1. This house believes that in 2014 antibiotics should be used to treat certain specific types of chronic back pain Philip Sell

2. What we have

4. Archie Cochrane

7. CONFOUNDING FACTORS

9. The Evidence Level one Single study Quality of evidence – Consort – Grade

10. Systematic Review Meta-analysis

11. Why the unease ? Why is it some have no doubts Why is it some have massive doubts?

12. Medically unexplained symptoms

13. Propioibacterium freudenreichii in Emmental cheese

14. The reason we are uncomfortable Miracle cure for back pain: Agony ended by everyday antibiotics CHEAP antibiotics could end the agony of back pain for millions of Britons for ever. DAILY EXPRESS

15. Press reports before peer acceptance MMR studies Steroids in cord injury Hence our doubts

16. Magical thinking in improvement

17. Need for a science-based approach Rigorous theory and methods Fully specify interventions and mechanisms How much evidence is needed

18. Problem: childbed fever

19. Vienna Maternity Institution: rates of puerperal fever 1841-1849

20. Intervention was right; theory was wrong The logic of hand-washing with chlorine was right (the technical intervention worked) But the big theory of resorption of cadaveric particles was wrong And the adaptive work was disaster

21. Why we should wait for further evidence

22. Original Article Magnetic Resonance Imaging in Follow-up Assessment of Sciatica Abdelilah el Barzouhi, M.D., Carmen L.A.M. Vleggeert-Lankamp, M.D., Ph.D., Geert J. Lycklama à Nijeholt, M.D., Ph.D., Bas F. Van der Kallen, M.D., Wilbert B. van den Hout, Ph.D., Wilco C.H. Jacobs, Ph.D., Bart W. Koes, Ph.D., Wilco C. Peul, M.D., Ph.D., for the Leiden–The Hague Spine Intervention Prognostic Study Group N Engl J Med Volume 368 March 14, 2013 N Engl J Med Volume 368 March 14, 2013

23. How it all began.....

24. Conclusion MRI performed at 1-year follow-up in patients who had been diagnosed with sciatica and a herniated disc on MRI …… did not distinguish between those with a favorable outcome and those with an unfavorable outcome

25. Back pain’s association with vertebral endplate signal changes in sciatica Abdelilah el Barzouhi, M.D., Carmen L.A.M. Vleggeert-Lankamp, M.D., Ph.D., Bas F. Van der Kallen, M.D., Geert J. Lycklama à Nijeholt, M.D., Ph.D., Wilbert B. van den Hout, Ph.D., Wilco C.H. Jacobs, Ph.D., Bart W. Koes, Ph.D., Wilco C. Peul, M.D., Ph.D., for the Leiden–The Hague Spine Intervention Prognostic Study Group Eurospine 2013

26. Evolution of back pain in surgically treated patients according to VESC Evolution of back pain in conservatively treated patients according to VESC Backpain diminishes over time

27. The Trial Unusual Control group show no change Trial recruitment Not spontaneous presentation Trial entry Invite to attend to 347 patients known to the organisation. 162 recruited

28. Harmless?

29. MMR Poor uptake of vaccines Measles epidemic in Wales

30. This house believes that in 2014 antibiotics should be used to treat certain specific types of chronic back pain MORE STUDY REQUIRED BE OPEN MINDED REJECT THE MOTION