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Volume 1:
No. 4, October 2004
ORIGINAL RESEARCH
Use of Complementary Therapies
Among Primary Care Clinic Patients With
Arthritis
Carla J. Herman, MD, MPH, Peg Allen, MPH, William C. Hunt, MA, Arti Prasad,
MD, Teresa J. Brady, PhD
Suggested citation for this article: Herman CJ, Allen P, Hunt WC, Prasad
A, Brady TJ. Use of complementary therapies among primary care clinic patients
with arthritis. 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
Introduction
Use of complementary and alternative medicine (CAM) for chronic conditions has
increased in recent years. There is little information, however, on CAM use among
adults with clinic-confirmed diagnoses, including arthritis, who are treated by
primary care physicians.
Methods
To assess the frequency and types of CAM therapy used by Hispanic and
non-Hispanic white women and men with osteoarthritis, rheumatoid arthritis, or fibromyalgia, we used stratified random
selection to identify 612 participants aged 18–84 years and seen in
university-based primary care clinics.
Respondents completed an interviewer-administered survey in English or Spanish.
Results
Nearly half (44.6%) of the study population was of Hispanic ethnicity, 71.4%
were women, and 65.0% had annual incomes of less than $25,000. Most (90.2%) had ever
used CAM for arthritis, and 69.2% were using CAM at the time of the interview.
Current use was highest for oral supplements (mainly glucosamine and chondroitin)
(34.1%), mind-body therapies (29.0%), and herbal topical ointments (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 therapies (10.6%), special
diets (10.1%), or copper jewelry or magnets (9.2%). Those with fibromyalgia
currently used an average of 3.9 CAM therapies versus 2.4 for those with
rheumatoid arthritis and 2.1 for those with osteoarthritis. Current CAM use was
significantly associated with being female, being under 55 years of age, and
having some college education.
Conclusion
Hispanic and non-Hispanic white arthritis patients used CAM to supplement
conventional treatments. Health care providers should be aware of the high use
of CAM and incorporate questions about its use into routine assessments and
treatment planning.
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Introduction
Rheumatic conditions such as arthritis and chronic joint pain are the leading
cause of limitation in daily activities and disability among adults in the
United States (1). In 2001, self-reported data obtained by the U.S. Behavioral
Risk Factor Surveillance System indicated that a third of American adults had
chronic joint symptoms or physician-diagnosed arthritis (1). Researchers
estimate that by 2030, some 41 million adults aged 65 and older will have
arthritis or chronic joint symptoms (2). Management of chronic rheumatic
conditions usually consists of physician-prescribed medications,
physician-recommended over-the-counter medications, physical therapy, and
self-management strategies recommended by physicians and the American College of
Rheumatology (3) such as exercise, weight control, use of heat or cold,
intermittent rest, and stress management. Increasingly, adults are also adopting
complementary and alternative medicine (CAM) to help manage their chronic
conditions (4,5).
This study addresses three gaps in the literature on CAM use for
arthritis. First, CAM use among adults with physician-confirmed arthritis who
are treated by primary care physicians has not been well studied. Previous
studies on prevalence of CAM use for arthritis in the United States have
typically included either patients seen by rheumatologists (6-8) or
community-based samples of adults with self-reported arthritis (9-12). The
rheumatology clinic studies have used clinic-confirmed diagnoses but excluded
adults treated by primary care physicians and have had small samples (n =
135–232). The community-based surveys have included adults treated by any type
of physician or none at all and have had larger samples (n = 122–1424), but
these studies have relied on self-report to determine the presence of arthritis.
Many such participants did not know what type of arthritis they had (9,10).
A second gap in the literature is the underrepresentation of Hispanic adults
in arthritis-specific CAM-use studies in the United States. Two community-based
studies conducted 10 or more years ago found that Hispanic and African American
adults with arthritis were more likely to use prayer, take herbs orally, or use
ointments and were less likely to see a physician for arthritis than were
non-Hispanic whites (13,14). Hispanic adults are better represented in studies
of CAM use among the general population (4). In studies of CAM use for any
purpose among adults in the general population, Hispanics or Latinos have been
as likely as non-Hispanic whites to use self-care types of CAM but less likely
to have seen a CAM provider (4,5,15-19).
