Complementary and Alternative Medicine: Canadian Physiatrists Attitudes and Behavior

Transcription

1 662 Complementary and Alternative Medicine: Canadian Physiatrists Attitudes and Behavior Gordon D. Ko, MD, David Berbrayer, MD ABSTRACT. Ko GD, Berbrayer D. Complementary and alternative medicine: Canadian physiatrists attitudes and behavior. Arch Phys Med Rehabil 2000;81: Objective: To document the prevalence and patterns of knowledge about, referrals to, training in, and practice of complementary and alternative medical therapies and their perceived effectiveness by a sample of Canadian physiatrists. Design: Cross-sectional survey by written questionnaire. Setting: Physiatrists in the province of Ontario, Canada. Subjects: All 116 physiatrist/rehabilitation specialists listed in the Ontario Medical Association directory. Data were obtained from 98 respondents. Main Outcome Measures: Statistical analysis of responses in these areas: attitudes, knowledge, and recommendations about alternative therapies, and clinical approach including referral pattern, training, and practice of alternative medicine. Results: Of the respondents, 72% reported referring patients for alternative medicine therapies, and 20% had training in and 20% practiced some form of alternative medicine. The therapies rated highest in usefulness were acupuncture (85%), biofeedback (81%), and chiropractic (80%). Sixty-three percent believed that alternative medicine had ideas and methods that would be of benefit to physiatrists. Only 9% believed it to be a threat to public health. A greater proportion of physiatrists who refer were women, were younger, had graduated more recently, and scored higher in their ratings of more useful alternative medicine therapies. Previous training in alternative medicine was correlated with a higher practice rate but not with referral rate. Practice profile and academic affiliation were not associated with greater or less use of alternative medicine. Conclusion: In Ontario, physiatrists report greater knowledge of and more use of alternative medicine therapies than do general practitioners. The most commonly used therapies are acupuncture, biofeedback, and manipulation (chiropractic, osteopathy). It is recommended that these approaches be taught in physiatry residency training and be the focus of future research. Incorporating such therapies into practice will help to meet the public demand for such approaches in the decade to come. Key Words: Alternative medicine; Acupuncture; Biofeedback; Chiropractic; Fibromyalgia; Rehabilitation by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation From the Department of Medicine, Division of Physiatry, Sunnybrook and Women s College Health Science Centre, University of Toronto, Toronto, Ontario, Canada. Submitted March 12, Accepted in revised form August 26, Supported by a research grant from PhytoPharmacia Inc. to fund the survey printings and mailings, statistical analyses, and donations. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprints requests to Dr. Gordon Ko, Complementary Medicine Research Coordinator, Room CG24, Sunnybrook and Women s College Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation /00/ $3.00/0 doi: /mr OMPLEMENTARY AND alternative medicine C(CAM) refers to treatments that are generally not used or recommended within the context of [the] mainstream biomedical community. 1 Over the past few decades, there has been a growing demand for CAM. A recent random telephone survey of 2,055 adults by Eisenberg and colleagues 2 found that 42.1% of adults in 1997 had used CAM during the previous year. This is an increase from 33.8% of adults in an earlier 1990 study. 3 It was also extrapolated from these studies that total visits to CAM practitioners increased from 427 million to 629 million, thereby exceeding total visits to all US primary care physicians. Estimated expenditures for such services reveal a 45.2% increase to $21.2 billion in The total out-of-pocket expenditures for CAM, including costs of herbal therapies, megavitamins, diet products, CAM literature, and equipment, was conservatively estimated to be $27.0 billion. This figure compares to the expenditures for all US physician services in the same year of $29.3 billion. Another survey of 1,035 adults in the US noted 40% used CAM and identified predictors of such use as being greater education, poorer health status, holistic orientation to health, and cultural factors; dissatisfaction with conventional medicine was not predictive of CAM use. 4 CAM use has also been evaluated in various patient subgroups. A recent Portland, Oregon, study of family practice patients reported 50% use. 5 An earlier 1988 study of gastroenterology patients noted a 27% use. 6 More recent studies of rheumatology patients documented 40.7% and 66% use of CAM. 7,8 In the physiatric managed population, a survey of 401 working-age individuals with physical disabilities found that 57.1% used at least one CAM in the previous year. 9 A lower percentage of 29.1% of rehabilitation outpatients reported such use in the previous year. 10 In Europe, CAM use appears high, with estimates of 56% of Belgians using homeopathy, 48% of Swedes using manipulation therapy, 24% of Britons using herbs, and 21% of French using acupuncture. 