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Can antibiotics treat some chronic low back pain?

PainSci » bibliography » Albert et al 2013
Tags: treatment, etiology, fun, back pain, pro, pain problems, spine

One article on PainSci cites Albert 2013: Complete Guide to Low Back Pain

PainSci notes on Albert 2013:

This study shows weirdly good, strong results treating low back pain with antibiotics, but was mired in controversy soon after publication when it came to light that the authors may have had serious, undeclared commercial conflict of interest.

In the unlikely event that the COI had no effect on the study, there are still some significant caveats. In particular, the study focused on a specific sort of back pain in rather carefully chosen subjects — so it’s probably not going to work on the average frustrated back pain patient. Also: there was a suspicious lack of response in the placebo group, a possible red flag that something was wrong with the methodology; the connection to the mouth is basically speculative (they didn’t culture the painful sites); and there are other ways to explain the effect (perhaps an immunomodulation effect of antibiotics).

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

PURPOSE: Modic type 1 changes/bone edema in the vertebrae are present in 6 % of the general population and 35-40 % of the low back pain population. It is strongly associated with low back pain. The aim was to test the efficacy of antibiotic treatment in patients with chronic low back pain >6 months) and Modic type 1 changes (bone edema).

METHODS: The study was a double-blind RCT with 162 patients whose only known illness was chronic LBP of greater than 6 months duration occurring after a previous disc herniation and who also had bone edema demonstrated as Modic type 1 changes in the vertebrae adjacent to the previous herniation. Patients were randomized to either 100 days of antibiotic treatment (Bioclavid) or placebo and were blindly evaluated at baseline, end of treatment and at 1-year follow-up.

OUTCOME MEASURES: Primary outcome, disease-specific disability, lumbar pain. Secondary outcome leg pain, number of hours with pain last 4 weeks, global perceived health, EQ-5D thermometer, days with sick leave, bothersomeness, constant pain, magnetic resonance image (MRI).

RESULTS: 144 of the 162 original patients were evaluated at 1-year follow-up. The two groups were similar at baseline. The antibiotic group improved highly statistically significantly on all outcome measures and improvement continued from 100 days follow-up until 1-year follow-up. At baseline, 100 days follow-up, 1-year follow-up the disease-specific disability-RMDQ changed: antibiotic 15, 11, 5.7; placebo 15, 14, 14. Leg pain: antibiotics 5.3, 3.0, 1.4; placebo 4.0, 4.3, 4.3. Lumbar pain: antibiotics 6.7, 5.0, 3.7; placebo 6.3, 6.3, 6.3. For the outcome measures, where a clinically important effect size was defined, improvements exceeded the thresholds, and a trend towards a dose-response relationship with double dose antibiotics being more efficacious.

CONCLUSIONS: The antibiotic protocol in this study was significantly more effective for this group of patients (CLBP associated with Modic I) than placebo in all the primary and secondary outcomes.

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