A third shortcoming is that there seems to be little information describing
use of specific CAM therapies by type of arthritis, even though the three most
common types of arthritis — osteoarthritis, rheumatoid arthritis, and fibromyalgia
— differ greatly in disease processes, clinical presentations, persons affected,
and the CAM therapies shown to be effective (20,21). Osteoarthritis affects both
women and men primarily over age 45, whereas rheumatoid arthritis and
fibromyalgia can start at younger ages and affect more women than men (20).
The purpose of this study is to assess the frequency and types of CAM
therapy used by Hispanic and non-Hispanic white adults treated by primary care
physicians in university-affiliated clinics in Albuquerque, NM, as part
of the management of osteoarthritis, rheumatoid arthritis, or fibromyalgia.
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Methods
Recruitment
Hispanic and non-Hispanic white women and men aged 18–84 years seen in any of
six primary care clinics at the University of New Mexico in Albuquerque between
June 2000 and May 2001 with a diagnostic code for osteoarthritis, rheumatoid
arthritis, or fibromyalgia were eligible for inclusion in the sample. The
sampling method is discussed below (Statistical analysis). Of the 1684 sampled
patients, 22 (1.3%) had died. For 97 (5.8%), permission to contact was denied by
the primary care physician, and for 69 (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 in English or Spanish to these patients to invite them to participate in
the study. Because of the known inaccuracy of ethnicity coding in the clinics,
interviewers screened patients during the invitational calls to ensure they
self-identified as Hispanic or non-Hispanic white and spoke English or Spanish.
During recruitment, we learned that the diagnostic code (ICD-9-CM) for fibromyalgia
was not specific to fibromyalgia, but also included people with other muscular
conditions. Consequently, some patients denied having fibromyalgia or arthritis
when contacted and were excluded.
Interviews
In-person interviews were conducted by appointment in participants’ homes or
in a clinic, according to participant preference. The interviewers were
university staff trained to conduct interviews for a variety of epidemiological
studies.
We used validated and reliable measures from the Centers for Disease Control
and Prevention’s Behavioral Risk Factor Surveillance System for demographic
questions, perceived health status, and comorbidity (22). The 20-item Stanford
Health Assessment Questionnaire (HAQ), commonly used in arthritis research, was
the measure of functional ability (23). The five-item short form of the
Arthritis Helplessness Index, validated by DeVellis and Callahan (24), measured
perceived helplessness (25). Fiscella’s four-item Medical Skepticism scale (26)
assessed beliefs about desire to control one’s own health care. We used the
Faces Pain Scale to assess average pain over the past week, with a range from 0
= no pain to 10 = worst possible pain (27,28). We used a visual analog scale to
evaluate average fatigue over the past week, with a range from 0 = no fatigue to
10 = extreme fatigue (29). A four-item scale measured sleep problems in the past
month (30). We also included Marin’s five-item Hispanic acculturation scale
(31).
We selected CAM items based on a review of the literature and feedback from
39 volunteers in four focus groups. CAM items were included in the survey if
they were reported in the CAM literature as commonly used for osteoarthritis,
rheumatoid arthritis, or fibromyalgia, or if focus group participants said they
were locally used for arthritis. (The
Appendix provides a full list of CAM
therapies included in the survey.) Participants were also asked to describe
other therapies they were using. Current use was defined as use at the time of
the interview.
Pilot testing of the questionnaire was conducted in two waves. The first wave
involved adults who had arthritis or fibromyalgia and were known to the
researchers. In the second wave, interviewers conducted pilot interviews using
the modified survey with 18 volunteers recruited from the community who met
eligibility criteria for the study. Final revisions were then made to the
English-language questionnaire. Previously validated Spanish translations 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 works in health care in
New Mexico translated the remaining measures. Several Spanish-speaking
researchers reviewed the translations to ensure a match to the English meaning,
proper grammar, and correct spelling and then pilot tested the Spanish version
with Spanish speakers who had arthritis.
