Approximately 80 percent of us will experience chronic low back pain at some point in our lives. In the United States, low back pain is the second most common reason for seeking medical attention after the common cold, with annual medical care costs for low back pain treatment estimated at $88 billion.1
The possible causes of low back pain are many and varied, with sprains, strains and injuries among the most common. But those conditions are often relatively short term compared to pain caused by systemic processes arising from "normal wear and tear" on the body, such as intervertebral disc degeneration, radiculopathy (compression and damage of the spinal nerve root), herniated or ruptured discs, spinal stenosis (a narrowing of the spinal column), sciatica (compression of the sciatic nerve) and spondylolisthesis (having the lower vertebrae slip out of place). Other known causes of low back pain are inflammation, tumors and cysts, osteoarthritis and rheumatoid arthritis, endometriosis (proliferation of uterine tissue outside the uterus), osteoporosis (bone degeneration), fibromyalgia, kidney stones, chronic liver disease and psoriatic arthritis.
Unfortunately, treating chronic low back pain is hit-or-miss. Only about 20 percent of patients presenting with low back pain are ever diagnosed with a physical cause for their pain and suffering. However, something called 'Modic changes,' where the endplates of vertebral discs show swelling, inflammation and edema (fluid accumulation) on magnetic resonance imaging (MRI) scans, has been strongly associated with low back pain and is now the subject of increased attention as a possible therapeutic target for affected patients.2
A meta-analysis of all previous studies to date found that approximately 43 percent of people suffering from low back pain showed Modic changes.3
But other studies have revealed something fascinating, namely that Modic changes are more common in patients who have had a previous disc herniation, and that patients who had surgery for a lumbar disc herniation also had a higher rate of Modic changes.4
What is going on? Is there a connection between disc herniation, Modic changes and surgery?
There is, and it's not even something we can see with the naked eye. Astonishingly, not only is Propionibacterium acnes—the bacteria that causes common acne—the most frequent anaerobic pathogen (one that does not need oxygen to survive) found in cases of disc and vertebral inflammation, called spondylodiscitis, but the presence of P. acnes in the spinal vertebrae is also closely linked to back surgeries.5
Today, it's clear that the presence of bacteria in the spinal disc is related to low back pain from disc herniation as well as Modic changes associated with disc herniation. Research has consistently shown that bacteria—primarily P. acnes—are commonly found in the discs of patients who have undergone disc surgery.6 Studies have also revealed that up to 53 percent of patients with herniated discs have anaerobic bacteria present, mostly P. acnes, and that up to 80 percent of patients with infected lumbar herniated discs develop Modic changes in adjacent vertebrae.7
Other bacterial causes?
Now that medical science is beginning to focus on bacterial infection as one of the many causes of low back pain, it is not hard to see other links between back pain and bacteria. At least 33 percent of people with psoriasis develop psoriatic arthritis,8 an inflammatory form of arthritis that affects the joints, sometimes causing a loss of function and back pain. And one common cause of psoriasis is, of course, bacterial infections of the throat and skin, mainly streptococcus.
"One of the theories behind psoriatic arthritis is that the toxins in the gut stimulate the psoriatic process and turn on the gene that causes psoriasis," says Dr Nooshin Darvish, chief medical officer at the Holistique Naturopathic Medical Center in Bellevue, Washington. "Then the endotoxins from the bacterial imbalance in the gut end up in the joints, and so they continue to stimulate the psoriatic arthritic process in the joints."
Fibromyalgia, which is known to cause back pain, has been linked to mycoplasmal (bacterial) infection.9 Patients with fibromyalgia also have high rates of small intestine bacterial overgrowth (SIBO)10 and test high on the lactulose breath test for bacterial overgrowth.11
Back pain has also been associated with gastrointestinal problems in women,12 and it's a common symptom of chronic liver disease, which is now being linked to gut problems including SIBO and microbial translocation—the movement of bacteria from the intestinal tract into other areas of the body.13
Not surprisingly, the first response from the medical community upon linking bacterial infection with Modic changes in the vertebrae and low back pain was to crack out the antibiotics and test to see if pain symptoms diminished upon their use. They did.
