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Research paper
Centers for Disease Control and Prevention (CDC), Office of Surveillance, Epidemiology, and Laboratory Services, Public Health
Surveillance Program Office, Division of Behavioral Surveillance, Atlanta, Georgia, USA and 2CDC, Office of Noncommunicable
Diseases, Injury and Environmental Health, National Center for Chronic Disease Prevention and Health Promotion, Division of
Adult and Community Health, Atlanta, Georgia, USA
Implications for Rehabilitation
Introduction
Complementary and alternative medicine (CAM) comprises a
diverse set of approaches used to prevent or treat disease that
are not generally considered part of conventional medicine [1].
In the USA, the use of CAM therapies, both as an adjunct to
conventional health care treatment and as an alternative source
of care, is prevalent and increasing [2]. In 2007, an estimated
Correspondence: Catherine A. Okoro, MS, Division of Behavioral Surveillance, Public Health Surveillance Program Office, Office of Surveillance,
Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, 1600 Clifton Road, NE, M/S E-97, Atlanta, GA 30333, USA.
E-mail: COkoro@cdc.gov
128
Methods
NHIS is an annual, computer-assisted personal interview
survey of a nationally representative sample of the civilian
community-dwelling US population. The survey is conducted
by the Centers for Disease Control and Preventions (CDC)
National Center for Health Statistics in cooperation with the
US Census Bureau [27]. The sampling plan for NHIS follows
a multistage area probability design. NHIS methodology
and data weighting procedures are fully described elsewhere
[27,28]. Trained interviewers from the US Census Bureau visit
selected households and administer the survey to consenting adult respondents in English or Spanish. The 2007 NHIS
survey included approximately 75, 764 persons from 29, 266
Copyright 2012 Informa UK Ltd.
households consisting of 29, 915 families. The household response rate for the 2007 survey was 87.1%. Because this study
was conducted using secondary data, approval from CDCs
institutional review board was not required.
NHIS includes three components in the basic module: the
Family Core, the Sample Adult Core, and the Sample Child
Core. All adult members of a household (aged 18 years) are
invited to complete the Family Core component, whereas a
randomly selected (if >1) adult family member is selected to
complete the Sample Adult Core. In the 2007 NHIS, respondents for the Sample Adult Core also completed the Adult
Complementary and Alternative Medicine Supplement, cosponsored by the National Center for Complementary and
Alternative Medicine (NCCAM), to estimate the national
prevalence and reasons for use of CAM therapies [29]. Data for
this study are from participant responses to questions in the
Family Core, the Sample Adult Core, and the Adult Complementary and Alternative Medicine Supplement. The Sample
Adult Core of the 2007 NHIS was completed by 23, 393 adults
(including 287 proxy respondents); of which, 23, 175 (99.1%)
had complete data on the functional limitation questions; and
22, 783 (97.4%) completed the Adult Complementary and
Alternative Medicine Supplement. We limited analyses to 20,
710 adults who responded to all 12 functional limitation questions, participated in the Adult Complementary and Alternative Medicine Supplement, and were not pregnant.
Functional limitation was defined based on 12 questions
that assessed the degree of difficulty that a respondent reported
in mobility and social functioning, as follows: The next questions ask about difficulties you may have doing certain activities because of a HEALTH PROBLEM. By health problem
we mean any physical, mental, or emotional problem or illness
(not including pregnancy). By yourself, and without using any
special equipment, how difficult is it for you to... walk a quarter of a mileabout 3 city blocks; walk up 10 steps without
resting; stand or be on your feet for about 2 hours; sit for
about 2 hours; stoop, bend, or kneel; reach up over your
head; use your fingers to grasp or handle small objects, lift
or carry something as heavy as 10 pounds such as a full bag of
groceries; push or pull large objects like a living room chair;
go out to things like shopping, movies, or sporting events;
participate in social activities such as visiting friends, attending clubs and meetings, going to parties; do things to relax at
home or for leisure (reading, watching TV, sewing, listening to
music). Responses were categorized as 0 (not difficult at all), 1
(only a little difficult), 2 (somewhat difficult), 3 (very difficult),
and 4 (cant do at all). As in other studies [3032], respondents
were classified based on the absence (0=not limited) or presence (14=limited) of functional limitation.
