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Study proposes antibiotics as possible new treatment for some types of chronic low back pain

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2988 (Published 09 May 2013) Cite this as: BMJ 2013;346:f2988

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Re: Study proposes antibiotics as possible new treatment for some types of chronic low back pain

The study is an attempt to try an address a common problem with a new angle. It succeeds in raising more questions than answers and provides a good platform for a trial to take this research further. The balance of treatment must be considered in light of widespread abuse of broad-spectrum antibiotics and multi drug resistance amongst pathogens.

Specific ambiguities relevant to the paper are as follows:
• The explanation for the improvement is given as “treatment” of Proprionibacterium infection, even though neither the diagnosis, nor the treatment is confirmed by any cultures.
• In studies involving pain medicines, there is normally a placebo response of 20% - 30 %(Pollo, Martina, Arslanian, & Casadio, 2001). In the present study, there is no improvement in placebo group in any parameters over one year. This is a very unusual. If the placebo response in this study was similar to what is usually expected, than the treatment effect is unlikely to be significant.
• 1 in 5 patients had gastrointestinal side effects that were labelled as “mild”. There needs to be an estimate of the “numbers needed to treat” versus “numbers needed to harm” for such an intervention before it is put into practice.
• The study hypothesis relies on previous studies that indicate the presence of Proprionibacterium in cultures of discs taken out during surgery, which had adjacent modic changes. There is every chance of introduction of skin commensals like Proprionibacterium in the discs as these patients are exposed to procedures like discographies and transforaminal epidurals, which would not be the case in discs cultured from scoliosis surgery patients.
• A Study by Keeler et al (Keeler, Boyle, Skogg, & Kassidy, 2012) showed Modic type 2 changes to be most common amongst back pain patients and that Modic changes were not significant covariates for the clinical course of pain, function or fear avoidance beliefs. Education was a strong prognostic factor for recovery.
• The present study protocol advised participants not to engage in active exercise programme for the duration of trial. This is contrary to the usual management strategies in uncomplicated low back pain (Samanta & Kendall, 2003).

It is imperative that balance of treatment must be considered in light of widespread abuse of broad-spectrum antibiotics and multi drug resistance amongst pathogens.

It is perhaps also worth mentioning that the authors have offered to train the individuals in this treatment (called MAST) by charging between £100 - £200 for online accreditation.

References:
Keeler, A., Boyle, E., Skogg, T. A., & Kassidy, D. J. (2012). Are Modic changes prognostic for recovery in a cohort of patients with non-specific low back pain? Eur Spine J , 21, 418–424.
Pollo, A., Martina, A., Arslanian, A., & Casadio, C. (2001). Response expectancies in placebo analgesia and their clinical relevance. Pain , 93, 77 - 84.
Samanta, J., & Kendall, J. (2003). Chronic low back pain. BMJ , 326, 535.

Competing interests: No competing interests

03 June 2013
Rahul Seewal
Consultant in Anaesthesia & Pain Medicine
Chelsea & Westminster Hospital
369, Fulham Road, London, SW10 9NH