical, mental, and emotional stress must all be considered in interpreting the “why” of such findings, if they prove to be consistent in subsequent findings over time, and an integrated treatment approach should be considered. Unfortunately that is not the prevailing thought process in the current model.

    [Reply]

    Anonymous Reply:

    Correction: “correlation does NOT imply causation”!
    Also, I came back for one additional thought (which is when I discovered the omission of a critical word in my post) …
    I wonder, if exploring broader reasons for the manifestation of such a problem were not explored, what will happen 6 months, 1 year, 2 years after finishing the antibiotic course? We certainly aren’t going to tell people to stop brushing and flossing their teeth as a preventative for developing back pain, are we?…

    [Reply]

    Neil O'Connell Reply:

    Hi Anonymous,

    “Evidence based mind body medicine” may indeed offer some hints (though I am not sure what they are) but it does not offer hard evidence that any such approach would actually be effective. I think mind-body interaction is a fascinating area but it would be fair to say that broadly the research is at the phenomenology stage rather than the “evidence of effectiveness stage”. Indeed this is a very much an areaa where your important point that correlation does not equal causation should be regarded most seriously.

    There is also a danger of taking the unsurprising finding that the mind influences the body and vice versa as a catch-all justification of any approach that might be shoe-horned under that banner – nutrition, herbs etc. I’m not entirely closed to it but I am steadfastly unimpressed by most evidence for the impact of herbal remedies or nutritional supplementation. Perhaps one reason the prevailing thought does not include these “integrated” strategies is becasue they do not meet a reasonable treshold of evidence.

    I have no doubt that the true picture is more complex than we can tell to date but it will be data that offers the detail and , in the meantime, conviction is not a great substitute.

    [Reply]

  5. Magdalena Portmann says:

    Anonymous, don’t you mean to say “Correlation does NOT imply causation”?

    I like what you say, by the way.

    [Reply]

  6. I currently take bactrim everyday to prevent back pain. I had been having increasing bouts of pain and was to the point I was losing sleep due to pain. I made a appointment with a back specialist as I knew I had modic changes and wanted to find out my options for pain control. I was actually put on bactrim by my dermatologist a few days prior to my appointment. I almost canceled my appointment because suddenly I had NO pain. They only thing that had changed was the antibiotic, I brought this up to the back doctor who discussed doing surgery and he mentioned there had been some studies but he had not tried this antibiotic treatment. I have been on a single dose daily of bactrim DS for a year now. If I come off my pain comes back but if I take it daily I am pain free. It is actually prescribed by my dermatologist as this was not offered as treatment from my back doctor. Hope this helps someone else. The pain was a deep ache in my spine worse at night when I had it.

    [Reply]

  7. Mick Thacker says:

    Hi Guys (Neil)
    Just a thought – the antibiotic minocycline has been shown to have analgesic effects as it attenuates microglia responses associated with pain – could other antibiotics have similar effects? This may be an interesting area for detailed study!

    [Reply]

    Neil O'Connell Reply:

    Cheers Mick,

    Interesting stuff. Looking at the pattern of recovery the latency of the most marked improvement might point towards a more standard anti-infection effect than an analgesic one, but no reason why there wouldn’t be a bit of both if amoxycillin also affects microglia that way I guess.

    [Reply]

    Neil O'Connell Reply:

    Cheers Mick, interesting stuff.

    I reckon the latency of the most marked improvement would argue that the main effect was a standard anti-infection response rather than an immediate analgesic one. That said no reason why there couldn’t be a bit of both if amoxycillin affects microglia similarly I guess.

    [Reply]

  8. Spinal Imaging says:

    Great article! Very helpful indeed. Back ache is a common issue these days.

    [Reply]

  9. Mick THacker says:

    Hi Neil
    Interesting indeed – the important thing to note is infact the time frame fits perfectly – went to the paper – the effects of minocycline are not typical temporally for an analgesic effect, it takes time for a therapeutic dose to build up in the CNS due to limited delivery across the blood-brain-barrier – my brain is now whirring as we have some monies to do some PET/fMRI in pain states in humans!

    [Reply]

  10. Chris Barnett says:

    HI Neill
    you spoke about placebo “Finally there is an almost total lack of a response in the placebo group suggesting no impact of placebo effects, natural recovery or regression to the mean. Which is odd”

    23% of placebo participants had low grade GI upset and 11% had what was known as a middle grade GI upset. This nocebic response would be appropriate and is guided by expectation and other complex neuro-phys issues as we know. It’s likely the participants would not have expected an analgesic response taking anti-biotics, hence no or little placebo analgesia

    [Reply]

    Neil O'Connell Reply:

    Thanks Chris,

    You make a very good point. That certainly might, at least in part, explain that result.

