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Disability & Rehabilitation, 2012; 34(2): 128135

Copyright 2012 Informa UK, Ltd.


ISSN 0963-8288 print/ISSN 1464-5165 online
DOI: 10.3109/09638288.2011.591887

Research paper

Use of complementary and alternative medicine among US adults


with and without functional limitations
Catherine A. Okoro1, Guixiang Zhao2, Chaoyang Li1 & Lina S. Balluz1
1

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

Purpose. This study characterizes the use of complementary


and alternative medicine (CAM) among adults with and
without functional limitations. We also examine the reasons for
using CAM and for disclosing its use to conventional medical
professionals. Methods. Data were obtained from the 2007
adult CAM supplement and components of the National Health
Interview Survey (n=20,710). Results. Adults with functional
limitations used CAM more frequently than those without
(48.7% vs. 35.4%; p<0.001). Adults with functional limitations
used mindbody therapies the most (27.4%) and alternative
medical systems the least (4.8%). Relaxation techniques were
the most common therapy used by adults with functional
limitations, and they used it more often than those without
limitations (24.6% vs. 13.7%; P<0.001). More than half of the
adults with functional limitations (51.3%) discussed CAM use
with conventional medical professionals, compared with 37.9%
of adults without limitations (p<0.001). The main reason for CAM
use was general wellness/disease prevention among adults with
and without functional limitations (59.8% vs. 63.1%; P=0.051).
Conclusions. CAM use among adults with functional limitations
is high. Health practitioners should screen for and discuss the
safety and efficacy of CAM when providing health care.

Complementary and alternative medicine (CAM) is


often used for overall health, disease prevention, and
to supplement conventional medical treatment.
While most adults used CAM on the recommendation of friends and family, one-third of adults with
functional limitations (FLs) reported CAM use recommended by a health care provider.
This study found that ~50% of adults with FLs discussed their CAM use with a health care provider.
Open discussion of CAM use and its safety and efficacy is vital.
38% of adults used CAM therapy in the past 12 months, representing an estimated 83 million USA citizens [2]. In addition,
in 2007, adults spent US$22 billion on CAM classes, materials,
and products and US$12 billion on 354 million visits to CAM
practitioners (~10.8 visits per adult) [3].
The use of CAM is prevalent among persons living with
chronic conditions. Among persons with an existing health
condition, additional comorbidities, severity of disease, and
perceived poor health have been associated with higher levels
of CAM use [48]. People use CAM therapies for many reasons. Those living with a chronic condition might use CAM
therapy when conventional medical treatment is perceived to
be costly, invasive, or ineffective (e.g. chronic or recurring pain,
spasticity, low energy, decreased immune function) [812].
People may use CAM for pragmatic reasons as well and seek
alternatives to conventional medicine that can assist in selfmanagement of specific health conditions and participation in
valued life activities (e.g. work, school, social events) [1317].
Other reasons include attempts to improve general health and

