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Home , Musculoskeletal disorder, Neck pain, Pain disorder

National Health Statistics Reports Number 98  October 12, 2016

Use of Complementary Health Approaches for Musculoskeletal Disorders Among Adults: , 2012 by Tainya C. Clarke, M.P.H., Ph.D., National Center for Health Statistics; Richard L. Nahin, M.P.H., Ph.D., National Institutes of Health; Patricia M. Barnes, M.A., National Center for Health Statistics; and Barbara J. Stussman, National Institutes of Health

Abstract Introduction Objective—This report examines the use of complementary health approaches Pain is a leading cause of disability among U.S. adults aged 18 and over who had a musculoskeletal . and a major contributor to Prevalence of use among this population subgroup is compared with use by persons utilization (1). Pain is often associated without a musculoskeletal disorder. Use for any reason, as well as specifically to treat with a wide range of injury and disease. musculoskeletal pain disorders, is examined. It is also costly to the United States, not Methods—Using the 2012 National Health Interview Survey, estimates of the just in terms of health care expenses use of complementary health approaches for any reason, as well as use to treat and disability compensation, but musculoskeletal pain disorders, are presented. Statistical tests were performed to also with respect to lost productivity assess the significance of differences between groups of complementary health and employment, reduced incomes, approaches used among persons with specific musculoskeletal pain disorders. lost school days, and decreased Musculoskeletal pain disorders included lower , , pain, quality of life (2). The focus of this pain or related conditions, arthritic conditions, and other musculoskeletal pain report is on somatic pain affecting disorders not included in any of the previous categories. Respondents could report the body’s musculoskeletal tissues having more than one disorder. (musculoskeletal pain disorders) and the Results—In 2012, 54.5% of U.S. adults had a musculoskeletal pain disorder. use of different types of complementary The use of any complementary health approach for any reason among persons with health approaches by persons who are a musculoskeletal pain disorder (41.6%) was significantly higher than use among affected. In order to better understand persons without a musculoskeletal pain disorder (24.1%). Among adults with any differences in use among this population musculoskeletal pain disorder, the use of natural products for any reason (24.7%) was subgroup, this report compares the use significantly higher than the use of mind and body approaches (15.3%), practitioner- of complementary health approaches based approaches (18.2%), or whole medical system approaches (5.3%). The pattern among those with a musculoskeletal of use of the above-mentioned groups of complementary health approaches was disorder with use among those without a similar for persons without a musculoskeletal disorder. However, prevalence of musculoskeletal disorder. use among these persons was significantly lower compared with persons with a Musculoskeletal pain disorders musculoskeletal disorder. include a wide range of acute and chronic For treatment, the use of practitioner-based approaches among persons with any injuries or inflammatory conditions musculoskeletal pain disorder (9.7%) was more than three times as high as the use of that cause pain in the body’s ; any other group of approaches (0.7%–3.1%). The patterns of use of specific groups of ; muscles; ; ; complementary health approaches also differed among specific musculoskeletal pain and structures that support the limbs, disorders. neck, and back (3). These disorders can impair daily functioning and are some of Keywords: • back pain • sciatica • National Health Interview Survey