Statistical analysis
Participants were randomly selected from the clinic population within strata
defined by ethnicity, sex, and diagnostic group. To obtain more rheumatoid
arthritis participants, more Hispanics, and more men, we sampled patients in
these categories at higher rates than non-Hispanic white women with diagnoses of
osteoarthritis or fibromyalgia. The strata were based on the clinic-assigned
ethnicity and diagnostic group, although self-reported ethnicity and
self-reported diagnosis of fibromyalgia were used in the analysis. Sampling
fractions were computed as the ratio of the number of participants who completed
an interview to the total number of clinic patients within each stratum. The
inverses of the sampling fractions were used as weights in all analyses. SUDAAN
software release 8.0.2 (Research Triangle Institute, Research Triangle Park, NC) was used to compute all weighted estimates of
proportions and tests of significance by means of a stratified sampling with
replacement design (34).
We conducted analyses separately by diagnostic group because the three types
of rheumatological conditions are different disease processes with different
clinical presentations and patient demographics. For arthritis type, we coded
each participant as having primarily rheumatoid arthritis, fibromyalgia, or
osteoarthritis. The clinic diagnostic codes were used to identify respondents as
having rheumatoid arthritis or osteoarthritis. Because of inaccuracies in the
diagnostic coding for fibromyalgia, we used participants’ self-reports to code
that condition. Participants having more than one type of arthritis were
classified in the following order of priority: 1) rheumatoid arthritis, 2)
fibromyalgia, and 3) osteoarthritis. Ninety-five patients were classified as having
rheumatoid arthritis, 95 as having fibromyalgia, and 422 as having
osteoarthritis. One patient with rheumatoid arthritis also had a clinical
diagnosis of osteoarthritis, and six reported having fibromyalgia. Nineteen with
self-reported fibromyalgia also had a clinical diagnosis of osteoarthritis.
Subjects who reported both Hispanic and non-Hispanic ethnicity were coded as
Hispanic.
Several survey items were excluded from frequency counts and analyses of CAM
use. Multiple vitamins, prayer, and drawing upon religious beliefs were excluded
because participants had difficulty distinguishing between use for general
health and use specifically for arthritis. Calcium, vitamin D, and folic acid
were excluded because participants reported that their physicians had recommended
their use
for other health reasons.
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Results
Demographics
A total of 612 primary care clinic patients completed the surveys. Of the
1496 primary clinic patients sent introductory letters, 286 (19.1%) were
ineligible per the telephone screening (self-reported ethnicity other than
Hispanic or non-Hispanic white or denied having arthritis). Of the 1210 eligible
patients, 110 (9.1%) were too ill to participate because of other illnesses, 36
(3.0%) had moved out of the area, 302 (25.0%) refused, 96 (7.9%) had no current
contact information, and 54 (4.5%) with valid telephone numbers could not be
reached despite repeated calls at different times of the day. The final response
rate of completed interviews among eligible patients was 50.6% (612 of the 1210
eligible patients). Information was not available on nonrespondents to compare
their characteristics with those of respondents.
Weighted estimates of the proportions of the clinic population with each of
several characteristics, both overall and by diagnostic group, are shown in
Table 1. An estimated 44.6%
were of Hispanic ethnicity and 71.4% were female.
About one fourth (26.9%) were aged younger than 55 years, 35.4% were aged 55–64,
and 37.7% were aged 65–84. Of the Hispanics, 71.4% self-identified as Spanish
American, 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 not know or refused to answer) (data not shown). As expected, clinic patients
with rheumatoid arthritis and fibromyalgia were younger and included a higher
proportion of women and non-Hispanic whites, and they had more education than
the group with osteoarthritis. Patients with fibromyalgia had higher levels of
pain in the past week and more frequent physician visits for their rheumatologic
condition than did patients with rheumatoid arthritis or osteoarthritis (P
< 0.01).
Overall CAM use
Most of the clinic population (90.2%) had ever tried CAM therapies for their
arthritis, and 69.2% currently used one or more CAM therapies at the time of the
interview (Table 2). CAM users with fibromyalgia had ever tried an average of
5.5 CAM therapies versus 4.4 among those with rheumatoid arthritis and 3.1 among
those with osteoarthritis (P < .05) (data not shown). CAM users with fibromyalgia currently used an average of 3.9 CAM therapies compared with 2.4
among those with rheumatoid arthritis and 2.1 among those with osteoarthritis (P
< .05) (data not shown).
