Complementary and alternative practices in rheumatology

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<ul><li><p>10</p><p>increasingly prominent part of health-care utilization by the healthy general population and by</p><p>WHO USES COMPLEMENTARY AND ALTERNATIVE MEDICINE?</p><p>1521-6942/$ - see front matter 2008 Elsevier Ltd. All rights reserved.</p><p>Best Practice &amp; Research Clinical RheumatologyVol. 22, No. 4, pp. 741757, 2008</p><p>doi:10.1016/j.berh.2008.05.001available online at http://www.sciencedirect.com* Corresponding author. Fax: 52 33 38 17 63 35.E-mail address: rramos@cencar.udg.mx (C. Ramos-Remus).group, soIt appears that the use of complementary and alternative medicine (CAM) is a world-wide phenomenon which is not restricted to any particular geographic or ethnic</p><p>cial status, or economic situation. Prevalence is in the range 673% of thepatients with various diseases, even in an era of rapidly advancing medical technology. It hasbecome a significant topic not just in the lay press but also in the biomedical literature. Since1966 more than 46,000 publications that bear this or a related term in titles or abstractshave been referenced in Medline alone. Several important journals have devoted editorialsand original papers to this subject during past decade. This review presents the most recentdata on the epidemiology of CAM utilization by rheumatic patients, with special emphasis onmagnitude and patterns of use, and concepts of alternative versus complementary medicine.</p><p>Key words: alternative therapies; complementary therapies; arthritis; rheumatic diseases;herbs; epidemiology; CAM therapies.Complementary and alternative</p><p>practices in rheumatology</p><p>Cesar Ramos-Remus* MD, MScDirector, UIECD, Professor of Rheumatology, Universidad de Guadalajara, and Attending</p><p>Rheumatologist at Hospital General Regional 45, IMSS Guadalajara, Mexico</p><p>Colomos 2292, Providencia, Guadalajara, Jal. 44620, Mexico</p><p>Ashwinikumar Raut MDDirector, Clinical Research &amp; Integrative Medicine</p><p>Medical Research Centre of Kasturba Health Society, SJAD, 17, K. Desai Road,</p><p>Ville Parle (West), Mumbai 400 056, India</p><p>Hundreds of non-conventional treatment modalities have been used to treat patients withdiverse diseases. Whatever term is used, non-conventional remedies, complementary medicineand/or alternative therapies (CAM), or even traditional systems of medicine, have become an</p></li><li><p>general population (Table 1). Variations in prevalence are better explained by differ-ences in study design, definition of CAM, the instruments used, and population selec-tion than by geographic, economic or ethnic factors. What it is clear is that its use hasbeen exponentially increasing in the past decade.</p><p>A high prevalence of CAM use has been also reported for a number of disease-specific groups. For instances, 764% of patients with cancer used CAM, accordingto a recently published systematic review1, as did 27% of patients attending a gastroen-terology clinic2, 20% of patients with inflammatory bowel disease3, 29% of the at-tendees of a rehabilitation outpatients clinic in New York4, and patients with AIDS,irritable bowel syndrome, and depression, among other conditions.57 In a survey of45,000 patients from 35 selected districts of India, about one third of patients pre-ferred indigenous systems of medicine for their common ailments.8</p><p>The scope of rheumatic diseases involves more than 150 different entities that pa-tients may suffer for 2030 or more years, with a multidimensional impact on all as-pects of daily living. Given these characteristics, and the lack of curative therapiesfor many of them, the usage of CAM should not be a surprise. Evidence exists thatrheumatic patients use CAM whether they live in developed or developing countries,are well or less-well educated, or richer or less fortunate (Table 1).</p><p>For instance, in one of the first papers on the frequency of CAM use in rheumatol-ogy, Kronenfeld and Wasner reported the results of a face-to-face interview with 98rheumatic patients attending a rheumatology clinic in a university setting in the UnitedStates.9 The mean usage was 3.7 different remedies, with three patients each havingtried 13 different modalities. Topical remedies were used by over 80% of all respon-dents, including alcohol, whiskey, snake oil, and gasoline; 36% of the respondentshad visited a CAM provider at least once for their arthritis. Interestingly, 5% used</p><p>742 C. Ramos-Remus and A. RautCAM before having contacted a physician, whereas 83% had been seeing a physicianfor more than 1 year before they sought these remedies. In another survey from</p><p>Table 1. Reported frequencies of complementary and alternative medicine (CAM) utilization.