Complementary and Alternative Medicine Use in the US Adult Low Back Pain Population

Neha Ghildayal, Pamela Jo Johnson, MPH, PhD, Roni L. Evans, DC, MS, PhD, and Mary Jo Kreitzer, PhD, RN, FAAN

Neha Ghildayal, Division of Health Policy & Management, University of Minnesota, Minneapolis (Ms Ghildayal), United States;

Contributor Information.

Corresponding author.

Correspondence Neha Ghildayal [email protected]

Abstract

摘要

SINOPSIS

BACKGROUND

Low back pain (LBP) places a heavy burden on healthcare systems in the United States, costing approximately $100 billion a year in costs related to healthcare utilization. It is also the fifth most common reason for physician visits.^1–3 LBP also causes enormous losses to the country’s economic efficiency, resulting in over 150 million lost workdays per year and $16 billion annually in lost productivity.^1,2 Back pain is one of the most common health complaints in the United States: Over 80% of adults in the US will experience it at some point during their lifetime.⁴

LBP is also a major cause of functional limitations and disability. People with back pain suffer from worse physical and mental health than people without back pain. Those with LBP are 3 times as likely to have limited functional ability and over 4 times as likely to experience serious psychological distress as people without.⁵ A key goal of healthcare for patients with chronic back pain is to maximize their functional status so that they are able to carry out activities of daily living.⁶ Accomplishing this goal may greatly increase a patient’s quality of life and reduce their healthcare costs. Thus because functional status is highly valued by patients, it is an essential outcome of medical care, with measures of functional status having been found to predict healthcare expenditures, mortality, and quality of life for patients with pain.⁷

Many people suffering from LBP have found conventional medical treatments to be ineffective and unreliable for treating their pain. Therefore, due to dissatisfaction with conventional treatments for LBP, individuals suffering from LBP are increasingly turning to complementary and alternative medicine (CAM) to find relief.⁸ CAM is a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine.⁹ A growing body evidence supports the use of CAM for improving back pain outcomes, with back pain being the most common condition for which patients use CAM.^10–12

Although in recent years there has been growing interest in the use of CAM for the treatment of back pain, limited work has been done to investigate CAM use in a nationally representative sample of patients with back pain. Most surveys with information on CAM use within the back pain population are limited to select populations (eg, cancer or maternity patients) and convenience samples.^13,14 A study by Kanodia et al used a nationally representative population to examine CAM use in the back pain population. However, that study used 2002 data and focused only on the perceived benefit of CAM use for back pain. Another study by Wolsko et al used nationally representative 1997 data but looked at CAM use within a combined back and neck pain population.¹⁵ No studies have examined CAM use in the back pain population by functional status. As CAM use for back pain in the US continues to grow, it is important to understand CAM usage patterns—especially among those whose back pain is causing functional limitations—in order to help guide future research, practice, and policy.

METHODS

RESULTS

DISCUSSION

About a third of US adults with LBP suffered from back pain that resulted in functional limitations. Over 40% of the US LBP population reported using CAM in the past year. Findings showed that those with limiting back pain were more likely to use provider-based therapies such as acupuncture, massage, and chiropractic manipulation, while therapies requiring a higher level of mobility, such as movement therapies and yoga/tai chi/qigong, were more likely to be utilized by those with nonlimiting LBP. Presumably, those with functional limitations are more likely to have limited dexterity and are in more pain than those without limiting back pain, which may have contributed to their utilization of CAM therapies requiring less movement. In addition, adults with limiting LBP are more likely to have lower levels of self-efficacy and elevated levels of pain-related fear than adults without limiting back pain, which could result in their lower use of movement-based CAM therapies.¹⁹

The CAM therapies most commonly used among the LBP population were consistent with previous findings by Kanodia et al using 2002 NHIS data and by Wolsko et al. However, compared to previous findings, the prevalence of CAM use has grown significantly. Compared to data from 1997, yoga/tai chi/qigong for back pain has increased 8-fold, while acupuncture for back pain has more than doubled.^12,15 The increased use of acupuncture may be due to increased insurance coverage for acupuncture in the United States. According to a survey released in 2004 by the Kaiser Family Foundation, employer coverage for acupuncture increased by 14%, to 47%, between 2002 and 2004, making it the fastest growing CAM therapy to be included as a covered service for American workers with health insurance. The number of licensed acupuncturists in the United States has also grown; in 1997, there were 9000 licensed acupuncturists and in 2005 there were over 22,000. Thus this growth in acupuncturists may be allowing patients easier access to acupuncture care.¹² Similarly, the doubling of yoga/tai chi/qigong for back pain may be due to the growth in popularity for these practices—particularly yoga—in the United States. In 1997, only 400,000 health clubs offered yoga classes, but in 2002, over 1.2 million health clubs offered yoga classes.²⁰ Overall, chiropractic manipulation was the most prevalent CAM therapy used within the LBP population, with utilization remaining consistent compared to past studies.¹⁵

