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VOLUME 1: NO. 4 OCTOBER 2004

Use of Complementary Therapies AmongPrimary Care Clinic Patients With Arthritis

ORIGINAL RESEARCH

Suggested citation for this article: Herman CJ, Allen P,Hunt WC, Prasad A, Brady TJ. Use of complementarytherapies among primary care clinic patients with arthri-tis. Prev Chronic Dis [serial online] 2004 Oct [date cited].Available from: URL: http://www.cdc.gov/pcd/issues/2004/oct/03_0036.htm.

PEER REVIEWED

Abstract

IntroductionUse of complementary and alternative medicine (CAM)

for chronic conditions has increased in recent years. Thereis little information, however, on CAM use among adultswith clinic-confirmed diagnoses, including arthritis, whoare treated by primary care physicians.

MethodsTo assess the frequency and types of CAM therapy used

by Hispanic and non-Hispanic white women and men withosteoarthritis, rheumatoid arthritis, or fibromyalgia, weused stratified random selection to identify 612 partici-pants aged 18–84 years and seen in university-based pri-mary care clinics. Respondents completed an interviewer-administered survey in English or Spanish.

ResultsNearly half (44.6%) of the study population was of

Hispanic ethnicity, 71.4% were women, and 65.0% hadannual incomes of less than $25,000. Most (90.2%) hadever used CAM for arthritis, and 69.2% were using CAMat the time of the interview. Current use was highest fororal supplements (mainly glucosamine and chondroitin)(34.1%), mind-body therapies (29.0%), and herbal topicalointments (25.1%). Fewer participants made current use

of vitamins and minerals (16.6%), herbs taken orally(13.6%), a CAM therapist (12.7%), CAM movement ther-apies (10.6%), special diets (10.1%), or copper jewelry ormagnets (9.2%). Those with fibromyalgia currently usedan average of 3.9 CAM therapies versus 2.4 for thosewith rheumatoid arthritis and 2.1 for those withosteoarthritis. Current CAM use was significantly asso-ciated with being female, being under 55 years of age,and having some college education.

ConclusionHispanic and non-Hispanic white arthritis patients used

CAM to supplement conventional treatments. Health careproviders should be aware of the high use of CAM andincorporate questions about its use into routine assess-ments and treatment planning.

Introduction

Rheumatic conditions such as arthritis and chronicjoint pain are the leading cause of limitation in dailyactivities and disability among adults in the UnitedStates (1). In 2001, self-reported data obtained by theU.S. Behavioral Risk Factor Surveillance System indi-cated that a third of American adults had chronic jointsymptoms or physician-diagnosed arthritis (1).Researchers estimate that by 2030, some 41 millionadults aged 65 and older will have arthritis or chronicjoint symptoms (2). Management of chronic rheumaticconditions usually consists of physician-prescribed med-ications, physician-recommended over-the-counter med-ications, physical therapy, and self-management strate-gies recommended by physicians and the AmericanCollege of Rheumatology (3) such as exercise, weight con-trol, use of heat or cold, intermittent rest, and stressmanagement. Increasingly, adults are also adopting com-

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and does not imply endorsement by any of the groups named above.

www.cdc.gov/pcd/issues/2004/oct/03_0036.htm • Centers for Disease Control and Prevention 1

Carla J. Herman, MD, MPH, Peg Allen, MPH, William C. Hunt, MA, Arti Prasad, MD, Teresa J. Brady, PhD

VOLUME 1: NO. 4OCTOBER 2004

plementary and alternative medicine (CAM) to helpmanage their chronic conditions (4,5).

This study addresses three gaps in the literature onCAM use for arthritis. First, CAM use among adults withphysician-confirmed arthritis who are treated by primarycare physicians has not been well studied. Previous stud-ies on prevalence of CAM use for arthritis in the UnitedStates have typically included either patients seen byrheumatologists (6-8) or community-based samples ofadults with self-reported arthritis (9-12). The rheumatol-ogy clinic studies have used clinic-confirmed diagnoses butexcluded adults treated by primary care physicians andhave had small samples (n = 135–232). The community-based surveys have included adults treated by any type ofphysician or none at all and have had larger samples (n =122–1424), but these studies have relied on self-report todetermine the presence of arthritis. Many such partici-pants did not know what type of arthritis they had (9,10).

A second gap in the literature is the underrepresenta-tion of Hispanic adults in arthritis-specific CAM-use stud-ies in the United States. Two community-based studiesconducted 10 or more years ago found that Hispanic andAfrican American adults with arthritis were more likelyto use prayer, take herbs orally, or use ointments andwere less likely to see a physician for arthritis than werenon-Hispanic whites (13,14). Hispanic adults are betterrepresented in studies of CAM use among the generalpopulation (4). In studies of CAM use for any purposeamong adults in the general population, Hispanics orLatinos have been as likely as non-Hispanic whites to useself-care types of CAM but less likely to have seen a CAMprovider (4,5,15-19).

A third shortcoming is that there seems to be little infor-mation describing use of specific CAM therapies by type ofarthritis, even though the three most common types ofarthritis — osteoarthritis, rheumatoid arthritis, andfibromyalgia — differ greatly in disease processes, clinicalpresentations, persons affected, and the CAM therapiesshown to be effective (20,21). Osteoarthritis affects bothwomen and men primarily over age 45, whereas rheuma-toid arthritis and fibromyalgia can start at younger agesand affect more women than men (20).