In a double-blind randomized controlled trial (RCT) in Denmark, 162 patients suffering from chronic lower back pain and Modic changes following a disc herniation were treated for 100 days with either the antibiotic amoxicillin or a placebo. Patients given the antibiotic "improved highly statistically significantly on all outcome measures," which were followed up to a year later.14
Not that simple
Other scientific studies of this caliber are currently underway to substantiate the findings. In the meantime, health and news publications have run with the story, exhibiting a variable degree of accuracy in their coverage of the findings and their implications. In the less accurate realm, for example, one newspaper ran an article flatly stating, "Up to 40 percent of patients with chronic back pain could be cured with a course of antibiotics rather than surgery."
Even if a person with low back pain has Modic changes on MRI, that doesn't necessarily mean there is either disc herniation or bacterial infection present. It is highly misleading to imply that antibiotics can be used as a blanket solution for a large number of back-pain sufferers. In addition, touting antibiotics as a broad-based answer to back pain sends a message that is dangerous on both a global and individual scale, considering the amount of antibiotics prescribed—258 million courses of antibiotics, or 833 prescriptions per 1,000 persons in the US alone in 2010 15—and the health problem caused by the global proliferation of antibiotic-resistant genes.16
On the individual level, not only does the patient taking more antibiotics run the risk of becoming antibiotic resistant, antibiotics have known side-effects such as upset stomach and diarrhea, rashes and possible allergic reactions. "The problem with antibiotics is when you look at the gut scenario, taking antibiotics is going to further destroy the good as well as the bad bacteria in the gastro-intestinal system," says Darvish. "Which means you're compromising the immune system and increasing inflammation even more, which, long-term, will lead to more chronic inflammation in your back or in your joints or wherever it might be."
The good news is there are other avenues to healing low back pain that's caused by bacteria. Infections in the discs and Modic changes in the vertebrae can be mitigated through the use of ozone injections and, potentially, other more natural approaches.
Dr Jam Caleda, a physician at the Integrative Naturopathic Medical Centre in Vancouver, Canada, says he has used prolozone—a connective tissue injection therapy of collagen-producing substances and ozone gas that can reconstruct damaged connective tissue in and around the joints—to treat over a hundred patients suffering from disc herniations and disc infections.
"I don't know how it clinically compares to antibiotics because I have never used antibiotics to treat low back pain," says Caleda. "But ozone optimizes the utilization of oxygen in the tissues ... and has a regenerative effect in the tissues, which stimulates regrowth. Another effect that ozone has is it's a very potent antimicrobial. It also acts as a pro-oxidant. And pro-oxidants have been shown to actually stimulate collagen growth in tissue."
Ozone in action
In a study conducted in 2003, 300 patients presenting clinical signs of lumbar disc nerve root compression and proven disc herniation received one intradiscal and periganglionic (the capsule surrounding a joint) injection of an oxygen-ozone mixture. Over 70 percent of the patients experienced relief from pain.17
Another study documents how ozone therapy for slipped and herniated discs that had resisted other treatment for a significant period of time created a "significant reduction" in the disc material impinging upon the spinal canal.18
Darvish uses ozone injections to treat herniated discs and bacterial infections in those areas. She injects the ozone around the ligaments of the disc but not into the discs themselves because ozone is a gas and, as such, is easily transported into and around the vertebrae.
She says that, unlike antibiotics, ozone specifically targets the infected areas. It also addresses other issues related to the bacterial infection.
"With herniated discs, the majority of disc issues can be related to either an infection or to the toxins from an infection," Darvish says. "Antibiotics are mainly addressing infection but not so much the endotoxins from the infections themselves. Beyond that, the disc really doesn't have much blood flow or circulation to it, so it's very difficult to get the antibiotics to the area where the problem is in the disc. Ozone also has very direct analgesic effects, so it shuts down the pain as well as helping the body regenerate the tissue."