11 In Australia, 48.5% use at least one form of CAM. 12 From the recent, larger surveys, 2-4 it was concluded that the most significant increases in CAM use were for patients with musculoskeletal problems and arthritis. The highest condition-specific rates were for neck (57.0%) and back (47.6%) problems. These are conditions commonly seen in physiatric practice. Several studies have investigated physician attitudes toward CAM. A 1990 Canadian study 13 of 400 general practitioners found that 54% make referrals and 16% practice CAM. The perception of usefulness was rated (highest first, in descending order): acupuncture, chiropractic, hypnosis, osteopathy, herbal medicine, faith healing, homeopathy, naturopathy, and reflexology. A 1993 study of Quebec General Practitioners found the same top three CAM therapies with a higher referral rate of 68%. 14 A recent review of physician referral for CAM found similar rates for American studies with acupuncture (51% referral rate) and chiropractic (57%) being the top two therapies. 15 Earlier studies on European physicians found even higher referral and practice rates of CAM use. In Germany, 95% of physicians use at least occasionally herbalism, neural therapy, and homeopathy. 16 As of 1993, the teaching of herbal medicine

2 ALTERNATIVE MEDICINE AND PHYSIATRISTS, Ko 663 is mandatory in all German medical schools. Medical students there must successfully pass the phytotherapy portion of their board examinations in order to practice medicine. 17 In the Netherlands, a survey of 360 physicians found that 90% make referrals for CAM, and 47% practice some form of it. 18 Two studies on New Zealand physicians found that 69% and 77% make such referrals. 19,20 A 1993 study in the United Kingdom found that 93% of general practitioners make referrals and 20% practice CAM. 21 This is a considerable increase from an earlier estimate of 76% in A recent meta-analysis, however, did not demonstrate a trend to suggest that CAM is increasingly perceived as useful by physicians there. 23 From this introductory review, it is noted that physicians in North America generally have lower CAM referral and practice rates than their European and Australasian counterparts. With the increasing demand for CAM by the public here, it becomes all the more important for physicians at least to be knowledgeable about such approaches. This was also stressed in recent work on specialists. 24 Most of the above studies surveyed family physicians. To date, there has been no study published reporting physiatrists attitudes towards CAM. METHOD Design Our survey was patterned after previous studies 13,14,18-20 on physician attitudes and CAM. A covering letter stated the objectives of the study. The four-page survey started with Attitudes Toward Alternative Medicine. For each opinion, the surveyed person was asked to check one of five responses: strongly agree, agree, neutral, disagree, or strongly disagree. This was then followed by another page asking about selfperceived knowledge and usefulness (including adverse effects) about the following 14 therapies: acupuncture, biofeedback, chelation, chiropractic, craniosacral therapy, faith healing, herbology, homeopathy, hypnosis, naturopathy, neural therapy, osteopathy, prolotherapy, and reflexology. In addition, we inquired about the commonly used supplement glucosamine sulphate and the popularized Zone diet. The third page dealt with the respondent s opinions about whether each therapy should be made available in the local hospital, be taught in medical school, and be covered by private or provincial (universal) insurance plans. The last page asked about clinical approach to CAM such as referral rate, training, and practice. Demographics such as sex, age, year of qualification in physiatry, and practice type/profile were also recorded. The survey was mailed to every physiatrist listed in the Ontario Medical Association directory. Each survey was mailed out with a stamped return envelope. Results