The Period Prevalence of Mind and Body Practice Use by Adult Emergency Department Patients

Introduction

The national center for Complementary and Integrative Medicine defines “complementary health approaches” as practices and products of nonmainstream origin. ¹ Most approaches are either “natural products” or “mind and body practices” (MBP) and are either complementary to or, less commonly, alternatives to conventional medicine. ¹

Natural products include herbs, vitamins and minerals, and probiotics. ^1,2 MBP comprise a wide range of techniques including yoga, chiropractic and osteopathic manipulation, meditation, acupuncture, relaxation techniques, tai chi, healing touch, hypnotherapy, and movement therapies. ^{1 –4} Traditional Chinese Medicine (TCM) is also a form of mind-body practice and includes acupuncture, Chinese herbal medicine, Tai chi, Qi Gong, and exercise and diet therapies. The unification of mind and body is one of the key theoretic principles of TCM and guides clinical diagnosis and treatment. However, some other approaches do not fit well into either of these groups for example, traditional healing, homeopathy, and naturopathy.

The distinction between natural products and MBP is often not clear. Natural products include substances procured by the individual and self-administered, and those prescribed by mind-body therapists. Alternatively, MBP include therapies administered mechanically, prescribed, or taught to the individual, in addition to therapies that may be practiced without specific teaching for example, meditation. Accordingly, therapies within both groups include both self- and therapist-administered approaches.

The use of complementary health approaches is common. ^2,5,6 In 2007, it was estimated that Australian taxpayers spent approximately $4.1 billion per annum on them. ⁵ Persons most likely to utilize complementary health approaches are highly educated and employed women, aged 18–34 years with private insurance and higher than average incomes. ^7,8 It has been speculated that patients with these demographics are more inclined to use these approaches due to financial access and self-education of personal medical ailments. ^5,7 Other predictors of use include certain health problems (anxiety, back problems, chronic pain) and spiritual and cultural interests. ⁹ Symptom relief is most commonly stated as the major benefit although use is generally not associated with dissatisfaction with conventional medicine. ⁸

The 2012 National Health Interview Survey (NHIS) ² reported that 17.7 percent of American adults had used a dietary supplement in the past year. In the emergency department (ED) setting, Taylor et al. ¹⁰ reported that up to 68% of patients used at least one natural product in the previous 12-month period. Users had perceptions that natural products were safe to use, prevent the onset of an illness, allow control over one's health, treat the mind, body, and spirit, and are more efficacious than prescription medications. ¹¹

Although the use of MBP is also common, ² research into their use varies considerably. While acupuncture, yoga, spinal manipulation, and meditation have been extensively investigated, other MBP have attracted less interest. ¹ To date, the use and perceptions of MBP, as distinct from natural products, have yet to be explored in the ED setting. This study aimed to determine the nature and period prevalence of MBP use among ED patients, their perceptions of MBP use and whether patients had disclosed their use to their ED doctor. The findings will inform the way that ED doctors should account for MBP use among their patients.

Materials and Methods

We conducted a voluntary, anonymous, cross-sectional survey in the EDs of three tertiary referral hospitals (Austin, St Vincent's, and Royal Melbourne) in metropolitan Melbourne, Australia. Data were collected between February and July 2016, inclusive. Ethics Committee approval was obtained at each site.

Patients were eligible for inclusion if they were aged 18 years or more and had presented for medical treatment. They were excluded if the ED staff considered their participation to be inappropriate (e.g., medically unstable, agitated, in considerable pain) or if they were unable to read and/or complete the study questionnaire.

A convenience sample of eligible patients was enrolled when an investigator was available in the ED (generally 0800-2000, weekdays). Suitable patients were identified through the ED electronic patient log and by the ED staff. After the initial assessment by their ED physician, an investigator briefly explained the project and invited the patient to participate. After completion of the questionnaire, the patient was asked to place all parts (whether completed or not) into a designated box in close proximity to the ED cubicles. Any questions or assistance required before, during, or following completion of the questionnaire was provided upon request by the investigator (e.g., explanation of a question). Completion of the questionnaire took approximately 10 min. Assistance from family or friends was permitted but rarely required.

The survey was voluntary and anonymous with no identifying information (e.g., names, patient number) collected. Completion of the questionnaire was deemed as implied consent to participate and no further involvement of the participant was required. All data were collected using the questionnaire only.

The study questionnaire was based on one validated and utilized during a similar study in a pediatric population. ¹² The pediatric questionnaire was slightly revised for adult use, trialed for face validity on 10 adult ED patients and revised accordingly (Appendix 1). The questionnaire collected basic demographical data (including age, gender, ethnicity), medical history, presenting complaint, and medications. A list of 40 MBP commonly reported in the medical literature was presented and patients were asked to report their use of these, and any other MBP, in the previous 12 months. A MBP course was defined as a discrete episode of use that may have comprised either single or multiple sessions under the direction of a therapist. Data were also collected on perceptions of MBP use and their effectiveness.

The primary outcome was the nature and 12 month period prevalence of MBP use. Secondary outcomes were variables associated with use and patient perceptions of MBP.