Types of therapies used
Fibromyalgia patients were most likely to use each type of CAM compared to
those with rheumatoid arthritis or osteoarthritis (Table 2). Specific CAM
therapies currently used by at least 3% of the clinic population in at least one
of the diagnostic groups are shown in
Table 3. Patients with osteoarthritis most
commonly used the nutritional supplements glucosamine (25.2%) and chondroitin
(17.9%) and the mind-body therapies of meditation (10.1%) and relaxation
techniques (10.0%) to manage their arthritis. Rheumatoid arthritis patients most
commonly used relaxation (16.3%), glucosamine (15.8%), meditation (11.1%), and
vitamin C (10.0%). Only 6.1% of rheumatoid arthritis patients
currently used fish oil supplements, and only 1.3% used supplements containing
gamma linolenic acid (GLA) (borage oil, evening primrose oil, and black currant
oil). Fibromyalgia patients most commonly used breathing techniques (36.7%),
relaxation (28.9%), meditation (27.6%), music therapy (22.8%), glucosamine
(20.7%), visualization (19.6%), acupressure (19.5%), massage therapy (17.1%),
magnesium (14.1%), and yoga (13.2%). Fibromyalgia patients with a concurrent
clinical diagnosis of osteoarthritis were more likely to use glucosamine than
were those without osteoarthritis (glucosamine: 49.3% vs 13.8%, P =
.01; chondroitin: 25.6% vs 6.9%, P = .08) (data not shown).
Patients currently used more than 40 different herbs taken orally and more
than 30 topical herbal therapies for arthritis. As Table 3 shows, massage
therapists, chiropractors, and acupuncturists were the most commonly seen CAM
therapists. Within the items worn category, only magnets and copper bracelets
were currently used by more than 1% of patients. Respondents were asked about
several CAM movement therapies, and they most often named yoga, tai chi, or the Feldenkrais method of movement reeducation. Current use of special diets
included an “arthritis diet” high in fish and fresh fruits and vegetables and
low in potatoes, tomatoes, eggplant, and peppers. Patients also used several
other special diets. Energy therapies included acupressure, reiki, reflexology,
therapeutic touch, aromatherapy, and other therapies intended to affect
theorized energy fields within and surrounding the body.
Characteristics of CAM users
Among osteoarthritis and fibromyalgia patients, current use of any type of
CAM did not differ by demographic characteristics (Table 4). Among rheumatoid
arthritis participants, however, current CAM use was associated with disease
duration of 0–5 years and having some college education (P < 0.05). Tests
for interactions showed the association between ethnicity and current use of any
type of CAM differed by diagnostic group. Similar proportions of Hispanic and
non-Hispanic white osteoarthritis patients currently used any type of CAM,
whereas significantly more non-Hispanic whites with rheumatoid arthritis
currently used CAM than did Hispanics with rheumatoid arthritis. We tested other
measures of disease burden not shown in Table 4 (including functional ability,
fatigue, sleep problems, perceived general health status, and presence of
comorbidity) for possible associations with current CAM use, but we found none
that was significant. Overall, current use of any type of CAM was significantly
higher among 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 are described below. The
percentages of the clinic population that found CAM therapies somewhat helpful or
helped a lot, among those who had ever used that type of CAM, are as follows:
mind-body therapies (90.4%); CAM movement therapies (82.7%); CAM therapists
(79.8%); energy therapies (79.4%); herbal topical rubs (77.1%); special diets
(64.9%); vitamins and minerals (63.0%); herbs taken orally (61.5%); nutritional
supplements (57.0%); homeopathic remedies (49.6%); and items worn (36.9%). Gaps
between percentages of ever use and current use were greatest for those CAM
therapies that fewer patients found useful, such as wearing copper jewelry or
magnets, or for costly therapies, such as seeing CAM therapists or using glucosamine and chondroitin. Among those who had ever used CAM, 13.6% of
osteoarthritis patients, 17.3% of those with rheumatoid arthritis, and 30.6% of
those with fibromyalgia reported that CAM use changed their use of conventional
therapies. The most common change reported in open-ended responses was the use
of smaller amounts or doses of prescription or over-the-counter medication
(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 suggested the therapies, and 2.7% were unsure. More
CAM users with fibromyalgia (82.8%) told their doctor about their CAM use than
did those with rheumatoid arthritis (69.7%) or osteoarthritis (62.0%) (P
< .001).