were tabulated and analyzed by the Department of Biostatistics at Sunnybrook Health Science Centre in Toronto, Ontario, Canada. The SAS version 6.12 software was used for this analysis. Sampling For the Ontario study, 116 surveys were mailed out in June To improve the return rate, a second mailing was sent to the same group in early September By November 1998, 101 surveys had been returned, for a response rate of 87.1%. To encourage survey completion, an incentive was given in the form of a donation to be made on behalf of the respondent to a recognized charity or research foundation. Of the 101 surveys received, 3 were excluded because they were returned completely blank. This left 98 surveys completed by rehabilitation specialists. Men outnumbered women by 67 to 31. The mean age was 49.7 years, with the youngest at 28 years and the oldest 80 years. The year of qualification in physiatry and place of medical school training were recorded. The oldest graduate was reported in Four physiatrists were mostly retired. The overwhelming majority had completed their medical school in Canada. The type of practice was full-time academic in almost one fourth of respondents, part-time academic in another one fourth, and nonacademic (group or solo) in the remainder. Respondents also estimated the percentage of practice engaged in different fields of physiatry (eg, independent medicolegal evaluations, chronic pain management, industrial medicine, spinal cord injury, electromyography, and nerve conduction studies). RESULTS The 98 respondents in this study rated their approach to CAM as follows: 71.9% referred their patients to CAM practitioners (12.5% often); 20% reported they had previous training in some form of CAM; and 19.8% practiced some form of CAM (cited therapies included biofeedback, acupuncture, manipulation, and prolotherapy). The attitudes of the majority tended to favor CAM as a useful supplement to conventional medicine and as having beneficial ideas and methods for the physiatrist (table 1). Only 38.8% believed that CAM worked by placebo effect and 9.2% believed it was a threat to public health. When asked about controversial syndromes, the majority agreed that a real disabling condition applied for fibromyalgia (54.6%) and for chronic fatigue syndrome (51.0%). Only 21.4% agreed that multiple chemical sensitivities syndrome is disabling. A wide variety of treatments were recommended for fibromyalgia, involving 14 different types of CAM. In terms of CAM therapies (table 2), respondents ranked the top five highest for: perceived usefulness (acupuncture biofeedback chiropractic hypnosis herbalism); personal Table 1: Physiatrists Attitudes Toward CAM Attitude Agree and Strongly Agree Neutral Disagree and Strongly Disagree CAM practitioners should be fully qualified and licensed by law separately in each of their disciplines. 70 (71.4) 14 (14.3) 14 (14.3) CAM includes ideas and methods from which physiatrists could benefit. 62 (63.3) 20 (20.4) 16 (16.3) Treatments not tested in a scientifically recognized manner should be discouraged. 53 (54.1) 27 (27.6) 18 (18.3) CAM is a useful supplement to regular medicine. 49 (50.5) 36 (37.1) 12 (12.3) Most CAM treatments stimulate the body s natural therapeutic powers. 17 (17.3) 49 (50.0) 32 (32.6) CAM results are usually due to placebo effect. 38 (38.8) 34 (34.7) 26 (26.5) CAM is a threat to public health. 9 (9.2) 34 (34.7) 55 (56.2) Results reported as n (%) of physiatrists.

3 664 ALTERNATIVE MEDICINE AND PHYSIATRISTS, Ko Approach I Know a Lot About It Table 2: Knowledge of CAM Approaches Perceived as Useful Very Useful Occasionally Useful Perceived as Not Useful Has Significant Adverse Effects Acupuncture 35 (35.7%) 83 (84.7%) Chiropractic 49 (50.0%) 78 (79.6%) Biofeedback 46 (46.9%) 79 (80.6%) Osteopathy 29 (29.6%) 54 (55.1%) Craniosacral 30 (30.6%) 28 (28.6%) Glucosamine sulphate 26 (26.5%) 62 (63.3%) Hypnosis 24 (24.5%) 65 (66.3%) Homeopathy 19 (19.4%) 38 (38.8%) Herbal medicine 15 (15.3%) 56 (57.1%) Naturopathy 13 (13.3%) 34 (34.7%) Prolotherapy 13 (13.3%) 14 (14.3%) Faith healing 12 (12.2%) 38 (38.8%) Reflexology 12 (12.2%) 17 (17.3%) Chelation 9 (9.2%) 16 (16.3%) Zone diet 6 (6.1%) 8 (8.2%) Neural therapy 5 (5.1%) 11 (11.2%) Others 16* * Therapeutic touch (2), Levitor back brace, Qi Gong, Massage therapy (4), Aromatherapy, European spa therapy, magnetotherapy (3), Shiatsu (2), crystals, colonic irrigation, therapeutic electrical stimulation, mindfulness meditation, thought field therapy, orthopaedic physiotherapy, iridology. knowledge (chiropractic biofeedback acupuncture craniosacral osteopathy); and recommended teaching in medical