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics Page 2 National Health Statistics Reports  Number 98  October 12, 2016 the leading causes of physical disability for treatment of their musculoskeletal previously described (19). The study in the United States (4). Conventional pain disorders. Comparisons are sample included 19,236 adults who medical treatment for chronic also made for persons with specific reported having one or more individual musculoskeletal pain (e.g., nonsteroidal musculoskeletal pain disorders. musculoskeletal pain disorders in the past anti-inflammatory drugs and surgery) 3 months. Respondents were asked not and use of opioids often lack long-term to report aches and that are fleeting benefit or subject patients to other risks Methods or minor. Only persons with pain that (5–7). Consequently, some persons with lasted a whole day or more were included these conditions may seek alternative Data source in these analyses. Questions about the treatment options. Alternative health individual musculoskeletal pain disorders Data from the 2012 NHIS were care interventions (e.g., and discussed in this report are located in the used for this analysis. NHIS is a osteopathic medicine), products (e.g., “Definition of terms” section at the end of nationally representative, cross-sectional herbs and natural products), or practices this report. (e.g., massage therapy and yoga) not household interview survey that is generally considered part of conventional fielded continuously by the National medicine may collectively be referred to Center for Health Statistics and produces Complementary Health annual estimates of the health of the as complementary health approaches. Approaches There is increasing clinical trial U.S. civilian noninstitutionalized evidence for the efficacy of some population. Interviews are conducted in Survey respondents were asked complementary health approaches in respondents’ homes, but follow-ups to about their use of up to 23 named treating specific musculoskeletal pain complete interviews may be conducted approaches in the past 12 months. Use disorders (7). However, there have been over the telephone. A detailed description of complementary health approaches for inconsistencies in the experimental of the 2012 NHIS sample design and any reason was determined by a positive designs and diagnostic criteria used the survey questionnaire is available response to having used or having seen a in patient selection for many of these elsewhere (18). The Household and practitioner for a complementary health clinical trials (7,8). As a result, there is Family Core of NHIS collect health and approach during the past 12 months, some discord among the clinical research sociodemographic information on each regardless of reason for use. For the three community regarding the efficacy of member of all families residing within a most frequently used approaches for each some of these approaches for various sampled household. Within each family, individual, persons were then asked if, musculoskeletal pain disorders (5,7–10). additional information is collected from during the past 12 months, they used the Despite this, examining which groups one randomly selected adult (the “sample specific named approach “for one or more of approaches are being used by persons adult”) aged 18 and over through the specific health problems, symptoms, or with individual musculoskeletal pain Sample Adult Core. The most recent conditions.” Those who responded yes disorders may better inform physician- Adult Alternative Medicine (ALT) were asked “for what health problems, patient dialogue and priority-setting supplement was administered to sample symptoms, or conditions did you see a efforts for clinical researchers. adult respondents in 2012. The ALT practitioner” or use the specific named Data from population-based supplement, sponsored by the National approach. There was no predetermined surveys on the use of complementary Institutes of Health’s National Center for list of conditions for this question, so health approaches in the United States Complementary and Integrative Health interviewers recorded the conditions now span 20 years (11–13). The 2002 (NCCIH), was implemented in order as reported by respondents. This report National Health Interview Survey to provide a national data source on only includes responses to whether the (NHIS) provided the first nationally complementary medicine use. three most frequently named approaches representative estimates of adult use Information on the use of were used for treatment of individual of complementary health approaches complementary health approaches in musculoskeletal pain disorders. Use for based on data collected from in-person the past 12 months was collected from treatment of nonmusculoskeletal pain interviews (14). Since then data on the a sample of 34,525 adults aged 18 disorders was not analyzed separately. use of complementary health approaches and over who participated in the ALT Use of complementary health approaches in the general U.S. population, collected supplement, while the information on for any reason includes use for treatment periodically by NHIS, have been used musculoskeletal pain disorders was of a musculoskeletal pain disorder. by numerous researchers (11,15–17). To obtained from the Sample Adult Core. For this report, the use of any better understand the patterns of use of In 2012, the sample adult response complementary approach includes the complementary health approaches among rate was 79.7%, with 34,525 adults use of one or more of the following U.S. adults with musculoskeletal pain completing the NHIS interviews. during the past 12 months: ; disorders, this report presents estimates The ALT supplement questions are ; Ayurveda; of the use of complementary health embedded in the NHIS sample adult biofeedback; chelation therapy; approaches for any reason, as well as module and are administered to all chiropractic or osteopathic manipulation; estimates for the subset of these adults sample adults. The processes used to energy healing therapy; Feldenkrais; who used these approaches specifically field the ALT supplement have been guided imagery; homeopathic treatment; National Health Statistics Reports  Number 98  October 12, 2016 Page 3 hypnosis; naturopathy; nonvitamin, widespread pain, diffuse tenderness, and mutually exclusive. However, treatment nonmineral dietary supplements; massage a number of other symptoms which result is specific to each disorder. Persons who therapy; meditation; Pilates; progressive in pain in the