NHIS asked respondents if they used 18 different CAM
therapies within the past 12 months. We combined 16 of the 18
CAM therapies into one overall group and four CAM groupings, excluding prayer and vitamin or mineral use. The four
CAM groupings were as follows: (i) alternative medical systems
(i.e. acupuncture, ayurveda, homeopathy, naturopathy, and
traditional healers [Curandero, Espiritista, Hierbero or Yerbera,
Shaman, Botanica, Native American healer/medicine man, and
Sobador]); (ii) biologically based therapies (chelation therapy;
Results
The 2007 NHIS sample represents a population in which
27.9% (n=5960) of adults report having at least one functional
limitation, representing an estimated 56 million adults nationwide. Respondent sociodemographic and health-related
characteristics differed significantly by functional status.
Compared with adults without functional limitations, adults
with functional limitations were older, more likely to be female, and had lower educational attainment and family incomes (TableI). Those with functional limitations were more
likely to have health insurance, were more likely to delay or
not get needed medical care due to cost, and to have lower
self-rated general health and more self-reported chronic conditions. Of adults with functional limitation, 44.0% reported
difficulty with one to two tasks, 32.0% with three to six tasks,
and 24.0% with seven to 12 tasks.
Data on the agesex-adjusted prevalence of CAM use
among adults with and without functional limitation are presented in Table II. Overall, 48.7% of adults with functional
limitations reported using at least one CAM therapy in the
past 12 months, representing an estimated 26.8 million adults,
compared with 35.4% of adults without functional limitations
(p<0.001). Adults with functional limitations were significantly more likely than those without limitations to use each
of the four CAM groupings. Mindbody therapy was the
most commonly reported form of CAM, used by 27.4% of
adults with limitations compared with 17.5% without limitations (P<0.001). This difference reflects the greater use of
relaxation techniques (24.6% vs. 13.7%; P<0.001), particularly deep breathing exercises (19.3% vs. 10.5%; P<0.001), by
adults with functional limitations. Yoga was the only therapy
in this CAM grouping to be more prevalent among adults
without functional limitations, though the difference was nonsignificant (6.0% vs. 6.3%; P=0.44). Biologically based therapy was the second most commonly reported form of CAM,
used by 24.8% vs. 18.3% (P<0.001). Within this category,
nonvitamin, nonmineral, natural products (22.2% vs. 16.3%;
P<0.001) and diet-based therapies (4.4% and 3.4%; P=0.01)
were more frequently reported by adults with functional limitations. Manipulative and body-based therapy was the third
most commonly reported CAM grouping (19.3% vs. 14.0%;
P<0.001), primarily due to the use of chiropractic and osteopathic manipulation (11.7% vs. 7.5%; P<0.001) and massage
(10.7% vs. 7.7%; P<0.001). Conversely, adults without functional limitations were significantly more likely to use movement therapies (1.6% vs. 1.0%; P=0.01). Alternative medical
systems were the least frequently used CAM grouping, used
by 4.8% of adults with functional limitations compared with
3.0% without limitations (P<0.001). Within this grouping,
acupuncture (1.9% vs. 1.2%; P=0.001) and traditional healers (0.8% vs. 0.3%; P=0.005) were more frequently reported
by adults with limitations, although homeopathy was most
prevalent among adults with limitations (2.2%).