school (acupuncture biofeedback osteopathy chiropractic hypnosis). More than one third of respondents recommended that acupuncture and biofeedback be made available in local hospitals (table 3). Almost one third responded that acupuncture, biofeedback, and chiropractic be covered by the provincial health insurance plan. Table 4 outlines demographics that are associated with CAM referral. There was a higher referral rate by women physiatrists (86.7%) than men (65.2%). This achieved borderline statistical significance ( p.054). Younger and more recently graduated physiatrists were also more likely to refer (high significance). There was a tendency for nonacademic physiatrists in group practices to refer more (not statistically significant). Previous training in CAM and practice profile did not demonstrate any Table 3: Attitudes About CAM Taught in Medical School CAM Should Be: Made Available in Local Hospital Paid by Private Insurer Paid by OHIP (Provincial Plan) Acupuncture 43 (43.9%) Biofeedback 33 (33.7%) Osteopathy 23 (23.5%) Chiropractic 21 (21.4%) Hypnosis 20 (20.4%) Herbal Medicine Chelation Prolotherapy Craniosacral Homeopathy Naturopathy Glucosamine sulphate Neural therapy Faith healing Reflexology Zone diet significant associations with CAM referral. Physiatrists who reported a higher number of useful CAM therapies were also more likely to refer their patients for CAM. For physiatrists who practice CAM (table 5), there were statistically significant associations with previous training in CAM, with increased knowledge of and usefulness ratings of CAM therapies. No significant associations were made between these variables (and demographics) and those who recommended teaching in medical school. DISCUSSION The attitudes and behavior of Ontario physiatrists appear to be supportive toward CAM, with more than 63% agreeing that such ideas and methods could benefit physiatrists. Only 9% felt that CAM was a threat to public health. This contrasts with the earlier 1990 study of Canadian family physicians that found 21% felt that CAM was a threat. 13 Of the various CAM therapies, physiatrists in our study reported knowing more about chiropractic, biofeedback, and acupuncture. Earlier studies found that Canadian general practitioners knew more about chiropractic, acupuncture, and hypnosis. 13,14 English doctors knew most about osteopathy, acupuncture, homeopathy 21 ; New Zealand doctors about acupuncture, chiropractic, and hypnosis 19 ; and Dutch doctors about homeopathy, chiropractic, and acupuncture. 18 Ontario physiatrists know more about biofeedback probably because it is taught in residency training and is used in the treatment of neuromuscular disorders. 25,26 This was also reflected in ratings of perceived usefulness (with acupuncture highest, followed by biofeedback, chiropractic, and osteopathy). The percentage of physiatrists in this study that refer patients to CAM practitioners (71.9%) is higher than Canadian general practitioners (54%) but below those for European physicians (rates are as high as or greater than 90%). Reasons for the higher knowledge and rates of referral to CAM practitioners in physiatrists, compared with family physicians, may include: (1) wider scope of training with knowledge of nondrug therapies such as physical therapy modalities (ultrasound, transcutaneous electrical nerve stimulation, laser, etc) and manual therapies; (2) greater exposure to patients with chronic physical disabilities who themselves report high

4 ALTERNATIVE MEDICINE AND PHYSIATRISTS, Ko 665 Table 4: Respondent Characteristics Versus Refer or Not to CAM Practitioners Variable Refer Do Not Refer p Value Total Sex M (66) Continuity adjusted F (30) 26 4 p Age, mean SEM yrs yrs p.02 Year of qualification in physiatry, mean p.008 ( 1.40yrs) ( 2.69yrs) Type of practice Solo Continuity adjusted 2.88 Group 14 3 p.35 (NS) Academic (Part-time, 21) (Part-time, 2) % Of practice involving independent medicolegal assessments, mean p.42 (NS) (ref, 66; no ref, 23) Trained in CAM? Yes (18) 16 2 No, want training (27) No, do not want training (48) p.08 (NS) No. of CAM approaches perceived as useful, mean SEM p.005 Abbreviations: SEM, standard error of the mean; NS, not significant; ref, refer; no ref, do not refer. rates of CAM use 9 ; and (3) greater exposure to the populations with the highest reported rates of CAM use 2 individuals with back pain (24%), fatigue (16.7%), arthritis (16.6%), headache, neck pain, sprains/strains, and insomnia. Thus, 7 of the top 10 conditions in such patients are typically seen in general physiatric outpatient practice. Physiatrists should become familiar with current literature (randomized clinical trials) on CAM. Studies have been published on the effectiveness of acupuncture, 27 biofeedback, 28,29 and manipulation. 