</p><p>CAM users (%) References</p><p>General population:</p><p>Australia 20e48.5 35</p><p>Canada 11e32 36,37,118United States 25e73 15,20,32,34,67,85</p><p>Israel 6 33</p><p>Netherlands 16 68</p><p>United Kingdom 25 68</p><p>France 36 68</p><p>South Africa 38.5 47</p><p>India 33 8</p><p>Rheumatic patients:</p><p>United States 18e94% 9,10,32,34,119e123</p><p>Canada 60e91 14,16,38</p><p>Mexico 56e83 17,124Australia 40e82 125e127</p><p>Germany 78 128</p><p>India 43e72 11e13</p></li><li><p>California, 84% of the patients with self-reported osteoarthritis or rheumatoid arthri-tis had used CAM during the previous 6 months.10 Two Indian studies, one each from</p><p>Complementary and alternative practices 743south and north India, in patients of rheumatoid arthritis have indicated CAM usage ofabout 43%11,12, whereas another study from Western India indicated use of CAM by72% patients.13</p><p>According to a Canadian survey, CAM practitioner use and dietary manipulationwere used more frequently by fibromyalgia patients.14 CAM usage was identified in91% of fibromyalgia patients and 63% of the other rheumatic patients. Of the fibro-myalgia patients, 79% had visited CAM practitioners, and 63% of them reported fre-quent use (defined as more than six visits per year). Fibromyalgia patients wereasked to rate their satisfaction with CAM on a scale of 010. The overall score givenwas 6.7. Health-care utilization by fibromyalgia patients was higher among the CAMusers (7.5 medical doctor visits per year) than in those that did no use CAM (4.5 med-ical doctor visits per year). Similar patterns have been reported in the United States.15</p><p>In other Canadian study16, 60% of the patients had used a total of 530 CAM rem-edies (range 125), and 79% of these patients had used 309 CAM remedies in the pre-vious 12 months (mean of 3, range 115 remedies). Overall, 47% had used at least oneCAM before the first rheumatology consultation, but an additional 8% initiated CAMafter their first contact with a rheumatologist. The group of CAM users saw a rheuma-tologist a mean of 6 times (range 152) and their family physicians 11 times (range052) during the previous year. Of the 119 users of CAM, 41 (34%) visited CAM pro-viders at least once in the previous 12 months (mean 11, range 1105). Of the 41patients who not only used CAM but also visited a CAM provider, there was a similarnumber of total visits to family physicians (mean 11, range 052) but a reduction invisits to rheumatologists (mean 3, range 025). Most of the patients (72%) usedCAM in the expectation of pain relief. Patients perceived great improvement with11% of the CAM remedies used, mild improvement with 29%, and no improvementat all with 59% of the remedies.</p><p>A Mexican survey17 of 300 consecutive rheumatic patients at three outpatientrheumatology clinics found that 83% of patients had a life-time usage of 1386 CAMremedies (mean 5.5 remedies, range 119); 203 patients (68%) had used CAM inthe previous 12 months (mean 3.5, range 115). In 61%, at least one CAM remedywas received before the first rheumatology consultation, but an additional 18% initi-ated these remedies after their initial contact with a rheumatologist. Interestingly,14% of the interviewed patients discontinued formal treatment on at least one occa-sion in order to receive CAM. Patients claimed that CAM practitioners recommendeddiscontinuation of conventional therapy on 57% of the occasions when formal treat-ments were discontinued; other authors found similar practices of formal treatmentdiscontinuation in South Africa18 and Mexico.19</p><p>In another study from Mexico, the authors conducted face-to-face interviews with107 consecutive patients with systemic lupus erythematosus (SLE).19 The mean dis-ease duration was 8 6 years, and the mean follow-up in the clinics was 6 years.Of these 107 patients, 70 (65%) had used CAM for a total of 121 remedies, equivalentto 14 new remedies per 100 person-years. There were 52 discontinuations of thetreatments prescribed by rheumatologists in 33 patients (31%, 1.6 per patient). Ofthe 33 patients who had used CAM, 28 (85%) discontinued formal treatment duringthe period using CAM, compared to 42 of 74 (60%) who had never used CAM(OR 4.3, 95%CI 1.512.3). Previous hospitalizations due to severity and/or compli-cations were higher in CAM users (0.83 per patient) than in non-users (0.32 perpatient) (P 0.008).</p></li><li><p>The former assumption that Western physicians discourage the use of CAM rem-edies and/or providers is not supported by the recently published data on referral pat-</p><p>sites in Britain had referred patients to CAM during the year preceding the investiga-</p><p>744 C. Ramos-Remus and A. Rauttion. Their views about the efficacy of different therapies were influenced primarily byuncontrolled observations or personal experiences (79%) and by the media (14%).24 Inthe district of Kassel, Germany, 95% of the general practitioners who replied to a mailsurvey (56% response rate) occasionally used at least some form of CAM: most com-monly herbal medicine, neural therapy, or homeopathy.25 Ernst et al reported that 67%of local health authorities in the United Kingdom are purchasing at least one form ofCAM.26 More recent evidence shows that CAM is gaining more acceptance among pri-mary-care health professionals, at least in Great Britain27, Switzerland28, Italy29, andAustralia.30 Even rheumatologists have begun using CAM to treat their patients inthe United States.31</p><p>WHY DO RHEUMATIC PATIENTS USE CAM?