Disability & Rehabilitation
38.2
21.9
19.8
11.8
5.6
2.8
0.7
0.4
0.4
0.3
0.2
0.2
52.3
47.7
0.5
0.5
66.3
0.6
11.8
0.4
15.4
6.4
0.5
0.3
13.2
27.1
59.7
0.4
0.5
0.6
13.8
15.1
28.2
42.9
0.5
0.4
0.6
0.7
17.3
23.3
37.0
22.4
0.5
0.8
0.8
0.7
81.2
18.8
0.4
0.4
9.2
90.8
0.3
0.3
73.1
22.7
4.1
0.5
0.5
0.2
53.5
46.5
0.6
0.6
Therapy
Any CAM usea,*
Alternative medical system*
Acupuncture*
Ayurveda
Homeopathy
Naturopathy
Traditional healersb,**
Biologically based therapiesc,*
Chelation therapy
Nonvitamin, nonmineral,
natural products*
Diet-based therapiesd,**
Manipulative and body-based
therapies*
Chiropractic or osteopathic
manipulation*
Massage*
Movement therapiese,**
Mindbody therapiesf,*
Biofeedback
Relaxation techniques*
Meditation*
Guided imagery*
Progressive relaxation*
Deep breathing exercises*
Support group meeting*
Stress management class***
Hypnosis
Yoga
Tai chi
Qi gong
Energy healing/Reiki
Functional
limitation
%
SE
No functional
limitation
%
SE
n
48.7
4.8
1.9
NA
2.2
0.5
0.8
24.8
NA
0.9
0.4
0.2
NA
0.2
0.1
0.2
0.8
NA
2768
275
114
5
125
32
42
1491
5
35.4
3.0
1.2
NA
1.7
0.2
0.3
18.3
NA
0.6
0.2
0.1
NA
0.1
0.1
0.1
0.5
NA
5108
459
196
11
240
40
48
2590
4
22.2
0.7
1356 16.3
0.4
2290
4.4
0.4
258 3.4
0.2
495
19.3
0.8
1041 14.0
0.4
2014
11.7
0.6
645 7.5
0.3
1055
10.7
1.0
27.4
NA
24.6
13.8
3.2
4.5
19.3
3.3
4.7
0.4
6.0
1.2
0.4
0.8
0.6
0.2
0.8
NA
0.8
0.6
0.3
0.4
0.7
0.3
0.3
0.1
0.4
0.2
0.1
0.1
0.3
0.1
0.4
NA
0.4
0.3
0.2
0.2
0.3
0.1
0.3
0.1
0.3
0.1
0.1
0.1
1150
242
2647
13
2092
1231
287
363
1604
200
103
39
991
168
41
82
560
50
1501
12
1376
747
162
236
1056
184
84
32
287
74
25
44
7.7
1.6
17.5
NA
13.7
8.1
2.0
2.5
10.5
1.2
3.6
0.3
6.3
1.0
0.3
0.5
aExcluding
the past year was found for those who had delayed care or been
unable to obtain care due to cost. For adults without functional
limitations, significant differences were observed for all the
characteristics examined. In contrast to adults with functional
limitations, however, use of CAM was highest among adults
aged 45 to 64 years old compared with other age categories and
among those who had delayed care or been unable to obtain
care due to cost.
