Modic Changes & Antibiotics – The Response …
In the ACA news publication, The Official Publication of the American Chiropractic Association, September 2013, there was an article published “CHRONIC LOW-BACK PAIN Is Infection a Common Cause?” by Daniel Redwood, DC. While the author does state “For now, the Chiropractic community would do well to take the Albert et al. study on modic changes seriously and at least begin discussions as to its possible implications.” What follows is an absurdity. I will let Dr. Albert handle the general medical community at large, something she is well qualified to do, however, my colleagues article on the treatment of modic changes with antibiotics indicates a troublesome venture in egoism that I feel must be addressed.
Lets start with the first comment, “But unlike the several-day course of antibiotics typically recommended for a bacterial infection of the upper respiratory tract, these intra-disc infections appear to require a much longer course of antibiotic therapy — 100 days in the Albert et al. study.” My colleagues should be well aware that comparing a bacterial infection in an aerobic environment of the lungs is very different than treating an infection within the anaerobic environment of the disc. Indeed, there are techniques claiming restoration and reduction of herniations based on the osmotic properties of disc nutrition. They might well forget the method of transportation into the disc and assume it is an aerobic environment similar to the lungs. The duration of antibiotic treatment used in Dr. Alberts’ modic changes study is commonly prescribed for post-operative discitis, which is not several days! Ask a surgeon.
Quoting Jan Hartvigsen, DC, PhD, “This is, however, only one small trial and before we begin awarding Nobel prizes and prescribing antibiotics on a large scale, the results should be replicated in other trials done by other groups.” This makes one curious if Dr. Hartvigsen read the entire modic changes study? Is this statement driven by media hype or scientific scrutiny? Furthermore, Dr. Albert, in her study states, “More confirmatory work in other populations and studies on improved protocols as well as the background science should be encouraged.”
Lets continue, the article by Dr. Redwood states, “With MRI, the known problems are largely financial. In this cost-conscious era, the private- and public-sector economic impacts of a substantial increase in the utilization of MRI must be given due consideration.” Due consideration compared to failed treatments including surgery, physical therapies and, dare I say chiropractic treatments? What about dependency on medicines and long term Chiropractic care, often noted as “maintenance”? What about disability and economic costs related to lost work? Are we comparing this with the cost of an MRI and antibiotics?
Modic Changes & Antibiotic Use …
Dr. Redwood continues, “But far more serious are the long-term consequences that could ensue from major increases in antibiotic usage. Since the widespread use of antibiotics in humans and animals has already raised the proliferation of antibiotic-resistant pathogenic organisms to dangerous levels, anything that would accelerate this dangerous trend must be viewed with a critical eye by guideline writers and health policy decision makers.” Followed by “On a population basis, it could be a disaster.”
This suggestion of useless antibiotic treatment for modic changes is a terrible accusation. One should be well aware of resistance and how it developes. In contagious diseases or infections, antibiotics may not be given enough time, or there is no response, or there can be bacteria left over and they contaminate next patient and the bacteria mutates and becomes tougher. However, we are not talking about a contagious disease, you can not transmit modic changes, the bacteria are in the mouth and hair follicles, it is difficult to develop resistance in this manner.
Since Dr. Redwood sought the opinion of Dr. Hartvigsen, who is a professor/researcher for the Chiropractic program at the University of Southern Denmark, the same institution at which Albert and colleagues performed their modic changes antibiotic research, lets use Denmark as an example. In Denmark, same as other countries that have agriculture for raising pigs, there are about 10,000 people per year who get disc herniations, half develop modic 1 changes afterwards. If you gave 5,000 of them a double dose of antibiotics for modic changes as in the study, you get an increase of 1.5 tons of antibiotics in the population per year.
In 2012, Denmark farmers produced over 27 million pigs, each pig receives 3.6 g of penicillin in its life. Pigs producing almost 100 tons of antibiotics per year in meat that is consumed by people. Compare that with 1.5 tons that will help save people from disability, get them back to work and let them sleep at night. Maybe its a better idea to cut down on the pigs instead of the people. Interestingly enough, we are not discussing the many antibiotics that have an anti-inflammatory effect through TNFa-inhibition and are fast-acting. The effects of this class of antibiotics are short lasting and would require an indefinite daily course to reduce pain and inflammation. This would seem a more ominous source of antibiotic use, whereas Augmentin, the antibiotic used in the study, has a small anti-inflammatory effect and only an inhibitory effect on IL-1 and IL-8, not TNFa. Instead, as we will see below, we are encouraged to “imagine”.
Possible Reactions To Modic Changes Therapy …
Dr Redwood states, “In addition, allergic or hypersensitivity reactions may occur in some individuals, including gastrointestinal reactions such as diarrhea, nausea or vomiting and dermatological reactions such as rashes, pruritus or urticaria.” I am surprised there would be side effects from any medications! Oddly, not mentioned would be the risk of Clostridium difficile, about 3% in clinical studies. Dr. Redwood is obviously not aware of the protocol used when encountering side effects. Perhaps no medications should be prescribed for heart conditions due to side effects, since we chiropractors are so efficient at treating cardiovascular conditions. Interesting how antibiotic allergy was part of the exclusion criteria in the study.
Lastly, Dr. Redwood indicates, “It is not difficult to picture CLBP patients with borderline Modic 1 diagnoses, or even without any Modic-related diagnosis, demanding 100-day antibiotic prescriptions from their medical physicians. Nor is it difficult to foresee many of those physicians succumbing to such strongly expressed patient preferences. It is also not that hard to imagine a second 100-day course of antibiotic therapy if the first one fails.”
Lets assume there is so much corruption that antibiotics will be prescribed for any kind of back pain. What about neck pain? Lets assume all chiropractors do not over-adjust or indiscriminately manipulate or foster dependency. Not to mention side effects of Chiropractic care like strokes, or is that media hype?
Perhaps Dr. Redwood is not aware that there are specific protocols. Should we not be demanding that this treatment should only be done under the supervision of a certified Modic Antibiotic Spinal Therapist? In Dr. Albert’s study she states, “We do not support the proposition that all patients with lumbar pain should have a trial course of antibiotics. The criteria in this study were very clear: CLBP for more than 6 months, Modic type 1 changes in the adjacent vertebrae following a previous disc herniation. As we do with other drugs, we rely on our fellow colleagues to use clear evidence-based criteria and to avoid excessive antibiotic use.”
Modic Changes Prediction …
I will make a prediction based on imagination; sometime in the near future, Chiropractors will try to incorporate antibiotic prescriptions in to the curriculum along with MAST certification, using techniques like Flexion-Distraction to aid the absorption of antibiotic into the disc to treat modic 1 changes. And I will support this.
Stephen Ornstein, D.C.
1. Albert HB, Sorensen JS, Christensen BS, Manniche C. Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a doubleblind randomized clinical controlled trial of efficacy. Eur Spine J. Apr 2013;22(4):697-707.