The purpose of this study is to assess the frequency andtypes of CAM therapy used by Hispanic and non-Hispanic white adults treated by primary care physicians

in university-affiliated clinics in Albuquerque, NM, aspart of the management of osteoarthritis, rheumatoidarthritis, or fibromyalgia.

Methods

Recruitment

Hispanic and non-Hispanic white women and men aged18–84 years seen in any of six primary care clinics at theUniversity of New Mexico in Albuquerque between June2000 and May 2001 with a diagnostic code for osteoarthri-tis, rheumatoid arthritis, or fibromyalgia were eligible forinclusion in the sample. The sampling method is dis-cussed below (Statistical analysis). Of the 1684 sampledpatients, 22 (1.3%) had died. For 97 (5.8%), permission tocontact was denied by the primary care physician, and for69 (4.1%), no responding physician could be found.Introductory letters were sent to the 1496 patients(88.8%) for whom physician consent was obtained.Trained bilingual interviewers made telephone calls inEnglish or Spanish to these patients to invite them to par-ticipate in the study. Because of the known inaccuracy ofethnicity coding in the clinics, interviewers screenedpatients during the invitational calls to ensure they self-identified as Hispanic or non-Hispanic white and spokeEnglish or Spanish. During recruitment, we learned thatthe diagnostic code (ICD-9-CM) for fibromyalgia was notspecific to fibromyalgia, but also included people withother muscular conditions. Consequently, some patientsdenied having fibromyalgia or arthritis when contactedand were excluded.

Interviews

In-person interviews were conducted by appointmentin participants’ homes or in a clinic, according to partici-pant preference. The interviewers were university stafftrained to conduct interviews for a variety of epidemio-logical studies.

We used validated and reliable measures from theCenters for Disease Control and Prevention’s BehavioralRisk Factor Surveillance System for demographic ques-tions, perceived health status, and comorbidity (22). The20-item Stanford Health Assessment Questionnaire(HAQ), commonly used in arthritis research, was themeasure of functional ability (23). The five-item short form

2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/oct/03_0036.htm



of the Arthritis Helplessness Index, validated by DeVellisand Callahan (24), measured perceived helplessness (25).Fiscella’s four-item Medical Skepticism scale (26)assessed beliefs about desire to control one’s own healthcare. We used the Faces Pain Scale to assess average painover the past week, with a range from 0 = no pain to 10 =worst possible pain (27,28). We used a visual analog scaleto evaluate average fatigue over the past week, with arange from 0 = no fatigue to 10 = extreme fatigue (29). Afour-item scale measured sleep problems in the pastmonth (30). We also included Marin’s five-item Hispanicacculturation scale (31).

We selected CAM items based on a review of the litera-ture and feedback from 39 volunteers in four focus groups.CAM items were included in the survey if they werereported in the CAM literature as commonly used forosteoarthritis, rheumatoid arthritis, or fibromyalgia, or iffocus group participants said they were locally used forarthritis. (The Appendix provides a full list of CAM thera-pies included in the survey.) Participants were also askedto describe other therapies they were using. Current usewas defined as use at the time of the interview.

Pilot testing of the questionnaire was conducted in twowaves. The first wave involved adults who had arthritis orfibromyalgia and were known to the researchers. In thesecond wave, interviewers conducted pilot interviewsusing the modified survey with 18 volunteers recruitedfrom the community who met eligibility criteria for thestudy. Final revisions were then made to the English-lan-guage questionnaire. Previously validated Spanish trans-lations were used for the functional ability HAQ (32);demographic, health status, and comorbidity items (22);Arthritis Helplessness Index (33); and acculturation scale(31). A native Spanish speaker born in Mexico who worksin health care in New Mexico translated the remainingmeasures. Several Spanish-speaking researchersreviewed the translations to ensure a match to theEnglish meaning, proper grammar, and correct spellingand then pilot tested the Spanish version with Spanishspeakers who had arthritis.

Statistical analysis

Participants were randomly selected from the clinicpopulation within strata defined by ethnicity, sex, anddiagnostic group. To obtain more rheumatoid arthritisparticipants, more Hispanics, and more men, we sam-

pled patients in these categories at higher rates thannon-Hispanic white women with diagnoses ofosteoarthritis or fibromyalgia. The strata were based onthe clinic-assigned ethnicity and diagnostic group,although self-reported ethnicity and self-reported diag-nosis of fibromyalgia were used in the analysis.Sampling fractions were computed as the ratio of thenumber of participants who completed an interview tothe total number of clinic patients within each stratum.The inverses of the sampling fractions were used asweights in all analyses. SUDAAN software release 8.0.2(Research Triangle Institute, Research Triangle Park,NC) was used to compute all weighted estimates of pro-portions and tests of significance by means of a stratifiedsampling with replacement design (34).

We conducted analyses separately by diagnosticgroup because the three types of rheumatological condi-tions are different disease processes with different clin-ical presentations and patient demographics. Forarthritis type, we coded each participant as having pri-marily rheumatoid arthritis, fibromyalgia, orosteoarthritis. The clinic diagnostic codes were used toidentify respondents as having rheumatoid arthritis orosteoarthritis. Because of inaccuracies in the diagnosticcoding for fibromyalgia, we used participants’ self-reports to code that condition. Participants having morethan one type of arthritis were classified in the follow-ing order of priority: 1) rheumatoid arthritis, 2)fibromyalgia, and 3) osteoarthritis. Ninety-five patientswere classified as having rheumatoid arthritis, 95 ashaving fibromyalgia, and 422 as having osteoarthritis.One patient with rheumatoid arthritis also had a clini-cal diagnosis of osteoarthritis, and six reported havingfibromyalgia. Nineteen with self-reported fibromyalgiaalso had a clinical diagnosis of osteoarthritis. Subjectswho reported both Hispanic and non-Hispanic ethnicitywere coded as Hispanic.