</p><p>The published information on consumer behaviour with respect to CAM is scarce. Ingeneral, people who use CAM come from all social classes, but tend to be overrepre-sented in the middle and upper classes, whether class is measured by income or levelof education.3236 They are more likely to be women, who are also more likely thanmen to use CAM services, and to be middle-aged.33,3537 It appears that many patientsuse physicians and CAM remedies or providers concurrently for the same medicalcondition3234, but some patients rely primarily on CAM to treat a medical condi-tion.3234 However, an important proportion of patients will not tell their physicianthey are using CAM.34</p><p>Rheumatic patients also come from all social classes, but the association with in-come or level of education has not been consistent.9,14,16,17,19,38 It seems that,amongst rheumatic patients, CAM users are slightly more disabled than non-users16,17,but associations with other disease characteristics have not been found. More patientsused more CAM remedies after the first rheumatology consultation9,16,17; this patterncould perhaps be explained by longer disease duration allowing greater opportunityterns of general practitioners and some specialists from various countries. Forinstance, in one study from the United States20 89% of both adult primary-care phy-sicians and obstetricians had used or recommended to patients at least one of the20 CAM remedies listed in the survey during the previous 12 months; 40% of thosephysicians interested in CAM were motivated by uncontrolled observations or anec-dotal experiences, whereas in only 5% was their interest motivated by articles read ina professional journal.</p><p>In Washington State, New Mexico, and southern Israel, Borkan et al found thatmore than 60% of community physicians (response rate 50%) had referred at leastone patient for CAM in the previous year21; 12% of the respondents incorporatedCAM techniques into their practice, and 47% had used CAM for themselves, their fam-ily members, or both. In one of the prescription studies from a tertiary-care allopathichospital in India, the prescriptions contained 12% Ayurvedic drugs.22</p><p>Canada and some European countries have similar referral patterns. For example,in one cross-sectional study of general practitioners in the provinces of Ontario andAlberta, 54% of the 200 respondents (52% response rate) indicated that they refer pa-tients to CAM practitioners, and 16% indicated that they practised some form ofCAM.23 In another study, 76% of 200 general practitioners in both rural and urban</p></li><li><p>for using such remedies, or by discrepancy between patient expectations of formaltreatment and actual response to therapy.</p><p>As shown in population studies, most of the rheumatic patients who use CAM con-currently use conventional therapies, and will not inform their attending physicians ofthis fact. It appears also that CAM users tend to be higher users of health care thannon-users, and those users of CAM practitioners tend to visit CAM providersmore frequently than general practitioners or rheumatologists.14,16,17 Moreover, sev-eral studies have identified a particular subgroup of higher CAM users (around 5% oftheir samples).9,14,16,17</p><p>Some authors suggest that sick people use CAM because of dissatisfaction withmainstream health care; however, other consuming patterns have not been properlyassessed. Health is influenced by factors in five domains: genetic, environmental expo-sures, behavioural patterns, social conditions, and health care.39 For most chronic con-ditions, such as many of the rheumatic diseases, the single greatest domain in whichhealth can be improved and premature disability reduced is personal behaviour.40,41</p><p>Figure 1 shows an explanatory framework for the use of CAM by rheumatic patients.Two of the domains influencing health genetics and environmental exposures givethe risks for the development of an illness, but the other three influence decisions toseek treatment in an ill person, and hence the outcome of a disease. At this point, in-troducing the marketing concept of positioning seems appropriate. Positioning is theperception in the minds of the target market: in this case, rheumatic patients. It is theaggregate perception the market has of a particular product or service (e.g. CAM) inrelation to their perceptions of the competitors in the same category (mainstream</p><p>Complementary and alternative practices 745Figure 1. A conceptual framework to explain the use of complementary and alternative medicine (CAM) by</p><p>rheumatic patients.</p></li><li><p>health care).42 People have learned to rank products on mental ladders, and the easyway to get into a persons mind is to be first.42 Our hypothesis is that the positioning</p><p>746 C. Ramos-Remus and A. Rautof CAM products and services is much higher in many rheumatic patients than main-stream health care, and there is a clear evidence to support our belief.43,44</p><p>In the framework we are presenting here (Figure 1), several factors interact and in-fluence behavioural patterns, social conditions and health-care dom...</p></li></ul>