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Low-Back Pain and CAM

Four out of five American adults will experience low-back pain at some time in their lives. It is a major public health burden in the United States and is the leading cause of work-related disability and missed days of work, and the fifth most common reason for physician visits. A 2006 report estimated that annual costs of low-back pain in this country exceed $100 billion. Two-thirds of that is for indirect costs, such as lost wages and reduced productivity.

Low-back pain is often classified either as acute (pain that lasts up to 4 weeks); sub-acute (pain lasting from 4 to 12 weeks); or chronic (pain lasting for 3 months or longer). Only a small percentage of acute cases of low-back pain‚ 2 to 7 percent, according to one guideline‚ become chronic. However, this condition can cause substantial disability and accounts for the majority of low-back pain associated costs.

Nonspecific low-back pain is pain occurring primarily in the back with no signs of a serious underlying condition, spinal stenosis or radiculopathy, or another specific spinal cause. Degenerative changes on lumbar imaging correlate poorly with symptoms and are usually considered nonspecific.

"Low-back pain is one of our society's most common, burdensome health problems," says Josephine P. Briggs, M.D., Director of NCCAM. "The currently available treatments have limitations. Many patients turn to complementary and alternative medicine (CAM) with the hope of decreasing pain, improving function and quality-of-life, preventing recurrence and chronicity, or avoiding side effects of other treatments."

According to the 2007 National Health Interview Survey, back pain is the most common condition for which American adults use CAM. Data suggest that the CAM therapies most frequently used for low-back pain are chiropractic/manipulation, massage, and acupuncture. Other CAM approaches include yoga, herbal and other dietary supplements, devices, and lifestyle products.

Identifying optimal treatment approaches for low-back pain can be difficult for both patients and clinicians. A thorough patient assessment is the first step for a clinician who may be considering recommending CAM therapies. Clinical practice guidelines stress the importance of ruling out serious underlying conditions and evaluating a patient's psychosocial factors and emotional distress when doing an assessment of low-back pain.

"There is much more to learn about the effectiveness and safety of CAM therapies for chronic low-back pain and other chronic pain conditions," says Dr. Briggs. "Building a better and clearer evidence base in these areas, and sharing reliable information, are priorities for NCCAM."

History of Magnets for Health Uses

Magnets have been used for many centuries for a variety of health purposes. By various accounts, magnets were discovered when people first noticed the presence of naturally magnetized stones, also called lodestones. By the third century A.D., Greek physicians were using magnetic rings to treat arthritis and magnetized pills made of amber to stop bleeding. In the Middle Ages, doctors used magnets to treat gout, arthritis, poisoning, and baldness; to clean wounds; and to retrieve arrowheads and other iron-containing objects from the body.

In the United States, magnetic devices (such as hairbrushes and insoles), magnetic ointments, and clothes with magnets attached came into wide use after the Civil War, especially in some rural areas where few doctors were available. Healers claimed that magnetic fields existed in the blood, and that people became ill when their magnetic fields were depleted. Thus, healers marketed magnets as a means of replenishing these magnetic fields. Magnets were promoted as cures for a wide range of health conditions, including paralysis, headache, backache, sleeplessness, upset stomach, and liver and kidney problems.

The use of magnets to treat medical problems remained popular well into the 20th century. Today, magnets are used for many different types of pain, including foot pain and back pain from conditions such as arthritis and fibromyalgia.

It is important not to use magnets in place of proven treatments for serious medical conditions. Tell your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

What Science Says About Magnets for Pain

Overall, the scientific evidence does not support the use of magnets for pain relief. Preliminary studies looking at different types of pain: such as knee, hip, wrist, foot, back, and pelvic pain‚ have had mixed results. Some of these studies, including a recent NIH-sponsored clinical trial that looked at back pain in a small group of people, have suggested a benefit from using magnets. The majority of rigorous trials, however, have found no effect on pain.

Some research results suggest that effects may depend on the type of pain treated. For example, results from a few studies suggest that magnets might provide some relief specifically from osteoarthritis pain. Effects may also depend on the type and strength of the magnets used, the frequency of use, and the length of time the magnet was applied during the study.

Many studies were not high-quality because they included a small number of participants, were too short, and/or were poorly designed. More rigorous research is needed before reaching any firm conclusions about the effectiveness of magnets for pain.