Several survey items were excluded from frequencycounts and analyses of CAM use. Multiple vitamins,prayer, and drawing upon religious beliefs were exclud-ed because participants had difficulty distinguishingbetween use for general health and use specifically forarthritis. Calcium, vitamin D, and folic acid were exclud-ed because participants reported that their physicianshad recommended their use for other health reasons.






Results

Demographics

A total of 612 primary care clinic patients completed thesurveys. Of the 1496 primary clinic patients sent intro-ductory letters, 286 (19.1%) were ineligible per the tele-phone screening (self-reported ethnicity other thanHispanic or non-Hispanic white or denied having arthri-tis). Of the 1210 eligible patients, 110 (9.1%) were too ill toparticipate because of other illnesses, 36 (3.0%) had movedout of the area, 302 (25.0%) refused, 96 (7.9%) had no cur-rent contact information, and 54 (4.5%) with valid tele-phone numbers could not be reached despite repeated callsat different times of the day. The final response rate ofcompleted interviews among eligible patients was 50.6%(612 of the 1210 eligible patients). Information was notavailable on nonrespondents to compare their characteris-tics with those of respondents.

Weighted estimates of the proportions of the clinic pop-ulation with each of several characteristics, both overalland by diagnostic group, are shown in Table 1. An esti-mated 44.6% were of Hispanic ethnicity and 71.4% werefemale. About one fourth (26.9%) were aged younger than55 years, 35.4% were aged 55–64, and 37.7% were aged65–84. Of the Hispanics, 71.4% self-identified as SpanishAmerican, 20.3% as Mexican American or Mexican, 2.9%as Central or Latin American, and 2.0% as “other” (3.4%were unidentifiable either because the respondents did notknow or refused to answer) (data not shown). As expected,clinic patients with rheumatoid arthritis and fibromyalgiawere younger and included a higher proportion of womenand non-Hispanic whites, and they had more educationthan the group with osteoarthritis. Patients withfibromyalgia had higher levels of pain in the past weekand more frequent physician visits for their rheumatolog-ic condition than did patients with rheumatoid arthritis orosteoarthritis (P < 0.01).

Overall CAM use

Most of the clinic population (90.2%) had ever tried CAMtherapies for their arthritis, and 69.2% currently used oneor more CAM therapies at the time of the interview (Table2). CAM users with fibromyalgia had ever tried an averageof 5.5 CAM therapies versus 4.4 among those withrheumatoid arthritis and 3.1 among those withosteoarthritis (P < .05) (data not shown). CAM users with

fibromyalgia currently used an average of 3.9 CAM thera-pies compared with 2.4 among those with rheumatoidarthritis and 2.1 among those with osteoarthritis (P < .05)(data not shown).

Types of therapies used

Fibromyalgia patients were most likely to use each typeof CAM compared to those with rheumatoid arthritis orosteoarthritis (Table 2). Specific CAM therapies currentlyused by at least 3% of the clinic population in at least oneof the diagnostic groups are shown in Table 3. Patientswith osteoarthritis most commonly used the nutritionalsupplements glucosamine (25.2%) and chondroitin (17.9%)and the mind-body therapies of meditation (10.1%) andrelaxation techniques (10.0%) to manage their arthritis.Rheumatoid arthritis patients most commonly used relax-ation (16.3%), glucosamine (15.8%), meditation (11.1%),and vitamin C (10.0%). Only 6.1% of rheumatoid arthritispatients currently used fish oil supplements, and only1.3% used supplements containing gamma linolenic acid(GLA) (borage oil, evening primrose oil, and black currantoil). Fibromyalgia patients most commonly used breathingtechniques (36.7%), relaxation (28.9%), meditation(27.6%), music therapy (22.8%), glucosamine (20.7%), visu-alization (19.6%), acupressure (19.5%), massage therapy(17.1%), magnesium (14.1%), and yoga (13.2%).Fibromyalgia patients with a concurrent clinical diagnosisof osteoarthritis were more likely to use glucosamine thanwere those without osteoarthritis (glucosamine: 49.3% vs13.8%, P = .01; chondroitin: 25.6% vs 6.9%, P = .08) (datanot shown).

Patients currently used more than 40 different herbstaken orally and more than 30 topical herbal therapies forarthritis. As Table 3 shows, massage therapists, chiroprac-tors, and acupuncturists were the most commonly seenCAM therapists. Within the items worn category, only mag-nets and copper bracelets were currently used by more than1% of patients. Respondents were asked about several CAMmovement therapies, and they most often named yoga, taichi, or the Feldenkrais method of movement reeducation.Current use of special diets included an “arthritis diet” highin fish and fresh fruits and vegetables and low in potatoes,tomatoes, eggplant, and peppers. Patients also used severalother special diets. Energy therapies included acupressure,reiki, reflexology, therapeutic touch, aromatherapy, andother therapies intended to affect theorized energy fieldswithin and surrounding the body.