The 12 month period prevalence of MBP use among ED patients is not known. Based upon natural product use, we expected use would range between 40% and 60%. To be 95% sure that the prevalence would fall within ±4% of the extremes of this range (i.e., 36%–64%), a sample size of least 625 patients was required. This would provide a rich database that allowed a determination of period prevalence and was sufficient to allow statistical comparisons between patient subgroups. The data were mostly analyzed descriptively. Comparisons between patient subgroups (males/females, MBP users/non users, ancestry groups) were undertaken using the Chi square, Student's t, and Mann–Whitney U tests. SPSS for Windows statistical software (version 22.0; SPSS, Inc., Chicago, IL) was used for all analyses. The level of significance was 0.05 and two–tailed tests were used.

Results

Of 734 patients invited to participate in the survey, 674 (91.8%) were enrolled. The three EDs enrolled 463, 122, and 89 patients: men 200 (64.1%), 71 (22.8%), and 41 (13.1%), respectively; mean age 48.8, 40.3, and 45.8 years, respectively.

The mean (SD) patient age was 46.9 (18.7) years, 312 (46.3%, 95%CI 42.5, 50.1) were male and 396 (58.8%, 95%CI 54.9, 62.5) identified as having Australian ancestry. Three hundred and seventy (54.9%, 95%CI 51.1, 58.7) patients had a chronic disease and 363 (53.9%, 95%CI 50.0, 57.7) had private health insurance (Table 1). The most common presenting complaints were trauma 118 (17.5% patients), chest pain 104 (15.4%), and abdominal pain 103 (15.3%).

Five hundred (74.2%, 95%CI 70.7, 77.4) patients reported using at least one MBP within the previous 12 months (Table 1). There was no difference in gender or ancestry between users and nonusers. Age was associated with use, with younger patients more likely to be users. Patients with private health insurance were significantly more likely to be users.

A total of 2094 courses of MBP were reported to have been used in the previous 12 months (a mean of 4.2 courses/user). Of the 40 MBP listed on the questionnaire, 338 (16.5%) and 52 (2.5%) courses were used during the week and 24 h preceding the ED presentation, respectively.

The users reported using a total of 68 different MBP (Appendix 2) although 10 may not have been MBP. All 40 MBP listed on the questionnaire, with the exception of prolotherapy, were used. Massage, meditation, chiropractic, acupuncture, and yoga were the most commonly used (Table 2). Some patients reported having used MBP not listed on the questionnaire for example, myotherapy (six patients), kinesiology (5), bowen therapy (3), hijama (cupping) (3), and iridology (2).

The users perceived that massage, chiropractic, and osteopathy were the most important MBP used in the previous 12 months (Table 2). A variety of reasons were given but varied with the practice. The most common reasons included musculoskeletal issues or pain, stress relief/mental health, general well-being, and relaxation.

Overall, 121 (24.2%) users reported that their most important MBP had not been recommended by another person. However, a friend/relative and the patient's doctor recommended the MBP to 145 (29.0%) and 55 (11.0%) users, respectively. Alternative therapists, the media, and pharmacists had recommended the MBP in seven, five, and two cases, respectively. The MBP was recommended by other sources in 56 (11.2%) cases.

Only 18 (3.6%) users reported an adverse effect from their MBP. These included pain/tenderness (n = 7), exacerbation of the condition (2), bruising, (1) and other (3). Five patients did not provide details of the adverse effect. Adverse effects were associated with massage (n = 7), osteopathy (3), naturopathy (2), reiki (1), yoga (1), craniosacral manipulation (1), chi exercise (1), myopathy (1), reflexology (1), and hyperbaric oxygenation (1). Three patients did not describe the MBP associated with the adverse effect.

One hundred and thirty five (27.0%) users reported that no one was aware of their MBP use. However, 119 (23.8%) and nine (1.8%) users had told their family doctor and alternative therapist, respectively. Seventy three (14.6%) users reported that “other” people knew about their use and this was most commonly family/friends.

Forty one (6.1%) of the 52 MBP courses used within 24 h of ED presentation were used in an attempt to manage the ED presenting complaint. However, only 14 (34.1%) users advised their ED doctor of this. Sixty-four (12.8%) users provided a total of 76 reasons for not advising their doctor: “the doctor did not ask” (45 patients, 59.2% of reasons given), “the doctor did not need to know” (15, 19.7%), “alternative therapies [MBP] are harmless” (13, 17.1%), and “the doctor would disapprove” of their MBP use (3, 4.0%).

The perceptions of MBP differed significantly between users and nonusers (Table 3). The users were significantly more likely to agree or strongly agree that MBP prevented illness, treated illness, were more effective than prescription medications, assisted prescription medications, were safe, and provided a more holistic approach than conventional medicine than nonusers.

Discussion

This multicenter, cross-sectional survey found that the 12 month period prevalence of MBP use among ED patients is high, with approximately three-quarters of patients using a mean of four courses from a range of 68 different MBP. To our knowledge, this is the first study to determine the prevalence of MBP use, as distinct from natural product use, among adult ED patients.