    [Reply]

  11. Hello Neil,
    great article!

    “The inflammation wherewith his head, his hands (arms), feet(legs) are inflamed, is due to his teeth. His teeth must be drawn : it is on this account that he is inflamed ; he will reduce(it(?)) through internal (channels)(?). Then will all be well…” Translated by Dr. R. Campbell Thompson http://www.jstor.org/discover/10.2307/4241624?uid=2&uid=4&sid=21102128358067

    ..hey, I remember also a nice article on periodontitis and premature births also, but you probably already know it.
    - I finally have a clue of why Reflexology or foot massage works, if you are scientifically into fascia.

    Take care,
    Spiros

    [Reply]

    Neil O'Connell Reply:

    Thanks Spiros,

    Sorry though, I see no connection with fascia here or reflexology.

    [Reply]

    spiros Reply:

    Thanks Neil for answering. There are teeth reflex(ology) charts(!), maybe they should check the “bad” teeth and see if they correspond with the lumbar vetrtebrae.
    Sorry, my last comment on fascia and reflexology had to do with a discussion we had in the past.

    [Reply]

  12. Bernard liew says:

    Hi Neil,

    I am intrigued by this study and it’s results. Methodologically, the quality seems on par with many RCTs on CLBP in the physiotherapy and medical literature. Limitations are present as you nicely pointed out. I do wonder why the authors presented their data in median and not mean (which is the more common route). Could this distort interpretation?

    [Reply]

    Neil O'Connell Reply:

    Hi Bernard,

    They will have presented the median where the data were not normally distributed(i.e. the bell curve was skewed) as it is the better measure of central tendency under those circumstances. So it is likley that this was a reasonable way to present their data.

    Best

    Neil

    [Reply]

    Bernard Liew Reply:

    Thanks Neil for the reply,

    in your comments of the article, you commented “a proportion of cases could be chipped away from the non-specificity mountain and be offered a substantially effective treatment”. I agree with this statement. Do you think that the significant proportion (some say 80%?) of CLBP patients are labelled as non-specific is due to the wrong diagnostic test used?
    In chapter 6 of “Rehabilitation of the Spine: A Practitioner’s Manual. 2nd Edition”, authored by Nikolai Bogduk and Charles Aprill, they correctly mention that pain is a sensory phenomenon, not a structure, so the “Gold Standard” test ought to be a physiological test (e.g. discography) not a radiographic test. The authors utilise 4 criteria to judge the source of pain – 1) Could it be a source of pain, 2) Can it be a source of pain, 3) Is it ever a course of pain, 4) Is it ever a source of pain. If one were to review the literature based on this criteria, the authors judge that 70% of patients have a specific cause of pain.

    In addition, it could be argued that degenerative disc is non-specific simply because the grade of disc degeneration wasn’t determined, and correlated with a specific LBP population (Hancock et al 2012). In fact, Kang et al (2009) and Chen et al (2011) did find an association between grade 4 degenerate disc on MRI and concordant discogram ( a true reflection if that structure is pain).

    Interested in knowing your thoughts..
    References:
    Eur Spine J. 2012 Feb;21(2):240-6
    Clin J Pain. 2011 Feb;27(2):125-30.
    Skeletal Radiol. 2009 Sep;38(9):877-85.

    [Reply]

  13. stuart miller says:

    Bernard, I am having a little difficulty understanding your last comment, especially the last statement (a true reflection if that structure is pain). It’s nice that you reference recent journal articles. If one looks further back to Jensen et al, 1994 in New England Journal of Medicine or Weishaupt et al, 1998 in Radiology in which MRIs were done of healthy (pain-free) volunteers in which there was evidence of degenerative disc disease in 72 % and herniated discs in 40 % (Weitshaupt’s) and abnormal findings in 66 % (Jensen’s) you might reconsider correlating discographies with pain. You might also reconsider the 4 questions as, is it a source of input to the central nervous system and what happens then ? Maybe I am missing your point. In terms of the attenuation of microglial response with antibiotics, what paper could I review ?

    [Reply]

    Bernard Liew Reply:

    Thanks Stuart for the kind comments, hope I answer it adequately below.