Characteristics of CAM users

Among osteoarthritis and fibromyalgia patients, currentuse of any type of CAM did not differ by demographic char-acteristics (Table 4). Among rheumatoid arthritis partici-pants, however, current CAM use was associated with dis-ease duration of 0–5 years and having some college educa-tion (P < 0.05). Tests for interactions showed the associa-tion between ethnicity and current use of any type of CAMdiffered by diagnostic group. Similar proportions ofHispanic and non-Hispanic white osteoarthritis patientscurrently used any type of CAM, whereas significantlymore non-Hispanic whites with rheumatoid arthritis cur-rently used CAM than did Hispanics with rheumatoidarthritis. We tested other measures of disease burden notshown in Table 4 (including functional ability, fatigue,sleep problems, perceived general health status, and pres-ence of comorbidity) for possible associations with currentCAM use, but we found none that was significant. Overall,current use of any type of CAM was significantly higheramong women (P = .03), patients under age 55 (P = .02),and those with some college education (P = .003).

Other aspects of CAM use

Additional results not presented in the tables aredescribed below. The percentages of the clinic populationthat found CAM therapies somewhat helpful or helped alot, among those who had ever used that type of CAM, areas follows: mind-body therapies (90.4%); CAM movementtherapies (82.7%); CAM therapists (79.8%); energy thera-pies (79.4%); herbal topical rubs (77.1%); special diets(64.9%); vitamins and minerals (63.0%); herbs taken oral-ly (61.5%); nutritional supplements (57.0%); homeopathicremedies (49.6%); and items worn (36.9%). Gaps betweenpercentages of ever use and current use were greatest forthose CAM therapies that fewer patients found useful,such as wearing copper jewelry or magnets, or for costlytherapies, such as seeing CAM therapists or using glu-cosamine and chondroitin. Among those who had everused CAM, 13.6% of osteoarthritis patients, 17.3% of thosewith rheumatoid arthritis, and 30.6% of those withfibromyalgia reported that CAM use changed their use ofconventional therapies. The most common change report-ed in open-ended responses was the use of smalleramounts or doses of prescription or over-the-counter med-ication (52.8%). Of those who had ever tried CAM, 6.6%used only CAM therapies and no conventional treatments.Overall, 22.6% of those who had ever used CAM had never

mentioned their CAM use to their medical doctor, 66.6%had told their doctor, 8.0% said their doctor had suggestedthe therapies, and 2.7% were unsure. More CAM userswith fibromyalgia (82.8%) told their doctor about theirCAM use than did those with rheumatoid arthritis (69.7%)or osteoarthritis (62.0%) (P < .001).

Open-ended responses on reasons for using CAM were inthe same rank order by how often they were mentioned ineach diagnostic group. Overall, reasons mentioned includ-ed the following: to relieve pain (36.1%); to prevent diseaseprogression (14.3%); to feel better (13.7%); to try CAM tosee if it would help (13.5%); and because CAM therapieshad helped them (9.2%). Sources of information aboutCAM were also similar across the diagnostic groups.Overall, these sources included family or friends (66.1%),medical doctors (56.1%), magazines or books (34.6%), andradio or television or newspapers (22.6%); only 11.3%named the Internet as a source. Patients who had everused any type of CAM currently spent from $0 to morethan $500 per month on CAM therapies, with 67.7%spending $50 or less per month and 15.1% spending morethan $100 per month. Thirty percent of CAM users withfibromyalgia spent more than $100 per month on CAMversus 24.0% of those with rheumatoid arthritis and 9.7%of those with osteoarthritis.

Discussion

In this study, 90.2% of Hispanic and non-Hispanic whitearthritis patients treated by primary care physicians hadever tried CAM for their arthritis, and 69.2% currentlyused one or more CAM therapies. Overall, 17.2% changedtheir use of conventional treatments after starting to useCAM, and more than one fifth (22.6%) had never discussedtheir CAM use with their medical doctor. These findingsare important because they indicate that conventionaltherapies alone are not meeting the needs of arthritispatients. Furthermore, many patients are supplementingor decreasing their medical treatment with or without theirphysician’s knowledge. Because some CAM therapies mayinteract with conventional medications and treatments, itis important for health care providers to be aware thatmany arthritis patients are using therapies on their ownand to inquire specifically about their patients’ CAM use.

The prevalence of CAM use found in this study is high-er than the range of 33%–66% reported in previous arthri-






tis studies (6-12). Differing definitions of CAM may partlyexplain the disparity, as the present study included abroader array of mind-body therapies, energy therapies,and CAM movement therapies than most previous stud-ies. Geographic location may also partly explain the differ-ence, given that national studies of CAM use among thegeneral population have found higher use in the West thanin other regions of the United States (5,18). Also, somearthritis studies have included only older adults (9-12)who in previous studies were less likely to use CAM thanadults under age 55 (4,5).

As in previous studies, most CAM use in the presentstudy was self-care, with a smaller percentage of peopleseeing a CAM therapist (4-6,10,12,15). Consistent withsome previous studies, current use of any type of CAM inthis study was associated with being female, beingunder age 55, and having some college education, anduse did not differ by Hispanic ethnicity (4-6,16,19).National studies on CAM use among the general popu-lation found higher income was associated with CAMuse (4,5), but the present study and some other arthritisCAM studies found no association between CAM use andincome (6,9,11).