She says she has successfully used ozone injections to treat many patients with low back pain who have disc herniations and infections. The most recent was a 66-year-old man with discitis who'd been dealing with chronic back pain for 30 years. "It was getting worse," she says. "The doctors were recommending surgery, and the ozone treatment was his last option." Darvish started doing direct ozone injections—four injections over the course of six to eight weeks. With every injection, he improved. "Now he's good," she says.
In addition to the ozone treatments, she made sure he was on an anti-inflammatory diet (inflammation is a major cause of back pain in general).
She also addressed the emotional component. "I always ask my patients with back pain, 'What are you carrying on your back? What baggage are you carrying?' We work a lot with patients helping them release emotional stressors and toxins that they're unknowingly carrying a lot of the time."
Caleda concurs it's vitally important to take a holistic approach to low back pain, treating the whole person and not just their symptoms.
"The idea that there is a single solution or protocol that is effective is too simple and objectified a way to approach chronic pain," he says. "As people we're a complex interaction of different processes. I'm hoping in the future we'll start thinking of more integrated ways to treat low back pain."
A holistic approach
If you've been diagnosed with a disc herniation and/or Modic changes in your vertebrae via MRI, and/or if you've had disc surgery, there is a good chance a bacterial infection is behind your chronic low back pain. If, despite the considerable downsides, you decide to take the antibiotic approach, taking high-potency probiotics during and after the course of antibiotics will help minimize the damage to helpful bacteria in your body and your gut microbiome. Probiotics also help your immune system to function properly, aid digestion, keep harmful microorganisms in check, stimulate the production of vitamins in the body and aid in nutrient absorption. Some food sources of probiotics are:
Yogurt and kefir. Don't buy brands with added sugar. If you're lactose intolerant, find sources made from goat's or sheep's milk and make sure the product comes from animals that are grass-fed and organic. Buy yogurts that tout added strains of healthy bacteria such as Lactobacillus bulgaricus, Streptococcus thermophiles, L. acidophilus, L. casei and Bifidus strains. If you don't eat dairy, try coconut milk (or other non-dairy) kefir and yogurt.
Raw cheese. Raw and unpasteurized cheeses contain many of the same probiotic strains as yogurt. If you're lactose intolerant, try cheese made from goat's or sheep's milk. Organic is best.
Kombucha. This fermented black tea brewed using a starter colony of bacteria and yeast called a 'SCOBY' is
loaded with good bacteria.
Tempeh/natto. Fermented soybeans can be found in Japanese food stores. They contain the probiotic Bacillus subtilis that favorably stimulates the immune system.
Fermented vegetables. Sauerkraut and kimchi are both made from fermented cabbage and other vegetables. In addition to containing probiotics, they are high in organic acids that support the growth of good bacteria in the gut.
No matter what course of treatment you take, it is imperative to support both the antibiotic and ozone protocols with an anti-inflammatory diet and supplements.
Says Dr Nooshin Darvish, chief medical officer at Holistique Naturopathic Medical Center in Bellevue, Washington: "You want to make sure to remove things like leptins [present in grains and pulses] and gluten from your diet. Dairy can be very inflammatory, and, of course, sugar is extremely inflammatory."
Aside from avoiding inflammatory foods and beverages such as alcohol, tea and coffee, she says including things like ginger and turmeric in the diet is helpful for dealing with both inflammation and pain. She also recommends an herbal product called Biocidin, which combines white willow bark, garlic, goldenseal, gentian, black walnut hulls, raspberry, lavender, oregano oil and a number of different antimicrobial as well as antiparasitic herbs. "It's great for establishing the gut bacteria," she says. "But it's also antimicrobial and antiparasitic and helps with local as well as systemic infections."
Back in action
Justis Morginn, age 53, was in bad shape. The Vancouver resident had experienced a lot of injuries earlier in his life, but his condition deteriorated after a terrible automobile accident. Both ACLs (anterior cruciate ligaments in the knee) were blown out. Every morning he did hours of exercise just to try to limber up enough to go to work, but his knees were so loose and wobbled so much from side to side that he would almost fall over. His left hip was damaged, his pelvis had been shattered and both his shoulders had been rebuilt.