Keywords: complementary medicine, alternative medicine,


alternative therapy, USA, functional outcomes

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

Complementary and alternative medicine 129


well-being, disease prevention, and a holistic (i.e. mind, body,
and spirit) approach to health and wellness [18,19].
Although several studies have investigated CAM use in the
general population and for persons with specific chronic conditions (e.g. arthritis, cancer, diabetes, HIV) [5,7,8,11,2022],
relatively few have examined CAM use among adults with
disabilities. Among the studies that have, analyses have been
primarily limited to adults with physical disabilities [4,2325].
For example, in an analysis of 1999 National Health Interview
Survey (NHIS) data, Hendershot [24] found that adults with
mobility limitations were significantly more likely than those
without such limitations to use CAM; however, the severity of
limitation had no bearing on the prevalence of CAM use. In
a study using 20002001 longitudinal national survey data,
researchers found that among adults with health insurance
and one of four disabling conditions (i.e. arthritis, multiple
sclerosis, cerebral palsy, and spinal cord injury), 19% had consulted a CAM practitioner in the past 12 months for treatment
of pain and decreased functioning and energy [23]. Another
study examined the use of alternative therapies and practitioners of those therapies among adults with physical disabilities
compared with the general population [4]. These researchers
found that adults with disabilities were more likely to use alternative therapies (57% vs. 34%) and twice as likely to visit
these providers (22% vs. 10%) than the general population
[4]. Moreover, half the adults with physical disabilities had
used at least one alternative therapy at the recommendation
of their conventional health care provider [4].
The International Classification of Functioning, Disability and Health (ICF) [26] promotes a concept of health that
includes several health-related domains (e.g. body function,
activity limitation, social participation)where impairment
in one domain can affect health (i.e. some degree of disability).
Using the ICF framework, we defined functional limitation
as some degree of difficulty in mobility or social functioning. Thus, the goal of this study was to characterize the use of
CAM among adults with and without functional limitations
and to further examine the use of CAM among adults with
functional limitations. We used data from the 2007 NHIS to
compare the CAM therapies used by adults with and without
functional limitations. In addition, we examined their reasons
for using CAM and for disclosing this information to conventional medical professionals.

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;

130 C.A. Okoro etal.


nonvitamin, nonmineral, and natural product use, such as combination herb pill, cranberry, or Glucosamine; and diet-based
therapies [vegetarian, macrobiotic, Atkins, Pritikin, Ornish
Zone, and South Beach]); (iii) manipulative and body-based
therapies (chiropractic or osteopathic manipulation, massage
[such as deep tissue, Swedish, Bowen, Rolfing, and reflexology],
and movement therapies [Feldenkreis, Alexander technique,
Pilates, and Trager psychophysical integration]); and (iv) mind
body therapies (biofeedback; relaxation techniques [meditation,
guided imagery, progressive relaxation, deep breathing exercises,
support group meeting; and stress management class]; hypnosis;
yoga, tai chi, qi gong; and energy healing therapy [such as Reiki,
therapeutic touch, polarity therapy, or magnet therapy]).
We also examined (i) disclosure of CAM use to conventional medical professionals and (ii) reasons for CAM use. For
each therapy used in the past 12 months, respondents were
asked about disclosure to conventional medical professionals
(i.e. medical doctor [including specialists], doctor of osteopathy, nurse practitioner/physician assistant, psychiatrist,
dentist [including specialists], psychologist/social worker,
and pharmacist). The reasons for CAM use assessed were
as follows: (i) to improve or enhance energy; (ii) for general
wellness or general disease prevention; (iii) to improve or enhance immune function; (iv) in place of ineffective medical
treatments; (v) in place of expensive medical treatments; (vi)
on recommendation by a health care provider; (vii) on recommendation by family, friends, or coworkers.
Respondents ages were assigned to six mutually exclusive
categories (1834, 3544, 4554, 5564, 6574, and 75).
Other sociodemographic characteristics and health-related
covariates included sex, race/ethnicity (non-Hispanic White,
non-Hispanic African American, non-Hispanic Other, and
Hispanic), educational attainment (<high school, high school/
GED, and >high school), imputed family income (<US$20,000,
US$20,000$34,999, US$35,000US$64,999, and $65,000)
[33], census region of residence (Northeast, Midwest, South,
and West), health insurance (yes/no), delayed care and/or
did not get care due to cost (yes/no), self-rated general health
(excellent/very good, good, and fair/poor), and self-reported
history of chronic conditions (<2 and 2).
First, we estimated the agesex-adjusted prevalence of
CAM use, reasons for, and disclosure of CAM use to conventional medical professionals among adults with and without
functional limitations. Second, we used bivariate analyses to
compare the use of various CAM therapies between these
populations. Third, we performed multivariable logistic regression to determine whether differences in CAM use persist
between adults with and without functional limitations after
adjusting for age, sex, race/ethnicity, imputed family income,
census region of residence, health insurance, delayed care
and/or unable to obtain care due to cost, self-rated general
health, and chronic conditions.
We used SAS-callable SUDAAN, Software for the Statistical Analysis of Correlated Data (Research Triangle Park,
North Carolina, USA) for analyses to account for the complex
survey design, to derive accurate standard errors, perform
tests of statistical significance, and estimate adjusted prevalences, adjusted odds ratios, and 95% confidence intervals

(Cls). Statistical inferences were based on a significance level


of p0.05. Data were weighted appropriately to represent the
community-dwelling adult US population [29].