Open-ended responses on reasons for using CAM were in the same rank order by
how often they were mentioned in each diagnostic group. Overall, reasons
mentioned included the following: to relieve pain (36.1%); to prevent disease
progression (14.3%); to feel better (13.7%); to try CAM to see if it would help
(13.5%); and because CAM therapies had helped them (9.2%). Sources of
information about CAM 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%), and radio or television or newspapers (22.6%); only
11.3% named the Internet as a source. Patients who had ever used any type of CAM
currently spent from $0 to more than $500 per month on CAM therapies, with 67.7%
spending $50 or less per month and 15.1% spending more than $100 per month.
Thirty percent of CAM users with fibromyalgia spent more than $100 per month on
CAM versus 24.0% of those with rheumatoid arthritis and 9.7% of those with
osteoarthritis.
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Discussion
In this study, 90.2% of Hispanic and non-Hispanic white arthritis patients
treated by primary care physicians had ever tried CAM for their arthritis, and
69.2% currently used one or more CAM therapies. Overall, 17.2% changed their use
of conventional treatments after starting to use CAM, and more than one fifth
(22.6%) had never discussed their CAM use with their medical doctor. These
findings are important because they indicate that conventional therapies alone
are not meeting the needs of arthritis patients. Furthermore, many patients are
supplementing or decreasing their medical treatment with or without their
physician’s knowledge. Because some CAM therapies may interact with conventional
medications and treatments, it is important for health care providers to be
aware that many arthritis patients are using therapies on their own and to
inquire specifically about their patients’ CAM use.
The prevalence of CAM use found in this study is higher than the range of
33%–66% reported in previous arthritis studies (6-12). Differing definitions of
CAM may partly explain the disparity, as the present study included a broader
array of mind-body therapies, energy therapies, and CAM movement therapies than
most previous studies. Geographic location may also partly explain the
difference, given that national studies of CAM use among the general population
have found higher use in the West than in other regions of the United States
(5,18). Also, some arthritis studies have included only older adults (9-12) who
in previous studies were less likely to use CAM than adults under age 55 (4,5).
As in previous studies, most CAM use in the present study was self-care, with
a smaller percentage of people seeing a CAM therapist (4-6,10,12,15). Consistent
with some previous studies, current use of any type of CAM in this study was
associated with being female, being under age 55, and having some college
education, and use did not differ by Hispanic ethnicity (4-6,16,19). National
studies on CAM use among the general population found higher income was
associated with CAM use (4,5), but the present study and some other arthritis
CAM studies found no association between CAM use and income (6,9,11).
The finding that patients with osteoarthritis used a lower average number of
CAM therapies than those with fibromyalgia and rheumatoid arthritis conflicts
with a previous rheumatology clinic study in which patients with rheumatoid
arthritis were less likely to use CAM than patients with osteoarthritis or
fibromyalgia (6). Both that study and ours, however, had small numbers of
patients with fibromyalgia and rheumatoid arthritis, and the previous study had
very few patients with osteoarthritis. Thus, caution should be used in
interpreting this finding. In previous studies among adults with arthritis, CAM
use was associated with poor perceived general health (10,11), sleep
disruption (12), or severe pain (35). In one study, use of three or more types
of CAM was associated with longer disease duration (35). In the present study,
however, shorter duration of arthritis among respondents with rheumatoid
arthritis was associated with current CAM use, and arthritis symptoms were not
significantly associated with CAM use. Although similar percentages of Hispanic
and non-Hispanic white respondents with osteoarthritis used any type of CAM, use
of specific CAM therapies may vary by Hispanic ethnicity. Exploration of this
issue is beyond the scope of the present overview.
An important finding of this study is that patterns of CAM use did not
necessarily correspond to CAM therapies with evidence of effectiveness for
particular types of arthritis. Most striking is the high percentage of patients
in each diagnostic group with past and current use of glucosamine and
chondroitin. Rigorous scientific studies have shown consistent moderate
short-term benefits and safety of glucosamine and chondroitin for osteoarthritis
of the knee, but there is no evidence for their effectiveness in rheumatoid
arthritis or fibromyalgia (21,36,37). We checked for concurrent osteoarthritis
as a possible explanation of use by those with rheumatoid arthritis and
fibromyalgia, but we found that none of the participants with rheumatoid
arthritis and only half of those with fibromyalgia using glucosamine and
chondroitin had osteoarthritis. Another example is the low use of fish oil and
GLA-containing supplements among patients with rheumatoid arthritis, even though
they have been shown to reduce pain and improve function in those who have
rheumatoid arthritis (21,38). Relying on friends, family members, and magazines
for information about CAM may have affected participants’ access to credible
information specific to arthritis type. High use of mind-body therapies was
found in the present study within each diagnostic group, especially among those
with fibromyalgia. The few efficacy studies of mind-body therapies among
patients with fibromyalgia have had equivocal findings, but results are
promising for patients with osteoarthritis and rheumatoid arthritis (39).