The finding that patients with osteoarthritis used alower average number of CAM therapies than those withfibromyalgia and rheumatoid arthritis conflicts with aprevious rheumatology clinic study in which patientswith rheumatoid arthritis were less likely to use CAMthan patients with osteoarthritis or fibromyalgia (6).Both that study and ours, however, had small numbers ofpatients with fibromyalgia and rheumatoid arthritis, andthe previous study had very few patients withosteoarthritis. Thus, caution should be used in interpret-ing this finding. In previous studies among adults witharthritis, CAM use was associated with poor perceivedgeneral health (10,11), sleep disruption (12), or severepain (35). In one study, use of three or more types of CAMwas associated with longer disease duration (35). In thepresent study, however, shorter duration of arthritisamong respondents with rheumatoid arthritis was asso-ciated with current CAM use, and arthritis symptomswere not significantly associated with CAM use.Although similar percentages of Hispanic and non-Hispanic white respondents with osteoarthritis used anytype of CAM, use of specific CAM therapies may vary byHispanic ethnicity. Exploration of this issue is beyondthe scope of the present overview.

An important finding of this study is that patterns ofCAM use did not necessarily correspond to CAM therapieswith evidence of effectiveness for particular types of arthri-tis. Most striking is the high percentage of patients in eachdiagnostic group with past and current use of glucosamineand chondroitin. Rigorous scientific studies have shownconsistent moderate short-term benefits and safety of glu-cosamine and chondroitin for osteoarthritis of the knee,but there is no evidence for their effectiveness in rheuma-toid arthritis or fibromyalgia (21,36,37). We checked forconcurrent osteoarthritis as a possible explanation of useby those with rheumatoid arthritis and fibromyalgia, butwe found that none of the participants with rheumatoidarthritis and only half of those with fibromyalgia usingglucosamine and chondroitin had osteoarthritis. Anotherexample is the low use of fish oil and GLA-containing sup-plements among patients with rheumatoid arthritis, eventhough they have been shown to reduce pain and improvefunction in those who have rheumatoid arthritis (21,38).Relying on friends, family members, and magazines forinformation about CAM may have affected participants’access to credible information specific to arthritis type.High use of mind-body therapies was found in the presentstudy within each diagnostic group, especially amongthose with fibromyalgia. The few efficacy studies of mind-body therapies among patients with fibromyalgia havehad equivocal findings, but results are promising forpatients with osteoarthritis and rheumatoid arthritis (39).

This study has several limitations. Sample sizes weresmall for those with rheumatoid arthritis (n = 95) and fibromyalgia (n = 95), although the numbers ofosteoarthritis participants (n = 422) and total participants(n = 612) were larger than in previous studies with clinicsamples. Results are not generalizable beyond the partic-ular clinic population for several reasons: the responserate was low; men, Hispanics, and those with rheumatoidarthritis were oversampled; the SUDAAN weighted analy-sis method provided estimates only within the particularclinic population in the study and not a larger population;the low-income, central New Mexican, university-affiliatedclinic population is unlikely to be representative of otherclinic populations in other locations; and New MexicanHispanics who self-identify as Spanish Americans may notbe representative of diverse Hispanic populations livingelsewhere. We used the SUDAAN weighted analysismethod to address oversampling certain groups, but thismethod is intended for use with larger samples (34). Use ofCAM ever to manage longstanding arthritis is prone to




recall bias, and so we defined current use as use at thetime of the interview. There is still the limitation of askingabout CAM use at only one point in time. Definitions ofCAM are increasingly blurred as some therapies such asvitamins have become part of conventional clinical prac-tice and others such as capsaicin cream are now recom-mended by the American College of Rheumatologybecause of evidence of efficacy (3).

Efforts are needed to investigate how best to translateand disseminate CAM efficacy research findings so peoplewill know which CAM therapies may benefit their type ofarthritis. Additional research is needed on efficacy andsafety of CAM therapies used by arthritis patients,including research on potential negative interactionsbetween CAM therapies and conventional treatmentssuch as medications.

In conclusion, this study found that CAM use was high,potentially costly, and not always communicated to thetreating physician among the osteoarthritis, rheumatoidarthritis, and fibromyalgia patients treated by primarycare physicians in these clinics. Overall, 69% of the clinicpopulation currently used any type of CAM, and currentuse was associated with being female, being under 55years of age, and having a college education. Two thirds ofCAM users spent less than $50 per month on CAM, butoverall 15%, including 30% of the CAM users withfibromyalgia, spent more than $100 per month on CAM.Two thirds of CAM users in the study discussed CAM usewith their medical doctor; the main reason cited for notdisclosing CAM use was that the physician did not ask.Physicians and other health care providers should beaware of this high degree of CAM use among arthritispatients and incorporate questions about such use intotheir routine assessments and treatment planning.

Acknowledgments

This study was funded by the Division of Adult andCommunity Health (DACH), through the PreventionResearch Centers Program, National Center for ChronicDisease Prevention and Health Promotion (NCCDPHP),Centers for Disease Control and Prevention (CDC). Specialthanks go to Shirley Pareo, MS, Center for HealthPromotion and Disease Prevention, University of NewMexico Health Sciences Center; Joseph Sniezek, MD,Arthritis Program, DACH, NCCDPHP, CDC; and Leigh

Callahan, PhD, Thurston Arthritis Research Center,University of North Carolina at Chapel Hill, for theirassistance in survey development. We also thank theEpidemiology and Cancer Control staff at the University ofNew Mexico Health Sciences Center, especially LlorynSwan, for recruitment data management; Barbara Evansfor designing the recruitment tracking system; RonDarling for designing the survey data entry screens; inter-viewers Julie Baum, Melissa Jim, and Phoebe Underwood;and Kim Ngan Giang, research assistant.