    Question 1: Difficulty in understanding statement
    Answer: What I probably meant was (apologies for sloppiness) was that a hypothesised structural cause of pain was bench marked against an “ideal” confirmation of pain (a discogram- I poke it, if the pain is your pain, then that is the cause of your pain).

    Question 2: Reconsider correlating discographies with pain.

    Answer: I do feel there are two (or more) questions you are implying here. First, images can tell us if something is pain. Pain is felt, it cannot be seen. Second, the best way to establish a cause of pain is making sure that a proposed lesion is present more in painful individuals than in healthy individuals. The studies quoted did not study painful individuals. So one cannot say the studies quoted was evidence that degenerative disc or what, are not a cause of pain. Imaging studies alone only fulfill criteria 3 of the 4 proposed by Boduk and Aprill. It is not sufficient.

    In addition, generalised statements of degeneration or herniation are made in many imaging studies, assuming that there is only one form of degeneration or herniation. On a side note, what is the correlation of knee ligament injuries to instability? If one were to undertake such a study, you would almost end up with a conclusion of no association. Just so because one is lumping up partial with complete tears, ACL with PCL with everything, where no consideration of the contribution of each ligament to stability in a specific direction is made. Also, no consideration of population was done as an ACL tear in a sedentary woman will not result in instability compared to a woman playing tennis.

    Question 3: An input to the CNS.. then what?
    Answer: I am not too sure what you are implying? I am certainly not going into hardcore neurorophysiology here. There isn’t a need to yet. Correct me if I am wrong, you are inquiring what are the pathways to the actual phenomenology of pain? If I press your cut, and you scream out… I do not need to know the pathway to pain to know that is the pain. If I want to confirm this, I too need to press adjacent areas, and you must not scream. That is discography (i think). Similarly, I do not need to know neuroanatomy to understand that if a person blows on a trumpet, he and the equipment are the source of noise.

    I have no information of glial response as yet.

    What are your thoughts? Have a read of Bogduk’s work… Refreshing it is..

    Cheers,
    Bernard

    [Reply]

  14. Neil O'Connell says:

    Hi Bernard,

    The issue of non-specificity is an interesting one. I await compelling data on the predictive value of discography but think that this rare longitudinal study is rather telling: Carragee,E., Alamin,T., Miller,J., Carragee,J. (2005). Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain The Spine Journal, 5 (1), 24-35 DOI: 10.1016/j.spinee.2004.05.250

    In fact we have discussed this issue here before: http://www.bodyinmind.org/discussing-bio-psycho-social-model-of-low-back-pain/

    Off of discs and on to facet joints Eugene Carragee offered a strong deconstruction on the diagnostic value/ reliability of facet joint tests that caused a bit of a hoohaa. http://www.ncbi.nlm.nih.gov/pubmed/17197329

    I don’t doubt that some people do have pain primarily driven by these structures, but their predictive value seems very weak to date and the relationships in the data are inconsistent based on the tests we have. Some, perhaps much, of that inconsistency at least might be explainable by causes away from the tissues.

    [Reply]

  15. Kieran says:

    As a contrast to the reasonable and measured analysis of this study here by Neil, check the front page of todays Daily Express about the exact same study! Can’t beat a quick fix!

    http://www.express.co.uk/news/health/397889/Miracle-cure-for-back-pain-Agony-ended-by-everyday-antibiotics

    [Reply]

    Neil O'Connell Reply:

    Cheers Kieran – shocker.

    [Reply]

  16. Anonymous says:

    hmm all very interesting, even if l don’t understand all of it!! personally if l could have my life back l really would mind what the side effects are!

    [Reply]

  17. Lorimer says:

    A very nice comment in the BMJ on this here: http://www.bmj.com/content/346/bmj.f3122. This blog post by Neil even gets a mention!

    [Reply]

  18. Paul Lagerman says:

    Hi Neil

    Great article. Being an ex Brunel student I have learnt to be open-minded about reports of a biomedical nature no matter how intriguing.
    I have now advised all my suspected disc pathology patients to stop brushing their teeth to prevent infection! ;-)

    Paul

    [Reply]

  19. Reno Chiropractor says:

    Antibiotics are not the answer for treating low back pain. They are already overprescribed in the US or else we wouldn’t be dealing with superbugs like MERSA. Diet, exercise, Chiropractic care and/or Physical therapy should be the first line of defense toward combating Low back pain. We need to get healthier from the inside out as a society not just count on a pill to fix all of our problems. Take responsibility for your health!