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

Complementary and alternative medicine 131


Table I. Characteristics of US adults with and without functional imitations,
National Health Interview Survey, 2007.

Functional limitation No functional


(n=5960)
limitation (n=14 750)
%
SE
%
SE
Age, years*
1834
15.0
0.7
3544
14.2
0.5
4554
20.6
0.6
5564
21.5
0.6
6574
14.0
0.6
75
14.6
0.6
Sex*
Male
42.9
0.7
Female
57.1
0.7
Race/ethnicity*
White, non-Hispanic
77.3
0.7
African American, non10.3
0.5
Hispanic
Hispanic
8.7
0.5
Other, non-Hispanic
3.6
0.4
Education*
<High school
18.2
0.7
High school/GED
32.2
0.8
>High school
49.5
0.8
Family imputed income*
<US$20,000
21.5
0.7
US$20,000US$34,999 20.7
0.6
US$35,000-US$64,999 27.3
0.7
US$65,000
30.5
0.9
Region*
Northeast
16.3
0.7
Midwest
26.9
1.0
South
34.2
1.0
West
22.7
0.8
Health Insurance*
Yes
86.9
0.6
No
13.1
0.6
Health care delayed or not obtained due to cost*
Yes
18.2
0.6
No
81.8
0.6
Self-rated health*
Excellent/very good
37.5
0.8
Good
33.4
0.7
Fair/poor
29.2
0.6
No. chronic conditions*
<2
8.7
0.4
2
91.3
0.4

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

SE, standard error; GED, general educational development.


*p<0.001.

For adults with functional limitations, after adjusting for age


and sex, use of any CAM in the past year was highest among
the following: adults aged 18 to 54 years old, women, adults
reporting non-Hispanic Other or White racial/ethnic group,
adults with a higher level of educational attainment and those
with a higher family income, adults living in the Western US,
adults with health insurance, adults who perceived their health
to be excellent/very good, and adults with 2 chronic conditions (Table III). No significant difference in CAM use during
Copyright 2012 Informa UK Ltd.

Table II. Agesex-adjusted prevalence of complementary and alternative


medicine (CAM) use during the past year by USA adults aged 18 years
with and without functional limitations, National Health Interview Survey,
2007.

vitamins or minerals and prayer.


healers include Curandero, Espiritista, Hierbero or Yerbera, Shaman,
Botanica, Native American healer/medicine man, and Sobador.
cExcluding vitamins or minerals.
dDiet-based therapies include vegetarian, macrobiotic, Atkins, Pritikin, Ornish Zone,
and South Beach.
eMovement therapies include Feldenkreis, Alexander technique, Pilates, and Trager
psychophysical integration.
fExcluding prayer.
*p0.001; **p0.01; ***p < 0.05.
%, weighted percentage; SE, standard error; n, unweighted sample size; NA; not
available due to insufficient sample size.
bTraditional

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

132 C.A. Okoro etal.


Table III. Agesexadjusted prevalence of complementary and alternative medicine (CAM) usea in the past year by US adults aged 18
years or older with and without functional limitations, National Health Interview Survey, 2007.