Author Information

Corresponding author: Carla J. Herman, MD, MPH,Chief, Division of Geriatrics, Department of InternalMedicine, School of Medicine, University of New MexicoHealth Sciences Center, MSC 10 5550, 1 University ofNew Mexico, Albuquerque, NM 87131. Telephone: 505-272-5630. E-mail: [email protected].

Author affiliations: Peg Allen, MPH, Arti Prasad, MD,Department of Internal Medicine, University of NewMexico Health Sciences Center, Albuquerque, NM;William C. Hunt, MA, Epidemiology and Cancer Control,University of New Mexico Health Sciences Center,Albuquerque, NM; Teresa J. Brady, PhD, ArthritisProgram, Division of Adult and Community Health,National Center for Chronic Disease Prevention andHealth Promotion, Centers for Disease Control andPrevention, Atlanta, Ga.

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23. Stanford University School of Medicine. The HealthAssessment Questionnaire [Internet]. Stanford (CA):Stanford University School of Medicine, Division ofImmunology & Rheumatology. Available from:http://aramis.stanford.edu/HAQ.html.

24. DeVellis RF, Callahan LF. A brief measure of help-lessness in rheumatic disease: the helplessness sub-scale of the Rheumatology Attitudes Index. JRheumatol 1993;20:866-9.

25. Stein MJ, Wallston KA, Nicassio PM. Factor structureof the Arthritis Helplessness Index. J Rheumatol1988;15:427-32.

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28. Herr KA, Mobily PR, Kohout FJ, Wagenaar D.Evaluation of the Faces Pain Scale for use with theelderly. Clin J Pain 1998;14:29-38.

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short acculturation scale for Hispanics. Hisp J BehavSci 1987;9:183-205.

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Hispanic (%)

Non-Hispanic white (%)

Female (%)

Male (%)

18-54 (%)

55-64 (%)

65-74 (%)

75-84 (%)

Mean

Median

Did not graduate from high school (%)

RheumatoidArthritis(n=95)

Diagnoses

Fibromyalgia(n=95)

All(n=612)

PearsonChi-squareP Value

Osteoarthritis(n=422)Characteristics

47.8

52.2

66.6

33.4

21.5

34.9

27.9

15.7

62.6

61.8

28.9

49.2

50.8

84.6

15.4

41.2

31.1

22.9

4.8

56.0

57.8

21.0

30.2

69.8

85.6

14.4

43.2

39.2

16.9

0.8

54.8

55.2

7.7

44.6

55.4

71.4

28.6

26.9

35.4

25.5

12.2

60.6

59.9

24.3

.001

<.001

<.001

<.001

<.001

Ethnic Group

Sex

Age at interview (years)

Education

(Continued on next page)


Table 1. (continued) Patient Characteristics by Diagnosis, Percentages Weighted by Inverse of Sampling Fraction, Survey onUse of Complementary and Alternative Medicine (n = 612), New Mexico, 2001–2002




High school graduate or GED (%)

Some college or technical school (%)

College graduate (%)

Unknown (%)

Less than $25,000 (%)

$25,000 to $50,000 (%)

$50,000 or more (%)

Unknown (%)

Never or <1 (%)

1-2 (%)

3-5 (%)

>5 (%)

Unknown (%)

0-5 (%)

6-14 (%)

15+ (%)

Unknown (%)

Mean

Median

Low (0-4) (%)

Moderate (5-7) (%)

High (8-10) (%)

Unknown (%)

Mean

Median


Diagnoses

Fibromyalgia(n=95)

All(n=612)


Osteoarthritis(n=422)Characteristics

19.5

21.9

29.5

0.2

64.4

18.2

12.8

4.6

26.6

24.9

30.8

16.0

1.6

34.0

33.1

32.8

0.2

12.6

9.1

38.1

38.9

21.6

1.3

5.3

5.0

26.6

27.1

25.3

0.0

66.2

15.0

13.9

4.9

10.5

30.2

32.9

26.4

0.0

21.0

41.7

37.2

0.0

15.3

11.8

41.2

33.8

25.0

0.0

5.3

5.0

22.0

39.8

30.5

0.0

66.9

16.8

14.0

2.3

14.3

17.4

30.0

38.3

0.0

32.4

36.8

30.3

0.6

12.0

8.2

23.2

36.1

40.7

0.0

6.6

6.3

20.5

25.7

29.4

0.1

65.0

17.7

13.1

4.2

23.2

23.9

30.8

20.9

1.2

32,8

34.4

32.6

0.2

12.6

9.1

35.5

38.0

25.5

1.0

5.6

5.2

<.001

.95

<.001

.07

.12

.004

<.001

Annual household income

Frequency of visits to medical doctor for arthritis (times per year)

Disease duration (years)

Pain in last week (0-10 visual scale)

Table 2. Weighted Estimates of Ever and Current Use of Complementary and Alternative Medicine Type, by Diagnosis, SurveyResults (n = 612), New Mexico, 2001–2002





Ever Current

Ever Current

Ever Current

Ever Current

Ever Current

Ever Current

Ever Current

Ever Current

Ever Current

Ever Current

Ever Current

Ever Current


%

Diagnoses

Fibromyalgia(n=95)

%

All(n=612)

%


Osteoarthritis(n=422)

