Conventional and Complementary Health Care Approaches Used by American Adults Reporting Joint Pain: Patterns from the National Health Interview Survey 2012

Introduction

Joint pain (e.g., knee, hip, and shoulder) is among the most frequent types of chronic pain reported in the U.S. population. ¹ The Centers for Disease Control and Prevention (CDC) reported that approximately one fourth (27.2%) of adults with arthritis had severe joint pain in 2014, whereas other estimates range up to 43%. ^1,2 Many individuals with joint pain may present with a diagnosis of arthritis, rheumatoid arthritis, or another joint condition. However, not all self-reported joint pain meets diagnostic criteria for a joint condition and not all individuals with joint pain seek help from a health care provider. ²

Joint pain management consists of conventional health care (CH), complementary and alternative medicine (CAM), and integrative health care (IH) approaches. CH approaches include pharmacologic therapies that include medications specific for pain and inflammation, and nonpharmacologic therapies such as protection, rest, ice, compression, elevation, simple office procedures, and physical therapy. ³ CAM approaches include acupuncture, chiropractic and osteopathic manipulative treatment, food supplements, mind–body therapies, homeopathy, and energy healing therapies. ⁴ IH involves the coordination of evidence-based CAM approaches alongside CH to manage disease conditions in a more holistic manner. ⁵

Few studies have examined CH, CAM, and IH implementation patterns among joint pain sufferers. Two non-U.S. multihospital studies estimated between 4% and 14% of hip and knee pain sufferers used CAM or IH approaches. ^6,7 Given the high joint pain prevalence in the United States, a description of treatment-seeking patterns is needed for better health care planning. Sound IH treatment requires CH and CAM practitioners to understand what other treatments their patients are receiving. This study describes self-reported CH and CAM use patterns among U.S. adults reporting joint symptoms using a large nationally representative data set. The authors are not aware of other national studies that have examined CH and CAM use patterns for a specific condition or symptom group, with focus on areas of overlap versus exclusive use of one type of health care.

Materials and Methods

The National Health Interview Survey (NHIS) is a cross-sectional, nationally representative health survey that samples the U.S. civilian noninstitutionalized household population. ⁸ In 2012, the Adult Alternative Medicine NHIS subsample asked 34,525 adult respondents to report individual CAM modalities they had used in the past 12 months, and for each CAM modality, they were asked to report the top three conditions for which it was used. We defined those using CAM for joint symptoms as those who reported using any CAM modality for arthritis, rheumatoid arthritis, gout, lupus, fibromyalgia, or other joint pain. Among the CAM supplement respondents, ∼30% (n = 10,964) self-reported joint symptoms (pain, aching, or stiffness) in the previous 30 days (excluding neck or back pain). A follow-up question asked whether the pain began >3 months previously.

We defined “acute pain” as symptoms that began <3 months ago, versus “chronic pain,” when symptoms began earlier than 3 months ago. Among those reporting joint pain, a follow-up question asked individuals whether they sought care from a doctor or other health care provider specifically for that pain. This question allowed us to identify individuals who reported seeking CH for joint pain. We combined responses from the above questions to create four comparison groups, including whether they sought treatment for their joint condition or symptoms through: (1) CH-only (or “CH”); (2) CAM-only (or “CAM”); (3) both CH and CAM; or (4) no treatment at all. Examining this subgroup of joint pain sufferers provided a unique picture of CH and CAM treatment choices in the population. The study used publicly available deidentified data and did not require institutional review board approval.

Results

Table 1 describes the type of care sought by acute and chronic joint pain sufferers. Roughly 64% of all joint pain sufferers sought help only from a CH, 26% sought out neither CAM nor CH, and 8% used both CH and CAM. The smallest group for health care seeking among joint pain sufferers were those who sought CAM only (1.6%). Over 10% of chronic joint pain sufferers used CAM compared to ∼6% of those reporting acute pain.

Table 2 compares demographic and health characteristics by type of health care sought for joint pain. Those using both CH and CAM were older and more likely female versus those using CAM. CAM users were less often obese, more likely to report very good or excellent health, and reported fewer comorbidities versus those using CH or both CH and CAM. Over 75% of those using both CH and CAM reported a joint condition diagnosis compared with roughly one quarter of CAM-only users.

Discussion

A majority of chronic joint pain sufferers reported only seeking care from CH, whereas a majority of acute joint pain sufferers reported seeking no treatment at all. Approximately 10% of chronic joint pain sufferers sought CAM (either alone or combined with CH) for a joint condition compared with 75% who sought CH for their pain. Eighty-three percent of those using CAM for a joint condition additionally reported seeking care from a CH provider, and alternately, 11% of those who reported seeing a CH practitioner for joint symptoms also reported CAM use for a joint condition. Since respondents were not asked if CAM treatments were coordinated with their CH provider, we did not formally classify these individuals as using IH.

Past research identified that 36% of arthritis sufferers reported CAM use in NHIS 2012, but that study reported use of CAM for any condition rather than specifically for joint-related symptoms or conditions. ⁴ Another study using NHIS 2002 data showed that 4.9% of American adults reported using CAM for joint pain or stiffness. ⁹ Although our study found ∼10% prevalence of CAM use for joint conditions, this number is not directly comparable with the aforementioned study, as this study examined only the subpopulation reporting recent joint symptoms. Nonetheless, NHIS data suggest that a number of CAM modalities, including yoga, homeopathy, acupuncture, and naturopathy, have increased in use from 2002 to 2012. ¹⁰

Past research shows that among individuals reporting musculoskeletal pain disorders in NHIS 2012, practitioner-based treatments were the most commonly used CAM modalities, ¹¹ although, relevant to this study, these techniques were used significantly less among arthritis and joint pain sufferers. ¹¹ This highlights the fact that CAM use across related conditions is not uniform, and sound IH coordination requires careful assessment by CH practitioners to ascertain different types of CAM used. Different from other musculoskeletal pain disorders, individuals with arthritis or other joint pain may use natural products or mind–body therapies as much or more than practitioner-based CAM. ¹¹

The fact that most CAM users for joint conditions have also visited a CH practitioner for joint symptoms highlights the need for coordinated IH care when managing painful joint conditions. CH practitioners should inquire about their patients' CAM use and abstain from negative judgment about it, especially when CAM treatments prove beneficial to the patient. ¹² Stigmatization of CAM by CH practitioners could produce the unintended consequence of patients underreporting CAM use, thereby missing the opportunity for coordinated IH. Further, more research is needed to understand how CH and CAM can be coordinated in an evidence-based manner to most effectively treat joint pain and associated conditions. ¹²

NHIS is a rich national data set for exploring health care seeking among joint pain sufferers in the United States, but relies on self-report for joint pain identification. Further, the NHIS questionnaire did not ask respondents about managing joint pain with prescription medication. Given the prevalence of both prescription and nonprescription opioid use during the 2012 data collection, the lack of this information constrains our understanding of how these care seeking patterns have changed as the opioid crisis has gained visibility. ¹³

Conclusions

This study reports CH and CAM use patterns for over 10,000 acute or chronic joint pain sufferers in a nationally representative sample of U.S. adults. It is among the first large population-based studies describing CH and CAM patterns specifically for joint pain, examining proportions seeking one type of care exclusively compared with those using both or neither. Future research and new data are needed to explore how these patterns may change over time as CAM and IH use becomes more widespread in the United States and as opioid-based pharmaceutical therapies become more restricted. By better understanding these dynamics, health care providers stand to improve IH coordination and delivery for joint pain management.