After adjustment for sociodemographic and health-related
characteristics, adults with functional limitations remained
more likely to use CAM in the past year than those without functional limitations (46.2% vs. 36.5%, P<0.001); and
n
Age, yearsb
1834
3544
4554
5564
6574
75
Sexc
Male
Female
Race/ethnicity
White, non-Hispanic
African American, non-Hispanic
Hispanic
Other, non-Hispanic
Education
<High school
High school
>High school
Family incomed
<US$20,000
US$20,000-US$34,999
US$35,000-US$64,999
US$65,000
Region
Northeast
Midwest
South
West
Health Insurance
Yes
No
Health care delayed or not obtained due to cost
Yes
No
Self-rated general health
Excellent/very good
Good
Fair/poor
No. chronic conditions
<2
2
Functional limitation
% (95% CI)
P
No functional limitation
% (95% CI)
P
<0.001
437
423
615
582
417
294
54.8 (50.259.5)
52.4 (48.156.7)
56.1 (52.559.7)
47.6 (44.051.3)
44.1 (40.248.0)
30.1 (26.633.6)
995
1773
43.1 (40.645.5)
51.8 (49.753.9)
2075
286
275
132
51.7 (49.753.7)
28.9 (25.232.7)
36.2 (32.040.5)
56.1 (45.366.8)
327
738
1694
31.5 (27.735.3)
42.0 (39.244.8)
58.5 (56.160.9)
635
546
760
827
36.8 (34.039.6)
43.8 (40.147.4)
49.5 (46.252.8)
57.6 (54.260.9)
416
752
834
766
44.6 (40.948.3)
51.1 (47.654.7)
42.4 (39.645.3)
55.5 (51.859.2)
2433
331
49.2 (47.451.1)
41.0 (36.645.3)
574
2194
49.9 (46.553.4)
47.7 (45.749.6)
1172
884
708
53.9 (51.456.5)
47.4 (44.750.0)
41.2 (38.044.3)
188
2580
36.5 (31.641.4)
49.2 (47.451.0)
<0.001
1761
1121
1080
678
331
137
32.9 (31.134.6)
35.8 (33.737.9)
39.4 (37.041.8)
40.1 (37.243.0)
35.4 (32.038.8)
24.4 (20.428.4)
2215
2893
31.1 (29.732.6)
40.4 (38.941.9)
3516
561
610
421
40.8 (39.342.2)
24.8 (22.627.1)
20.5 (18.522.5)
37.6 (34.041.2)
331
974
3784
16.2 (14.318.0)
25.2 (23.427.0)
44.8 (43.446.2)
804
719
1383
2202
29.2 (26.831.6)
26.8 (24.529.0)
32.7 (30.834.6)
42.5 (40.644.4)
876
1174
1667
1391
36.6 (34.938.3)
38.2 (35.640.8)
30.0 (27.932.1)
41.2 (38.743.7)
4324
762
37.4 (36.138.7)
27.3 (25.229.5)
654
4453
44.1 (40.647.5)
34.7 (33.535.9)
3915
1012
179
38.0 (36.739.4)
29.2 (27.031.3)
26.7 (22.730.7)
2126
2982
28.2 (26.729.6)
44.1 (42.445.7)
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.2638
<0.001
<0.001
<0.001
<0.001
<0.001
aExcluding
professional, compared with 37.9% of adults without functional limitations (P<0.001), after adjusting for age and sex.
Adults with functional limitations used CAM more often than
those without limitations because their friends, families, or
coworkers recommended it (42.9% vs. 38.5%; P=0.012), their
provider recommended it (29.5% vs. 15.6%; P<0.001), conventional medical treatment was ineffective (21.6% vs. 11.2%;
P<0.001), or conventional treatment was too expensive (9.2%
Disability & Rehabilitation
Therapy
Any CAM useb
Functional limitation
No functional limitation
Alternative medical systems
Functional limitation
No functional limitation
Biologically based therapiesc
Functional limitation
No functional limitation
Manipulative and body-based therapies
Functional limitation
No functional limitation
Mindbody therapiesd
Functional limitation
No functional limitation
1.58 (1.431.74)
1.00
4.2**
3.2
1.37 (1.101.70)
1.00
23.1*
19.1
1.30 (1.161.44)
1.00
18.7*
14.2
1.43 (1.251.62)
1.00
25.1*
18.2
1.58 (1.421.76)
1.00
aAdjusted
vs. 3.8%; P<0.001), after adjusting for age and sex (Figure 1).
Although the main reason adults with and without a functional
limitation used CAM was for general wellness/disease prevention (59.8% vs. 63.1%), adults with functional limitations had
borderline significance (P=0.051) for being less likely to use
CAM for this reason, after adjusting for age and sex.