%Types of CAM

89.466.7

55.434.1

16.812.1

23.510.1

46.223.1

28.28.3

27.923.7

18.37.6

15.18.4

32.27.6

10.16.4

3.30.9

86.470.7

59.826.6

28.820.8

30.215.6

48.315.6

43.910.2

42.531.1

28.113.2

14.85.8

45.013.7

27.417.4

7.10.0

94.878.3

72.836.5

42.732.9

50.826.7

64.936.5

39.312.0

59.448.9

55.034.3

32.620.7

64.632.2

29.421.8

9.33.6

90.269.2

59.034.1

22.616.6

29.113.6

49.925.1

31.39.2

34.829.0

25.913.0

18.410.6

39.212.7

14.910.1

4.81.3

.08

.06

.007.21

<.001<.001

<.001.002

.005

.004

.006.56

<.001<.001

<.001<.001

.005.01

<.001<.001

<.001<.001

.10

.06

Any type of CAM

Nutritional supplements

Vitamins and minerals

Herbs taken orally

Topical herbal rubs

Items worn

Mind-body therapies

CAM therapists

Dietary approaches

Homeopathy

Energy therapiesa

Movement therapiesb

aTherapies such as acupressure, reflexology, reiki, therapeutic touch, and aromatherapy.bPrimarily yoga, tai chi, and Feldenkrais.


Table 3. Weighted Estimates of the Percentages of Osteoarthritis, Rheumatoid Arthritis, and Fibromyalgia Patients Using

Complementary and Alternative Medicine at Time of Interview, Survey Results (n = 612), New Mexico, 2001–2002a




Nutritional supplements

Vitamins and minerals

Herbs taken orally

HomeopathyTopical rubs

GlucosamineChondroitinMSMFlaxseed oilVinegarFish oilCod liver oilGLA (Gammalinolenic acid) (e.g.,borage oil, blackcurrant oil, eveningprimrose oil)MagnesiumVitamin EVitamin CVitamin B12Niacin ZincVitamin B ComplexSeleniumGarlicGingerValerian rootAloe vera St. John’s wortTurmericArnica (oral)Tiger balmArnica creamChamomile oilCapsaicin creamSesame oilHorse linimentTraumeel ointmentRosemary oilAloe vera cream


%

Diagnoses

Fibromyalgia(n=95)

%

All(n=612)

%



%Type of Complementary andAlternative Medicine

25.217.94.61.94.53.01.90.6

3.14.34.13.40.21.30.90.34.41.41.11.00.00.50.35.12.21.04.60.31.31.20.51.1

15.87.54.25.35.16.10.91.3

4.28.6

10.04.70.03.12.40.06.94.62.93.41.71.70.04.21.70.00.90.03.91.71.20.0

20.710.69.99.93.46.43.63.5

14.111.19.75.05.53.94.03.78.24.04.63.13.33.43.6

10.85.14.93.63.62.84.63.03.1

23.715.85.63.64.33.92.21.2

5.35.95.63.81.21.91.20.95.32.11.91.60.71.10.96.12.71.64.10.91.81.81.01.4

.09.006.26.02.83.27.35.31

.02

.08

.06

.74

.06

.32

.23

.15

.34

.16

.19

.29

.09

.24

.15

.19

.42

.02

.03

.09

.33

.33

.34

.02(Continued on next page)


Table 3. (continued) Weighted Estimates of the Percentages of Osteoarthritis, Rheumatoid Arthritis, and FibromyalgiaPatients Using Complementary and Alternative Medicine at Time of Interview, Survey Results (n = 612), New Mexico,

2001–2002a

Items worn

Mind-body therapies

Energy therapies

Movement therapies

CAM therapists

Dietary approaches

MagnetsCopper jewelryRelaxation techniquesMeditationBreathing techniquesMusic therapyVisualizationAcupressureReflexologyAromatherapyTherapeutic touchSelf-massageElectromagneticReikiYogaTai chiFeldenkraisMassage therapistsChiropractorsAcupuncturistsMyofascial therapistsOsteopathic doctor“Arthritis diet”Fasting or cleansingdietHypoglycemic dietVegetarian diet


%

Diagnoses

Fibromyalgia(n=95)

%

All(n=612)

%



%Type of Complementary andAlternative Medicine

4.64.2

10.010.18.46.26.82.40.71.11.10.21.50.44.92.60.54.81.52.10.20.01.40.2

0.41.2

7.63.8

16.311.19.88.87.42.92.03.22.73.22.00.94.90.90.04.41.72.90.00.98.54.0

0.01.7

9.62.8

28.927.636.722.819.619.59.87.44.80.94.13.5

13.26.35.1

17.110.35.53.23.24.47.3

5.03.6

5.73.9

14.013.513.89.59.25.72.52.41.90.52.01.16.53.21.37.13.12.80.80.72.41.8

1.21.7

.22

.79.001.004

<.001.002.02

.001.02.05.16.19.54.32.09.09.04.01.05.46.14.13.02

.006

.04

.45

aTable includes complementary and alternative medicine (CAM) items used by 3% or more of patients in at least one diagnostic group. See Appendix forcomplete list of CAM items included in the survey.