For 15 years, Justis lived with constant chronic back pain, especially in the low back, and tension headaches. "It was so bad that if I would work for an hour, I'd have to lie down for an hour," he says. "If I worked through the whole day, I'd be down for two days. I was really incapacitated."
He saw a coterie of doctors, osteopaths, physical therapists, massage therapists and acupuncturists, but aside from brief moments, nothing relieved the pain. As a last resort he went to see Dr Jam Caleda, a naturopath at the Integrative Naturopathic Medical Centre in Vancouver, for prolozone therapy (see page 35).
"He worked up and down my spine with the ozone on both sides. It wasn't a magic bullet, but the treatments gave me my mobility and stability back and enabled me to walk and ride my bike and do Pilates and all the other things to get my low back in shape." Morginn says overall the prolozone treatments, which he continues to receive on an as-needed basis, plus exercise, have been able to reduce his suffering by 95 percent.
"It's been a game changer and given me emotional release as well," he says. And now I can even put my arms above my head!"
• The most common cause of low back pain throughout the world is lumbar disc degenerative disease.1 In the United States, more than 80 percent of adults over age 40 will develop lumbar spondylosis—a degenerative condition affecting the discs, vertebrae and the lumbar joints of the low back.2
• Disc herniation—a situation where one or more of the cushioning discs between the spinal vertebrae bulge to the point where the interior 'jelly' in the disc begins to spill out—is quite common. In one study of 60 "asymptomatic" men and women between 20 and 50 years old, magnetic resonance imaging (MRI) showed that approximately 65 percent of the test subjects had at least one protruding disc.3
• Because of the way we use our bodies when bending and lifting heavy objects, most herniated discs occur in the lumbar spine, in the first through fifth lumbar vertebrae in the
• Standard treatments for low back pain, including disc herniations, include physical therapy, movement therapy (such as yoga), pain medications, chiropractic, massage, acupuncture, cortisone injections, muscle relaxants and, of course, surgery.
Plenty of foods and natural products have antimicrobial properties. Actinomycetes bacteria found in soil are the source of many antibiotics, including streptomycin, actinomycin and erythromycin. The red soils of Jordan, used for millennia for their curative powers for skin infections, are rich in such antibiotic-producing bacteria and are still used by local communities today.1
Most natural antibiotics, however, are no further away than your kitchen and the local drug store.
Garlic. A broad-spectrum antibacterial, garlic extract is effective against bacteria and boosts the immune system.
Myrrh extract. Destroys several pathogens including E. coli, S. aureus and Candida albicans.
Neem. The leaves, bark and seeds have potent medicinal and antibiotic properties. It is used for everything from malaria and stomach ulcers to skin diseases, pain, fever and bacterial infections in the GI tract.
Grapefruit seed extract. Studies show it to be effective against a wide range of bacteria.
Raw apple cider vinegar. Established to have antimicrobial/antioxidant properties when used topically and ingested.
Virgin coconut oil. The medium chain triglycerides (MCTs, a type of fat) found in coconut oil have antiviral, antibacterial, and antifungal properties. It can also inhibit the growth of Clostridium difficile, the leading cause of antibiotic-associated diarrhea.
Turmeric. Highly effective for reducing inflammation and a potent anti-oxidant, this bright yellow tuber also fights Helicobacter pylori, a common infectious bacteria in the stomach linked to ulcers and stomach cancer.
Colloidal silver. A mineral, colloidal silver fights against bacterial infections of the skin, nose and throat by binding to the bacterial cell membranes, blocking the cells' ability to convert nutrients into energy.
Manuka honey. Produced from the nectar of the tea tree plant, manuka honey has been used to treat the methicillin-resistant Staphylococcus aureus (MRSA) superbug. Taken internally, it treats strep and stomach infections.
Thyme essential oil. Effective against various bacteria. For external use only.
Oregano essential oil. Reduces inflammation and kills skin fungi.