Researchers face challenges when studying magnets in clinical trials:

Something other than the magnet may relieve a study participant's pain. For example, relief could come from a placebo effect or from a warm bandage or cushioned insole that holds the magnet in place.

It can be difficult to design a sham magnet that participants cannot distinguish from an active magnet. If participants know whether they are using an active magnet, study findings may be less reliable.

It is possible that the magnetic properties of low-strength magnets, which are sometimes used as shams, can actually have a therapeutic effect.

Opinions differ about how to administer magnet therapy, including what strength magnet to use, where to place the magnets on the body, and how long to use them. These factors have not been fully studied in humans. Clinical trials that look at these factors are needed.

No scientific theory or manufacturer claim about how magnets might work has been conclusively proven. Although some preliminary research has been conducted in animals and in small clinical trials, the mechanisms by which magnets might affect the human body are not yet known.

Scientific researchers and magnet manufacturers have proposed that magnets might work by:

- Changing how nerve cells function and blocking pain signals to the brain

- Restoring the balance between cell death and growth

- Increasing the flow of blood and the delivery of oxygen and nutrients to tissues

- Increasing the temperature of the area of the body being treated.

Findings from preliminary studies in healthy people‚ including one study funded by NIH‚ suggest that magnets may not affect blood flow or nerve function.

Magnets may not be safe for some people to use, including those who:
- Use a medical device such as a pacemaker, defibrillator, or insulin pump, because magnets may interfere with the functioning of the medical device

- Have a wound that has not healed.

Otherwise, magnets are generally considered safe when applied to the skin. Reports of side effects or complications have been rare.

It is important not to use magnets in place of proven treatments for serious medical conditions. Tell your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

Magnets to Manage Pain

Magnets have been used for health purposes for centuries. Static, or permanent, magnets are widely marketed for pain control and are considered part of complementary and alternative medicine (CAM).

Magnets in products such as magnetic patches and disks, shoe insoles, bracelets, and mattress pads are used for pain in the foot, wrist, back, and other parts of the body.

Preliminary scientific studies of magnets for pain have produced mixed results. Overall, there is no convincing scientific evidence to support claims that magnets can relieve pain of any type. Some studies, including a recent National Institutes of Health (NIH) clinical trial for back pain, suggest the possibility of a small benefit from using magnets for pain. However, the majority of rigorous studies have found no effect on pain. More research on magnets for pain is needed before reaching any firm conclusion.

Magnets are generally considered safe when applied to the skin, but they may not be safe for some people, such as those who use medical devices like pacemakers or defibrillators, as magnets may interfere with the device.

A magnet produces a measurable force called a magnetic field. Static magnets have magnetic fields that do not change (unlike another type called electromagnets, which generate magnetic fields only when electrical current flows through them). Most are made from metals (such as iron) or alloys (mixtures of metals, or of a metal and a nonmetal).

Magnets come in different strengths, often measured in units called gauss (G) or, alternatively, units called tesla (1 tesla = 10,000 G). Magnets marketed for pain usually claim strengths of 300 to 5,000 G‚ many times stronger than the Earth's magnetic field (about 0.5 G) and much weaker than the magnets used for MRI machines (approximately 15,000 G or higher).

Various products with magnets in them are marketed for health purposes, including shoe insoles, bracelets and other jewelry, mattress pads, bandages, headbands, and belts. These products are often placed in contact with painful areas of the body with the goal of providing relief.

As with any complementary or alternative practice that you use, it is important to talk to your health care providers and give them a full picture of what you are doing to manage your health. This will help ensure coordinated and safe care.

Symptoms of Spinal Stenosis

There may be no symptoms of spinal stenosis, or symptoms may appear slowly and get worse over time. More often, people experience numbness, weakness, cramping, or general pain in the arms or legs. If the narrowed space within the spine is pushing on a nerve root, people may feel pain radiating down the leg (sciatica). Sitting or flexing the lower back should relieve symptoms. (The flexed position "opens up" the spinal column, enlarging the spaces between vertebrae at the back of the spine.) Flexing exercises are often advised, along with stretching and strengthening exercises.

One type of spinal stenosis, cauda equine syndrome, is very serious. This type occurs when there is pressure on nerves in the lower back. Symptoms may include:

Loss of control of the bowel or bladder

Problems having sex

Pain, weakness, or loss of feeling in one or both legs.

Cauda equina syndrome is a serious condition requiring urgent medical attention.