Discussion
In this large, nationally representative study, we found CAM use
to be prevalent among adults with functional limitations. Nearly
one of two adults with a functional limitation used CAM (49%)
compared with 35% without limitation. Mindbody therapies
were used the most; alternative medical systems were used
the least. Relaxation techniques, particularly deep breathing
exercises, were the most common therapy used by adults with
functional limitations, followed by the use of herbs. More than
half the adults with functional limitations discussed their CAM
use with a conventional medical professional. The main reason
reported for CAM use was general wellness/disease prevention,
regardless of functional status. However, adults with functional
limitations were more likely than those without these limitations to report using CAM because their family, peers, or health
care provider recommended it or because conventional medical treatments did not help or were too expensive.
Our reported rate of CAM use among adults with functional
limitations (49%) falls within the range reported by similar studies [2325] but was higher than that of the general USA adult
population (38%) [2]. Carlson etal. [23] reported that 19% of
adults with physical disabilities had used CAM in the past year;
however, the sample was restricted to four disabling conditions
Copyright 2012 Informa UK Ltd.
Figure 1. Agesexadjusted prevalence with 95% CI of reasons for complementary and alternative medicine use among US adults aged 18 years or
older with and without functional limitation, National Health Interview Survey, 2007.
integrated into the practice of allopathic medicine and are covered by health insurance plans (e.g. chiropractic or osteopathic
manipulation, massage therapy, psychotherapy) [3638] or are
available at little or no cost (e.g. nonvitamin, nonmineral, natural products; deep breathing exercises; meditation) [39]. Other
researchers have found that CAM therapies might be seen as a
less expensive alternative to the growing cost of conventional
health care, especially among those reporting difficulties in obtaining needed medical care due to cost [40,41].
This study has limitations. First, NHIS data are based on selfreports and are subject to recall bias. Second, because of small
sample size, we could not estimate the prevalence of ayurveda,
biofeedback, and chelation therapy use. Finally, NHIS is crosssectional, thus, we could not determine if CAM use by adults
with functional limitations occurred before or after they experienced difficulties with 1 to 12 of the assessed tasks.
Our study has several strengths. It is based on a large,
nationally representative survey of the community-dwelling
US adult population, and it assesses a comprehensive list of
CAM therapies. In addition, our study adds to the literature
on CAM use not only among adults with difficulties in mobility functioning, but among those with difficulty in social
functioning as well.
Given that the use of CAM is driven by several local- and
state-level variables (e.g. health consumer demands, health
insurance coverage, licensing and availability of CAM practitioners, medical school curriculums that include CAM, population characteristics), efforts to conduct surveillance of CAM
use at the state level are essential. The need to be able to monitor
state-based CAM estimates is further heightened by the aging
of the US population and the resulting impact CAM use may
have, not only on population health and quality of life, but on
the health care economy as well. CDCs Behavioral Risk Factor
Surveillance System (BRFSS) [42,43] may be an invaluable public health tool in this regard. The BRFSS has been used for more
than two decades to provide state public health departments,
public health professionals, researchers, and policy-makers
with state-based estimates that are collected using standardized
protocols and cost-effective methods. Notably, Rafferty etal. [44]
have already demonstrated BRFSSs utility by producing statebased estimates of CAM use among Michigan adults.
In conclusion, the use of CAM among adults with functional limitations is high and more frequent than among adults
without such limitations. Not surprisingly, adults with functional limitations seek an integrated framework from which to
manage their health and enhance their quality of life and wellbeing. The fact that more than half the adults with functional
limitations had disclosed their use of CAM to a conventional
medical professional and that almost one-third had had CAM
recommended to them by their health care provider further
highlights the prevalence of CAM use among adults with
functional limitations. To inform decision making at the state
level by public health professionals, health care providers, and
policy -makers, state-based surveillance of CAM use is recommended. In addition, further research is needed to determine
whether CAM is used primarily to treat the condition underlying the functional limitation or for other purposes. Given that
adults with functional limitations may have a narrower margin
of health than those without limitations, a health care environment that encourages open dialogue about CAM use and its
safety and efficacy is essential.
Acknowledgments
The findings and conclusions in this article are those of the
authors and do not necessarily represent the official position
of the Centers for Disease Control and Prevention.
Declaration of interest: The authors report no declarations of
interest.
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