    [Reply]

    Bernard Liew Reply:

    Dear RenoChrio,

    Your conclusion of “Antibiotics are not the answer for treating low back pain” seem to stem from several premises you made 1) that antibiotics overprescription are the cause of superbugs, hence it is undesirable, 2) there are better answers (diet, exercise..), and 3) being unhealthy is a cause of low back pain…

    First, no doubt that indiscriminate use of antibiotics is one reason (not the only reason) for the development of resistance. Just like with any infection, the dosage and duration of consumption are stringent (not indiscriminate). The authors of the paper are clear on this and also acknowledged that the use of antibiotics in modic changes (not just any LBP!!!) must be with consideration of the larger health issues at the individual and probably societal level.

    Second, there is no argument that multiple forms of rehabilitation (physio and exercise) are beneficial but mildy so. The stance that they should constitute the first line of defense is in my opinion untenable. What constitutes first and second line of treatment should be based explicitly on the magnitude of benefit and risks involved in each treatment. You seem to make no effort in what defines “chiro” and “physio” care (I am a physio). I do not know about dieting and LBP, again, you present no data.

    Third, you present no sort of data in what constitute “healthy” and LBP.

    You seem to assume that the paper is a cure for all problems, when in fact the authors simply work to find a solution to one aspect of LBP (modic changes). You also assume that taking a pill is not taking responsibility for once health. If that assumption is to hold weight, you would be implying that taking a pill for any disease (infection, diabetes, etc) is a sign of irresponsibility. I find that hard to understand. Taking antibiotics requires money, effort to remember to take for a prolonged period of time.

    Hence, the argument you present seem to be weak. Everyone needs to be cautious, but good data should be expanded upon, not ignored.

    [Reply]

  20. Cricket Cole says:

    For years I have had intermittant mild tooth infections, which when they flair up, are almost invariably accompanied by back pain and pain in my right hip (where some rather impressive damage was done by a rank horse six or eight years ago). When the tooth pain has become great enough to inspire scrounging amoxicillin, the back and hip pain has invariably been greatly reduced.

    I have been arguing this point for a number of years with a number of people, and of course, one person doth not a study make (though twenty or so episodes that all ended the same is suggestive). I suspect, if I was in a position to have some dental care and close up the bad tooth, etc, that I might very well deal with the back and hip pain permanently – when it’s gone, it is *gone*… I can shoe horses, do yoga, etc., without a twinge.

    I would dearly love to find a study to participate in (though the tooth thing might disqualify me?), to see if under more controlled conditions it still worked the same.

    [Reply]

  21. James Jorner says:

    I have pretty chronic neck and back pain and general body stiffness and pain. Movement and activity definitely helps. A few years back, I had to have a dental procedure done. The dentist wanted me to take Amoxicillin because an infection developed. I did not want to take it because I had read that antibiotics can wipe out good bacteria and I am just generally distrustful of medications and their side effects. He insisted I take it and I decided I would take it a couple of days, with the hope it would kill the infection and I could be done with it. Honestly, with all the bad things I’ve read about antibiotics (reactions to cipro, killing off of beneficial bacteria etc) I was a little scared of it and was nervous taking it half expecting bad side effects.

    To my surprise, the second day into taking it I had the completely bizarre sensation and experience of not having pain or aches at all. I felt the best I have ever felt in my life. It did not feel like when you take say advil and you get some pain relief. I was more like whatever the issue was was just gone. Not only no pains or aches or any negative feeling in the muscles and joints, but also a dramatically increased range of motion. The best I could describe it is I felt happy with a sensation of good feeling throughout my body. I ended up taking the full course. The effect lasted a few weeks after finishing but slowly seemed to fade back to the way it was (sped up after having a beer). What I took from it was the antibiotic killed off some infection that was causing pain in my back and other parts. I mentioned this to the dentist and he didn’t think much of it.

    I do have a heavy hand when I brush my teeth and somedays I would brush 3-4 times a day. I used to wonder after reading that teeth brushing can send more bacteria into the blood (bacteremia) than dental procedures that were given antibiotics to deal with this if brushing the teeth often could cause health issues related to the transient bacteremia. Damage to enamel aside from heavy handed frequent brushing, I wonder if softer less brushing (once a day which will prevent plaque from hardening) might allow the body to recover from any ill affects from the regular 3-4 a day bacteremia assault.

    [Reply]

    James Jorner Reply:

    Here is a link to a recent study about brushing, extraction with antibiotic, and extraction and resulting bacteremia:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746717/

    [Reply]

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