Our findings indicate that the majority of respondents (58.1%) who used CAM in the past year for back pain perceived a “great deal” of benefit. This is similar to results from previous studies.^12,15 Though it was not possible to ascertain the perceived benefit of conventional medical treatments on LBP through this analysis, the high levels of perceived benefit of CAM support the need for additional investigation into the mechanisms by which CAM approaches may help relieve LBP, studying the efficacy and safety of CAM therapies in specific back pain populations or healthcare settings, and continued randomized trials with higher levels of methodological rigor.²¹

Similar to general population patterns, those with lower self-reported health used CAM less than those with higher self-reported health statuses. However, those with limiting LBP had higher CAM use than those with nonlimiting LBP. These findings suggest that while those with overall poorer health are not seeking CAM treatment options as widely as those who are healthier, people facing limiting back pain are turning to CAM as an option for their health management at a higher level than those with less severe LBP. For people with severe LBP, turning to CAM may seem a better alternative due to its more conservative, noninvasive nature as compared to more conventional medical treatments such as epidural steroid injections, surgeries, and prescriptive medications—all which may carry higher risks than CAM treatments.²² Alter natively, those with severe pain may have exhausted all other possibilities and may be looking for any possibility of relief. It may be important for policymakers to consider methods of improving access to CAM for individuals with poor health because of the potential of noninvasive, low-risk CAM options to manage their health.²³

There are several study limitations. First, responses to the CAM use questions were self-reported and limited by survey respondents’ willingness and ability to report CAM use and LBP status accurately. Since CAM use and LBP status were based on self-report, there was a potential for recall bias, which may have resulted in an underestimation or overestimation of CAM use and limiting LBP status. Additionally, because the recall periods differed for these 2 key variables, there may be some people for whom CAM use occurred before the reported LBP experience. However, we did look at CAM users to identify and distinguish those who used CAM specifically for their LBP. Moreover, the question on functional limitations combined limitations due to back or neck pain. It is possible that some proportion of our population was limited due to neck pain rather than back pain. Second, the outcome of perceived benefit of CAM for back pain was subjective. It is possible that those who answered these questions were those who responded most favorably to CAM treatment. Third, the NHIS alternative health supplement is collected only every 5 years, and a single year of NHIS data restricts the sample sizes for some subgroup analyses. For example, we were unable to include individual Asian race/ethnicity subgroups in our analysis due to small sample sizes and instead had to create an aggregate Asian group. Last, the NHIS did not include information on different types of LBP (subacute, acute, and chronic), and instead our analysis focused on differences of CAM use by limiting LBP vs nonlimiting LBP groups.

A major strength of this study was that it used a large, nationally representative survey of the US adult population with LBP and included a comprehensive list of CAM therapies. By examining CAM usage in a nationally representative sample, findings will be helpful in facilitating future practice, policy, and research recommendations involving CAM for treating LBP in the United States. Our results indicate it may be useful for policymakers to develop strategies to improve access to CAM services for the LBP population, especially for those with poor health and/or limiting back pain. Also due to the high perceived benefit of using CAM for back pain, it may be beneficial for healthcare professionals to be aware of the potential CAM types their patients may be using and be able to educate LBP patients about the CAM services that could be used to help manage their pain. In addition, future research should examine other validated self-reported outcomes within this population, such as back pain intensity, disability, and mobility, in order to determine how CAM therapies may be useful as part of a complementary and integrative healthcare approach to the management of LBP.

CONCLUSION

CAM therapies are becoming an increasingly important component of care for people with LBP. A large proportion of the LBP population—over 40%—used some form of CAM in the past year, with higher use reported among those with limiting back pain. Among the most popular therapies used in the LBP population included herbal therapies, chiropractic manipulation, and massage. Differences in specific therapies used were found by LBP status; patients with limiting pain were more likely to use herbal therapies, acupuncture, and chiropractic manipulation, and patients with nonlimiting pain were more likely to use movement therapies. The majority of the LBP population used CAM specifically to treat back pain, and most adults who used CAM for back pain perceived a great deal of benefit. Thus CAM use appears to be an important and growing part of healthcare for the back pain population, and these results support the need for large pragmatic trials of CAM therapies for LBP in the United States. Additional understanding of patterns of CAM use among the LBP population will help healthcare professionals make more informed care decisions, help policymakers to create frameworks for future policy implementation, and guide investigators in the development of future back pain–related CAM research.

Notes

Disclosures The author completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and had no conflicts to disclose.

Contributor Information

Neha Ghildayal, Division of Health Policy & Management, University of Minnesota, Minneapolis (Ms Ghildayal), United States.

Pamela Jo Johnson, Division of Health Policy & Management, University of Minnesota, Minneapolis; Integrative Health and Wellbeing Research Program, Center for Spirituality and Healing, University of Minnesota; Division of Epidemiology & Community Health, University of Minnesota (Dr Johnson), United States.

Roni L. Evans, Integrative Health and Wellbeing Research Program, Center for Spirituality and Healing, University of Minnesota (Dr Evans), United States.

Mary Jo Kreitzer, Integrative Health and Wellbeing Research Program, Center for Spirituality and Healing, University of Minnesota; School of Nursing, University of Minnesota (Dr Kreitzer), United States.

REFERENCES