What is Spinal Stenosis?

The spine, a row of 26 bones in your back, allows you to stand up straight and bend over. The spine also protects your spinal cord from being hurt. In people with spinal stenosis, the spine is narrowed in one or more of three parts:
1. The space at the center of the spine
2. The canals where nerves branch out from the spine
3. The space between vertebrae (the bones of the spine).

Pressure on the lower part of the spinal cord or on nerve roots branching out from that area may give rise to pain or numbness in the legs. Pressure on the upper part of the spinal cord (that is, the neck area) may produce similar symptoms in the shoulders, or even the legs.

Spinal stenosis is most common in men and women over 50 years old. However, it may occur in younger people who are born with a narrowing of the spinal canal or who suffer an injury to the spine.

Changes that occur in the spine as people get older are the most common cause of spinal stenosis. As people get older:
The bands of tissue that support the spine may get thick and hard.

Bones and joints may get bigger.

Surfaces of the bones may bulge out (these are called bone spurs).

In some cases arthritis, a degenerative condition can cause spinal stenosis. Two forms of arthritis may affect the spine: osteoarthritis and rheumatoid arthritis.

Some people are born with conditions that cause spinal stenosis. For instance, some people are born with a small spinal canal, while others are born with a curved spine (scoliosis). Other factors that have been know to cause spinal stenosis include: tumors of the spine, injuries, Paget’s disease (a disease that affects the bones), too much fluoride in the body, and calcium deposits on the ligaments that run along the spine.

Non-surgical Treatments for Spinal Stenosis

In the absence of severe or progressive nerve involvement, a doctor may prescribe one or more of the following conservative treatments for spinal stenosis:

Non-steroidal anti-inflammatory drugs, such as aspirin, naproxen (Naprosyn), ibuprofen (Motrin, Nuprin, Advil), or indomethacin (Indocin), to reduce inflammation and relieve pain.

Analgesics, such as acetaminophen (Tylenol), to relieve pain.

Corticosteroid injections into the outermost of the membranes covering the spinal cord and nerve roots to reduce inflammation and treat acute pain that radiates to the hips or down a leg.

Anesthetic injections, known as nerve blocks, near the affected nerve to temporarily relieve pain.

Restricted activity (varies depending on extent of nerve involvement).

Prescribed exercises and/or physical therapy to maintain motion of the spine, strengthen abdominal and back muscles, and build endurance, all of which help stabilize the spine. Some patients may be encouraged to try slowly progressive aerobic activity such as swimming or using exercise bicycles.

A lumbar brace or corset to provide some support and help the patient regain mobility. This approach is sometimes used for patients with weak abdominal muscles or older patients with degeneration at several levels of the spine.

Brand names included in this fact sheet are provided as examples only. Their inclusion does not mean that these products are endorsed by the National Institutes of Health or another government agency. Also, if a particular brand name is not mentioned, this does not imply that the product is unsatisfactory.

Structures of the Spine & Spinal Stenosis

The spine is a column of 26 bones that extend in a line from the base of the skull to the pelvis. Twenty-four of the bones are called vertebrae. The bones of the spine include 7 cervical vertebrae in the neck; 12 thoracic vertebrae at the back wall of the chest; 5 lumbar vertebrae at the inward curve (small) of the lower back; the sacrum, composed of 5 fused vertebrae between the hip bones; and the coccyx, composed of 3 to 5 fused bones at the lower tip of the vertebral column. The vertebrae link to each other and are cushioned by shock-absorbing disks that lie between them.

The vertebral column provides the main support for the upper body, allowing humans to stand upright or bend and twist, and it protects the spinal cord from injury. Following are structures of the spine most involved in spinal stenosis.

Intervertebral disks, pads of cartilage filled with a gel-like substance, which lie between vertebrae and act as shock absorbers.

Facet joints‚ joints located on the back of the main part of the vertebra. They are formed by a portion of one vertebra and the vertebra above it. They connect the vertebrae to each other and permit backward motion.

Intervertebral foramen (also called neural foramen)‚ an opening between vertebrae through which nerves leave the spine and extend to other parts of the body.

Lamina‚ part of the vertebra at the back portion of the vertebral arch that forms the roof of the canal through which the spinal cord and nerve roots pass.