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

vitamins or minerals and prayer.


sex adjusted.
ageadjusted.
dImputed.
n, unweighted sample size; %, weighted percentage; CI, confidence interval; P, pvalue.
bOnly
cOnly

they also remained more likely to use therapies in each


CAM grouping (alternative medical systems: 4.2% vs. 3.2%,
P<0.01; biologically based therapies: 23.1% vs. 19.1%,
P<0.001; manipulative and body-based therapies: 18.7% vs.
14.2%, P<0.001; and mindbody therapies: 25.1% vs. 18.2%,
P<0.001; TableIV).
More than half the adults (51.3%) with functional limitations discussed their CAM use with a conventional medical

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

Complementary and alternative medicine 133


Table IV. Adjusteda prevalence (%) and odds ratios for complementary
and alternative medicine (CAM) use in the past year by USA adults aged
18 years or older with and without functional limitations, National Health
Interview Survey, 2007.

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

Use in the past year


%
AOR (95% CI)
46.2*
36.5

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

for age, sex, race/ethnicity, education, income, region, self-rated health,


number of chronic conditions, health insurance, and delayed or unable to obtain
health care due to cost.
bExcluding vitamins or minerals and prayer.
cExcluding vitamins or minerals.
dExcluding prayer.
*p<0.001; **p<0.01.
AOR, adjusted odds ratio; CI, confidence interval.

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.

and only the use of CAM practitioners was examined. Waianae


etal. [25] reported that 29% of patients aged 13 to 96 years in an
urban rehabilitation outpatient practice had used one or more
CAM therapies in the past year, including vitamin/mineral
supplements. Conversely, Krauss et al. [4] reported a higher
prevalence of CAM use, but their sample population consisted
of working-age adults with physically disabling conditions at an
urban outpatient vocational rehabilitation facility and they also
included prayer and megavitamin therapy as CAM therapies.
If we had included either prayer (i.e. praying for self or having others pray for you) or the use of vitamins or minerals as
CAM therapies, the prevalence of CAM use among adults with
functional limitations would have risen above that reported by
Krauss etal. (77% and 72%, respectively vs. 57%).
As in other studies, we found that certain sociodemographic and health-related characteristics are associated with
increased use of CAM therapies, and these characteristics did
not vary substantially by functional limitation status. The two
groups had in common the patterns that women, adults with
higher educational attainment and income levels, adults living
in the West, those with health insurance, those who perceived
themselves to be in good health, and those with more chronic
health conditions were more likely to use CAM therapies
compared with their counterparts. These findings mirror
those reported to be associated with CAM use in the general
USA adult population [2,34].
Patterns of CAM use by age and for delayed or unattained
health care because of cost, however, did vary by functional
limitation status. Among adults with functional limitations,
those aged 18 to 54 years had the highest CAM use, whereas
among adults without limitations, those aged 45 to 64 years
were more prevalent CAM users. In addition, adults with
functional limitations did not vary in their use of CAM when
their access to health care was restricted by cost, whereas those
without limitations who did experience difficulties accessing
health care due to cost were more likely to use CAM. These
findings are similar to those of Carlson etal. [23]. They showed
that CAM practitioner use was, though not significantly, associated with younger age among adults with cerebral palsy,
multiple sclerosis, and arthritis [23]. In contrast, researchers
studying working-age adults with physical disabilities found
no association between CAM use and age [4].
We found that CAM use was not affected by restricted
health care access due to cost among adults with functional
limitations; yet, cost was an important variable for those without limitations, which may be partially explained by the higher
rates of health insurance coverage among adults with disabilities [35]. For example, in the general US adult population aged
18 to 64 years, CAM use is more prevalent among those with
private health insurance than those with public health insurance or the uninsured; and among those aged 65 years or older,
CAM use is more prevalent among those with private or public
health insurance than the uninsured [2]. Adults with disabilities
are more likely than those without disabilities to have public
health insurance, which may not offer the same range of benefits (e.g. CAM therapies) as employer-sponsored health plans
[35]. It is also plausible that a higher proportion of the CAM
therapies used by adults with functional limitations have been

134 C.A. Okoro etal.

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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