Calling for cocktail of open-mindedness and skepticism in UK news about antibiotics for back pain

Newspapers in the UK went nuts today with stories about “Nobel-worthy” research and “breakthrough” and “cure.” Interestingly, the story is slow to crack US news organizations yet.

That last piece of independent perspective was one of the only somewhat skeptical views presented in the stories we saw.

An American journalist wrote to me, “The complete lack of skepticism in these media reports is astonishing.”

I asked for a reaction from Dr. Steven J. Atlas, one of our story reviewers, and a researcher whose work focuses on improving the quality of care for patients with low back disorders.  He open-mindedly began, “On the one hand, this seems pretty out there. On the other, this was once the same thought about H. pylori and gastritis.”  He notes that a possible plausible mechanism is that antibiotics can also have anti-inflammatory properties independent of their anti-infectious effects.

The European Spine Journal recently published a paper by this research team.

Atlas attended the annual meeting of the International Society for the Study of the Lumbar Spine in Bergen, Norway in 2006.  He recalls that there was skepticism about this hypothesis at that meeting.  (But you’ll note that there was very little skepticism in any of the UK stories published today.) But the scientific skepticism continues – whether it made into these news stories or not. One thing that is puzzling is why the control group in this study showed lack of improvement across the board after one year of followup.  That’s not what is usually seen in people with chronic back pain.  The condition waxes and wanes.  Is it possible that the people in the study became unblinded and became aware of what treatment they were receiving?  Is it possible that the results reflect the placebo effect?

Further, Dr. Atlas points out that in the antibiotic treatment group, most of the benefit occurred between 3 and 12 months. If you take out the 12 month data, the effects of treatment at the end of the course are modest.

The European Spine journal published an editorial by Dr. Max Aebi in which he outlines some important questions about how difficult it would be to prove the antibiotics theory.

Meantime, Kevin Lomangino, another of our story reviewers, reminded people on Twitter about an earlier blog post of ours, in which Dr. Elizabeth Loder of the BMJ called for a “quarantine of groundbreaking studies about new treatments.”  At the very least, how about a cocktail of a healthy dose of open-mindedness and an equal healthy dose of skepticism?

ADDENDUM ON MAY 8:  The Behind the Headlines services of the NHS Choices site in the UK posted a thorough review of the evidence, concluding:

“As strong as this research it is, it is not definitive. Further research, most likely with larger numbers of people in the study, will be needed to confirm these findings before any treatment is likely to be approved and licensed for routine use in UK. There will also need to be extensive safety investigations.

Crucially, the study recruited a very select group of lower back pain sufferers who showed small changes in their vertebrae next to the site of a previous slipped disc. This select group therefore is not representative of all lower back pain sufferers.

This research certainly does not advocate giving antibiotics to all lower back pain sufferers. However, if the results are confirmed in subsequent studies and this form of treatment is deemed safe, it may provide a new treatment option for this type of lower back pain in the future. This is cause for much optimism.

The researchers’ estimate that approximately 35-40% of long-term back pain sufferers experience excess fluid in the spinal vertebrae and could potentially benefit from this type of treatment in the future. However, it is unclear how accurate this estimate is, and may indeed be an overestimate.

Even if all these hurdles are overcome, media talk of a “back pain cure” could still be premature. Antibiotics may help relieve symptoms, but there is currently no conclusive evidence that they can correct the underlying causes of chronic back pain.”

ADDENDUM on May 14:  Dr. Margaret McCartney published a Medicine and the Media column in the BMJ, “Antibiotics for back pain: hope or hype?” Excerpt:

“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.”

It also reported that the launch had been organised for (Peter) Hamlyn (the surgeon quoted as saying the work was worthy of a Nobel), director of a private clinic, and that he and (Hanne) Albert (the Danish researcher who made the discovery) had set up a website “to promote the therapy known as MAST—Modic Antibiotic Spinal Therapy,” a fact missing from many reports. Indeed, the website, which was referred to by Albert in the Guardian webchat and was registered by her in February of this year, says that “only careful scrutiny” can identify patients who will benefit from treatment; that “possible side effects” need care because of the “complicated disease process”; and that a “MAST certified doctor and/or therapist will ensure that optimal results are obtained and can transform you [sic] life into a relatively pain free status.”

Hamlyn is a doctor at the only UK centre listed. An advantage of becoming a “MAST certified doctor” is a listing on its homepage; the cost of the course is £200, and two retakes in the exam are allowed before reapplying a minimum of three weeks later. The training and multiple choice test can be taken online.

Could the potential for financial reward in the build up of this network of clinics represent a conflict of interest?”




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