30 There are also published double-blind randomized clinical trials for prolotherapy, 31 homeopathy, 32 and even intercessory prayer. 33 Guidelines for advising patients using CAM have been put forward in recent papers One Dutch study suggests that open-minded physicians have more satisfied outpatients whether or not they use CAM. 37 In our study, CAM referrals and utilization also appear to be higher in younger, more recently graduated physiatrists. There is also borderline statistical significance that women physiatrists have a greater referral rate. Similar gender preference was also noted in a previous study of general practitioners that found women were more likely to perceive CAM as being useful and more likely to want training in acupuncture. 14 Higher use in well-educated women is also reported in studies on the public. 2,3 Our results also revealed that training in CAM is correlated with higher CAM practice but not with referral rates. As Table 5: Respondent Characteristics Versus Practice CAM Variable Practice Do Not Practice p Value Total Sex M Continuity adjusted F 3 24 p.29 (NS) Age, mean SEM yrs yrs p.46 (NS) Year of qualification in specialty p.62 (NS) ( 2.71yrs) ( 1.59yrs) Type of practice Solo 3 24 Continuity adjusted 2.10 Group 7 9 p.75 (NS) Academic 8 36 (P/T 7) (P/T 17) % Of practice involving independent medicolegal assessments p.25 (NS) Trained in CAM? Yes (18) No, want training (27) 4 23 p.001 No, do not want training (44) 2 42 No. CAM approaches perceived as very useful, mean SEM p.02 (pract, 18; no pract, 73) (For occasionally useful, p.59) No. of CAM approaches not useful p.02 No. of CAMs about which a lot is known, mean SD p.05 Refer to CAM practitioners? Yes Continuity adjusted 2.27 No 4 23 p.60 (NS)

5 666 ALTERNATIVE MEDICINE AND PHYSIATRISTS, Ko expected, the greater the rating of CAM usefulness, the higher the referral and practice rates. No correlation was noted with particular practice profile (IMEs, chronic pain, etc). Although there was a tendency for academic physiatrists to refer less, this was not statistically significant. The results of the present study should be interpreted cautiously. Reliability and internal and external validity of the questions need to be evaluated in future studies. Not all parts of the survey were completed fully by every single respondent. Future studies could look at the influence of inpatient versus outpatient practices, neurorehabilitation versus musculoskeletal/ pain groups, ethnicity, and personal CAM use by physicians 36 on CAM referral behavior. We will also present a comparative study with American physiatrists in the near future. CONCLUSION Recommendations for teaching CAM in medical school scored highest for acupuncture, biofeedback, and manipulation therapies (chiropractic and osteopathy), which suggests that physiatry residency programs should include structured teaching in these areas. Herbal medicine was a surprising next highest recommendation. In view of the increasing use of herbals by the public and the reports of adverse effects and drug interactions, it would be prudent for physiatrists to get training in this area. Also, more than 60% of our respondents rated glucosamine sulfate as useful. Scientific literature supporting this should be reviewed and guidelines implemented. 42 We therefore recommend that our physiatric residency programs incorporate training in not only biofeedback, but also these other alternative therapies. DeLisa in his recent lecture 43 suggested that our specialty is too broad-based, not tied to one organ system (though linked by the pillars of function, modalities, and disability), and that we look at adopting skeletal muscle as our organ system. If this is to be the case, then (in addition to drugs, surgery, exercise, orthotics, and traditional physiotherapy modalities), physiatrists should assist in the scientific study of acupuncture, biofeedback, manipulation, and nutritional approaches, all of which have direct effects on skeletal muscle. We should incorporate into training and practice those techniques that have demonstrable benefit. Acknowledgments: Statistical analyses were conducted by biostatisticians Dr. John Paul Szalai and Mr. Marko Katic. References 1. Shiflett SC, Schoenberger NE, Diamond BJ, Nayak S, Cotter AC. Complementary and alternative medicine. In: DeLisa JA, Gans BM, editors. Rehabilitation medicine: principles and practice. 3rd ed. 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