This study has several limitations. Sample sizes were small for those with
rheumatoid arthritis (n = 95) and fibromyalgia (n = 95), although the numbers of
osteoarthritis participants (n = 422) and total participants (n = 612) were
larger than in previous studies with clinic samples. Results are not
generalizable beyond the particular clinic population for several reasons: the
response rate was low; men, Hispanics, and those with rheumatoid arthritis were
oversampled; the SUDAAN weighted analysis method provided estimates only within
the particular clinic population in the study and not a larger population; the
low-income, central New Mexican, university-affiliated clinic population is
unlikely to be representative of other clinic populations in other locations;
and New Mexican Hispanics who self-identify as Spanish Americans may not be
representative of diverse Hispanic populations living elsewhere. We used the SUDAAN weighted analysis method to address oversampling certain groups, but this
method is intended for use with larger samples (34). Use of CAM ever to manage
longstanding arthritis is prone to recall bias, and so we defined current use as
use at the time of the interview. There is still the limitation of asking about
CAM use at only one point in time. Definitions of CAM are increasingly blurred
as some therapies such as vitamins have become part of conventional clinical
practice and others such as capsaicin cream are now recommended by the American
College of Rheumatology because of evidence of efficacy (3).
Efforts are needed to investigate how best to translate and disseminate CAM
efficacy research findings so people will know which CAM therapies may benefit their type of arthritis. Additional research is needed on efficacy
and safety of CAM therapies used by arthritis patients, including research on
potential negative interactions between CAM therapies and conventional
treatments such as medications.
In conclusion, this study found that CAM use was high, potentially costly,
and not always communicated to the treating physician among the osteoarthritis,
rheumatoid arthritis, and fibromyalgia patients treated by primary care
physicians in these clinics. Overall, 69% of the clinic population currently
used any type of CAM, and current use was associated with being female, being
under 55 years of age, and having a college education. Two thirds of CAM users
spent less than $50 per month on CAM, but overall 15%, including 30% of the CAM
users with fibromyalgia, spent more than $100 per month on CAM. Two thirds of
CAM users in the study discussed CAM use with their medical doctor; the main
reason cited for not disclosing CAM use was that the physician did not ask.
Physicians and other health care providers should be aware of this high degree
of CAM use among arthritis patients and incorporate questions about such use
into their routine assessments and treatment planning.
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Acknowledgments
This study was funded by the Division of Adult and Community Health (DACH),
through the Prevention Research Centers Program, National Center for Chronic
Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control
and Prevention (CDC). Special thanks go to Shirley Pareo, MS, Center for Health
Promotion and Disease Prevention, University of New Mexico 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 their assistance in survey development. We also thank the
Epidemiology and Cancer Control staff at the University of New Mexico Health
Sciences Center, especially Lloryn Swan, for recruitment data management;
Barbara Evans for designing the recruitment tracking system; Ron Darling for
designing the survey data entry screens; interviewers Julie Baum, Melissa Jim,
and Phoebe Underwood; and Kim Ngan Giang, research assistant.
Back to top Author Information
Corresponding author: Carla J. Herman, MD, MPH, Chief, Division of
Geriatrics, Department of Internal Medicine, School of Medicine, University of
New Mexico Health Sciences Center, MSC 10 5550, 1 University of New Mexico,
Albuquerque, NM 87131. Telephone: 505-272-5630. E-mail: cherman@salud.unm.edu.
Author affiliations: Peg Allen, MPH, Arti Prasad, MD, Department of Internal
Medicine, University of New Mexico 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, Arthritis
Program, Division of Adult and Community Health, National Center for
Chronic Disease Prevention and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Ga.
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