Ligaments‚ elastic bands of tissue that support the spine by preventing the vertebrae from slipping out of line as the spine moves. A large ligament often involved in spinal stenosis is the ligamentum flavum, which runs as a continuous band from lamina to lamina in the spine.

Pedicles‚ narrow stem-like structures on the vertebrae that form the walls of the front part of the vertebral arch.

Spinal cord/nerve roots‚ a major part of the central nervous system that extends from the base of the brain down to the lower back and that is encased by the vertebral column. It consists of nerve cells and bundles of nerves. The cord connects the brain to all parts of the body via 31 pairs of nerves that branch out from the cord and leave the spine between vertebrae.

Synovium‚ a thin membrane that produces fluid to lubricate the facet joints, allowing them to move easily.

Vertebral arch‚ a circle of bone around the canal through which the spinal cord passes. It is composed of a floor at the back of the vertebra, walls (the pedicles), and a ceiling where two laminae join.

Cauda equina‚ a sack of nerve roots that continues from the lumbar region, where the spinal cord ends, and continues down to provide neurologic function to the lower part of the body. It resembles a "horse's tail" (cauda equina in Latin).

When Should Surgery Be Considered for Spinal Stenosis and What Is Involved?

In many cases, the conditions causing spinal stenosis cannot be permanently altered by non-surgical treatment, even though these measures may relieve pain for a period of time. To determine how much non-surgical treatment will help, a doctor may recommend such treatment first. However, surgery might be considered immediately if a patient has numbness or weakness that interferes with walking, impaired bowel or bladder function, or other neurological involvement. The effectiveness of non-surgical treatments, the extent of the patient's pain, and the patient's preferences may all factor into whether or not to have surgery.

The purpose of surgery is to relieve pressure on the spinal cord or nerves and restore and maintain alignment and strength of the spine. This can be done by removing, trimming, or adjusting diseased parts that are causing the pressure or loss of alignment. The most common surgery is called decompressive laminectomy: removal of the lamina (roof) of one or more vertebrae to create more space for the nerves. A surgeon may perform a laminectomy with or without fusing vertebrae or removing part of a disk. Various devices may be used to enhance fusion and strengthen unstable segments of the spine following decompression surgery.

Patients with spinal stenosis caused by spinal trauma or achondroplasia may need surgery at a young age. When surgery is required in patients with achondroplasia, laminectomy (removal of the roof) without fusion is usually sufficient.

All surgery, particularly those involving general anesthesia and older patients, carries risks. The most common complications of surgery for spinal stenosis are a tear in the membrane covering the spinal cord at the site of the operation, infection, or a blood clot that forms in the veins. These conditions can be treated but may prolong recovery. The presence of other diseases and the physical condition of the patient are also significant factors to consider when making decisions about surgery.

Removal of the obstruction that has caused the symptoms usually gives patients some relief; most patients have less leg pain and are able to walk better following surgery. However, if nerves were badly damaged before surgery, there may be some remaining pain or numbness or no improvement. Also, the degenerative process will likely continue, and pain or limitation of activity may reappear after surgery. NIAMS-supported researchers have published results from the Spine Patient Outcomes Research Trial (SPORT), the largest trial to date comparing surgical and non-surgical interventions for the treatment of low back and associated leg pain caused by spinal stenosis. The study found that for patients with spinal stenosis, surgical treatment was more effective than non-surgical treatment in relieving symptoms and improving function. However, the functional status of patients who received non-surgical therapies also improved somewhat during the study.

Alternative Therapies for Spinal Stenosis

Alternative (or complementary) therapies are diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Some examples of these therapies used to treat spinal stenosis follow:

Chiropractic treatment‚ this treatment is based on the philosophy that restricted movement in the spine reduces proper function and may cause pain. Chiropractors may manipulate (adjust) the spine to restore normal spinal movement. They may also employ traction, a pulling force, to help increase space between the vertebrae and reduce pressure on affected nerves. Some people report that they benefit from chiropractic care. Research thus far has shown that chiropractic treatment is about as effective as conventional, non-operative treatments for acute back pain.

Acupuncture involves stimulating certain places on the skin by a variety of techniques, in most cases by manipulating thin, solid, metallic needles that penetrate the skin. Research has shown that low back pain is one area in which acupuncture has benefited some people.

More research is needed before the effectiveness of these or other possible alternative therapies can be definitively stated. Health care providers may suggest these therapies in addition to more conventional treatments.