Table 4. Weighted Estimates of Current Use of Any Type of Complementary and Alternative Medicine, by PatientCharacteristics and Diagnostic Group, Survey Results (n = 612), New Mexico, 2001–2002

Ethnic group

Sex

Age at interview(years)

Education

Annual householdincome

Frequency of visits tomedical doctor forarthritis (times peryear)

Duration of disease(years)

Hispanic Non-Hispanic White(Pearson chi-square Pvalue)FemaleMale (Pearson chi-square Pvalue)18-5455-6465-84(Pearson chi-square Pvalue)Did not graduate fromhigh school High school graduateor GED Some college or tech-nical schoolCollege graduate (Pearson chi-square Pvalue)Less than $25,000 $25,000 to $50,000$50,000 or more (Pearson chi-square Pvalue)Never or < 1 1-2 3-5 >5(Pearson chi-square Pvalue)0-56-14


%

Diagnoses

Fibromyalgia(n=95)

%

AllParticipants

(n=612)%

Test ofInteractionP Value


%Patient Characteristics

65.567.8(0.62)

69.361.5(0.11)

71.968.362.8(0.30)

60.7

65.7

66.6

73.1(0.24)

67.062.272.0(0.54)

60.469.069.167.1(0.52)

60.367.4

54.886.0(0.001)

71.864.0(0.60)

77.970.160.6(0.37)

57.0

59.8

72.7

91.3(0.02)

66.980.482.2(0.36)

82.984.659.164.3(0.08)

91.560.3

70.981.5(0.27)

79.670.7(0.55)

84.878.162.9(0.26)

49.0

69.1

81.2

88.7(0.14)

75.982.190.0(0.45)

51.381.386.181.0(0.25)

74.679.8

65.472.2(0.08)

71.962.4(0.03)

76.470.462.7(0.02)

59.8

65.9

71.3

77.3(0.009)

68.766.876.3(0.34)

60.172.071.471.7(0.14)

64.369.3

NAa

NA.03

NANA.98

NANANA.84

NA

NA

NA

NA.44

NANANA.68

NANANANA.15

NANA

(Continued on next page)


Table 4. (continued) Weighted Estimates of Current Use of Any Type of Complementary and Alternative Medicine, by PatientCharacteristics and Diagnostic Group, Survey Results (n = 612), New Mexico, 2001–2002

Nutritional supplements: glucosamine, chondroitin, MSM, SAMe,shark cartilage, bovine cartilage, collagen, cod liver oil, fish oil,flaxseed oil, GLA-containing supplements (borage oil, black currantoil, evening primrose oil), vinegar, bromelain, quercetin, noni juice,pregnenolone, DLPA, glutathione, malic acid. Vitamins & miner-als: Multiple vitamina, calciuma, vitamin Da, vitamin C, vitamin E,beta carotene, niacin, vitamin B5, vitamin B12, folic acida, mag-nesium, selenium, boron, copper, zinc. Oral herbs: aloe vera,angelica root, black cohosh, boswellia (guggul), burdock root &seed, cactus, calendula, cat’s claw, cayenne, celery seed, coix,corydalis, devil’s claw, eucalyptus, fennel, feverfew, foti (Hou ShuWu), garlic, gentian, ginger, kava kava, thundergod vine, licorice,oregano, St. John’s wort, stinging nettle, turmeric, valerian root,white willow bark, wild yam, yucca. Topical oils, rubs and oint-ments: arnica cream, calendula, capsaicin creams, chamomile oil,clay, coriander cream, DMSO, horse liniment, linseed oil, MSMcreams, pine tree sap, rosemary oil, sesame oil, tiger balm,traumeel or traumed ointment, volcanico. Items worn: acupres-sure beads or seeds, copper jewelry, herbal plasters, infraredwraps, magnets, Q-ray ionically charged bracelet. Mind-body ther-apies: meditation, visualization, special breathing techniques,

relaxation techniques, music therapy, draw upon religious or spiri-tual beliefsa, praya, attend religious services regularlya. Energytherapies: acupressure, aromatherapy, biofeedback, cranio-sacraltherapy, hypnotism, polarity, reflexology, reiki, therapeutic touch.Movement therapies: yoga, tai chi, qigong, pilates, Feldenkraismethod (“Awareness Through Movement”), Alexander movementtechniques, Trager approach (“Mentastics”). CAM therapists: doc-tor of oriental medicine or acupuncturist, ayurvedic doctor, chiro-practic doctor, curandero/curandera, herbalist, hypnotist, iridologist,massage therapist, myofascial therapist, naturopathic doctor,osteopathic doctor, religious leader, spiritual healer. Dietaryapproaches: “arthritis diet” with fish, fresh fruits, and vegetablesexcept potatoes, tomatoes, eggplant, peppers; ayurvedic diet; fast-ing and cleansing diets; hypoglycemic diet; vegetarian diet.

aItem excluded from analyses.

Pain in last week

15+(Pearson chi-square Pvalue)Low ModerateHigh(Pearson chi-square Pvalue)


%

Diagnoses

Fibromyalgia(n=95)

%

AllParticipants

(n=612)%

Test ofInteractionP Value


%Patient Characteristics

72.9(0.09)

64.366.572.9(0.36)

70.6(0.01)

77.870.958.5(0.33)

80.1(0.85)

85.081.371.9(0.46)

74.0(0.13)

67.969.471.6(0.77)

NA.11

NANANA.23

aNA indicates not applicable.

AppendixComplementary and Alternative Medicine Items Included in Survey of Hispanic and Non-Hispanic White Women and MenAged 18–84 (n = 612), New Mexico, 2001–2002




original research use of complementary therapies among ... · use of complementary therapies among...

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