The prevalence of MBP use in the community has not been clearly determined, mainly because MBP are often included among studies of natural products. Reports of natural product use among ED patients range between 43.0% and 68.1%. ^10,11,13,14 While our findings indicate that MBP use is substantially higher than these natural product reports, these older studies may not reflect natural product use at the time of this study. One recent report has, however, reported a 12 month period prevalence of MBP use of 48.8% among pediatric ED patients. ¹² This prevalence is substantially lower than we found among adult patients. Although speculative, this may be due to a lack of the child's autonomy or resources, parental views about MBP, or the inappropriateness of some MBP for small children, for example, meditation.

In this study, gender was not associated with MBP use, unlike the association reported between women and natural product use. ¹⁰ Our finding that younger patients were significantly more likely to be MBP users is consistent with natural product studies, which found a similar association between age and natural product use. ^9,10 The trend for chronic disease status to be associated with MBP use is consistent with an ED study of natural product use among children. ¹² Other variables reported to be associated with natural product use include higher education, chronic pain, employment, and higher than average incomes. ^7,9,10,14 These variables were not investigated in this study.

In this study, a very wide range of MBP was reported to have been used, especially massage, meditation, chiropractic, acupuncture, and yoga. These findings are consistent with previous natural product studies (which included MBP) in ED patient populations. ^3,4,14,16,17 They are also consistent with the 2012 NHIS findings that chiropractic, meditation, and massage were among the most commonly used MBP among American adults. ² In our study, massage, chiropractic, and osteopathy were reported to be the important MBP.

The common indications for MBP (musculoskeletal conditions, relaxation, stress, mental health, general well-being) are consistent with those reported from natural product-based studies. ^3,4,8,18 A small proportion (6.1%) of patients had used an MBP to treat their ED presenting complaint. This proportion is less than the 10% reported by Zun et al. ¹⁴ However, as the MBP reported by Zun et al. ¹⁴ were inclusive of home remedies and herbal medicines, this likely accounts for their higher proportion. Li et al. ¹⁷ also reported that natural products, especially herbs, are commonly used to treat ED presenting complaints.

Only approximately one-third of patients who used an MBP to treat their presenting complaint, disclosed its use to their ED doctor. This rate is similar to that reported by Gulla et al. ⁶ but substantially less than the two-thirds reported by Rolniak et al. ¹⁶ Interestingly, the majority of patients in Rolniak et al.'s study who did not disclose their MBP use believed there was no reason to notify the doctor of their use. This contrasts with our study, where the main reason given for nondisclosure was that the doctor did not ask. Importantly, only three patients believed that the doctor would disapprove of their MBP use. These findings hint that ED patients may be willing to discuss their use but are unlikely to do so spontaneously. To be fully informed about their patient's condition and the range of medications and therapies previously used to treat it, it is recommended the ED doctor include MBP use in the medical history taking. Others have also reported that very few patients do actually discuss their use with their treating physician. ^{3 –5} However, as patients are also generally willing to discuss their natural product use ⁹ and it has been recommended that natural product use is included in the medical history. ¹⁰ Further research is recommended to evaluate the safety profiles of MBP and to determine whether the taking of an MBP history affects a change in ED management.

The users' perceptions of MBP were much more favorable than those of nonusers. The users' reports that MBP were more effective than prescription medications, safe, and similar to those previously reported by natural product studies. ^3,11,12,18

This study has important limitations. The convenience sampling and exclusion of various patient subgroups may have introduced selection bias. Whether users were more or less inclined to participate is not known. However, as the survey was anonymous and the response rate high, the impact of participation bias is likely to have been small. The reported use of MBP over a 12 month period is likely to have been affected by recall bias resulting in an underestimation of overall MBP use. Although the questionnaire presented 40 MBPs to aid the patient's memory, a number of other MBP were also used. It is possible that some patients had forgotten about their use of MBP not on the list, resulting in an underestimation of their use. The 10 MBP that may not have been MBP were included in the analyses as the exact nature of these practices is not known, for example, herbs used in herbal therapy may have been ingested as a natural product or used for aromatherapy. Hence, the number of MBP used may be an overestimate. The final page of the questionnaire asked patients to report their reasons for use of their most important practice, its adverse effects, and whether it had been used to treat the ED presenting complaint. As this page was often incomplete, measurement bias may have been introduced. Although the study was undertaken in three large, metropolitan EDs, the findings may not be representative of all EDs across the country. Also, as one ED enrolled the majority of patients, especially male patients, the findings are more representative of this ED's patient population.

Conclusion

This study found that ED patients commonly use MBP, especially massage, meditation, chiropractic, acupuncture, and yoga. Overall, MBP users were more likely to be younger and have private health insurance. There was no association between MBP use and gender, ancestry, or chronic disease. Users were also much more likely to perceive MBP favorably in regard to treating and preventing illness, safety, and in relation to prescription medicines or conventional medicine. Very few patients spontaneously reported their MBP use to the ED doctor. This underreporting was mainly due to failure of the doctor to ask about MBP use. Knowledge of the MBP used for a patient's presenting complaint may better inform the ED physician when making management decisions.