muscles, ligaments, and responded “no” to having any of the relaxation; traditional healers; Trager tendons). Persons who responded “no” musculoskeletal pain disorders mentioned psychophysical integration; qi gong; tai to having arthritis and “yes” to having were used for comparison of the use of chi; or yoga. joint pain or related conditions were complementary health approaches among Approaches were further grouped categorized as having non-arthritic joint persons with a musculoskeletal pain by similar mode of practice or pain or related conditions. disorder. administration for analyses: natural Sciatica typically refers to pain that Groups of complementary health products (nonvitamin, nonmineral radiates along the path of the sciatic approaches (natural products, mind and dietary supplements and special diets); , which branches from the lower body approaches, practitioner-based practitioner-based (Alexander technique, back through the hips and buttocks and approaches, and whole medicine systems) chiropractic or osteopathic manipulation, down each leg. In NHIS, sciatica was are mutually exclusive. However, an Feldenkrais, massage therapy, and identified by a “yes” response to the individual could use multiple approaches Trager psychophysical integration); question, “During the past 3 months, and could be counted in more than one mind and body approaches (biofeedback, did you have ?” and “Did group of approaches. These persons energy healing therapy, guided imagery, this pain spread down either leg to areas were counted only once for use of any hypnosis, meditation, progressive below the knees?” Only respondents who complementary health approach. relaxation, Pilates, tai chi, qi gong, answered “yes” to both questions were Analyses were conducted using and yoga); and whole medical systems defined as having sciatica. Back pain SAS-callable SUDAAN version 11.0.0 (Ayurveda, acupuncture, homeopathy, was defined by a response to the initial (20), which accounts for the complex naturopathy, and traditional healers). question only. Other musculoskeletal sample design of NHIS. All estimates Information on use of each type of problems include muscle or , for adults were weighted using the approach was collected on an individual or strain, and jaw pain. Persons annual sample weights for adults and, basis. More information about specific could report having more than one so, are representative of the U.S. civilian health approaches is available from musculoskeletal pain disorder. noninstitutionalized population of NCCIH at: https://nccih.nih.gov/health/ adults aged 18 and over. Data weighting integrative-health. procedures are described in more Statistical Analyses detail elsewhere (21). Calculations of estimates excluded persons with missing Musculoskeletal Pain The sample of persons with any musculoskeletal pain disorder included information for musculoskeletal pain Disorders all adults aged 18 and over who disorders or use of complementary responded “yes” to having one or more health approaches. The Taylor series Musculoskeletal pain disorders were linearization method was chosen for examined as a collective group (any named musculoskeletal pain disorders surveyed on the NHIS sample adult estimation of standard errors. Estimates musculoskeletal pain disorder), as well were considered reliable if the relative as individually. The musculoskeletal module. The number of people with a positive response to having one or standard error (RSE) was less than pain disorders examined in this report 30%. Statistical tests performed to include lower back pain without sciatica more of these musculoskeletal pain disorders (19,236) was the denominator assess the significance of differences (this will be referred to as lower back between estimates were two-tailed tests pain), sciatica with back pain (referred for all questions pertaining to use of complementary health approaches among with no adjustments made for multiple to as sciatica), , non-arthritic comparisons. joint pain or related conditions, arthritic persons with any musculoskeletal pain conditions, and other musculoskeletal disorder. The denominator for the use pain disorders not included in any of the of complementary health approaches Strengths and among persons with a specific previous categories. Arthritic conditions Limitations of the Data include several forms of arthritis: musculoskeletal pain disorder was those (an autoimmune who responded “yes” to having that A major strength of these analyses disorder that first targets the lining of specific disorder. Persons who reported is that the data are from a nationally joints [synovium]); (an abnormal using a complementary health approach representative sample of U.S. adults, metabolism of uric acid, resulting in an to treat a musculoskeletal pain disorder allowing for population estimates. The excess of uric acid in the tissues and in the ALT supplement had to respond large sample size allows for estimation blood causing swollen joints); lupus “yes” to having the condition in the past of the use of complementary health (a chronic autoimmune disease that 3 months in the sample adult module approaches among subgroups of U.S. can damage any part of the body [skin, to be included in the numerator of adults with self-reported musculoskeletal joints, or organs inside the body]); or analyses. Respondents could respond pain disorders, both of which are fibromyalgia (a syndrome of common “yes” to having more than one specific collected in NHIS. and chronic disorders characterized by musculoskeletal pain disorder. As such, the specific disorder subgroups are not Page 4 National Health Statistics Reports  Number 98  October 12, 2016

The data in this report also have some limitations. NHIS does not collect information on the specific dates of use of Any musculoskeletal pain disorder 54.5 complementary health approaches or of the incidence date for the musculoskeletal Arthritic conditions 1 pain disorders, so it is not possible to 22.1 determine if use occurred prior to having a musculoskeletal pain disorder. NHIS Lower back pain (without sciatica) 220.3 also does not collect information on Non-arthritic joint pain or simultaneous treatment of these disorders 317.5 with mainstream or conventional other joint conditions medicine. Responses are dependent on 4 participants’ recall of complementary Neck pain or problems 14.3 health approaches that they used in the past 12 months, as well as their Sciatica 59.8 willingness to report their use accurately. Other musculoskeletal problems 28.1 Results 02 040 60 More than 50% of U.S. adults Percent

(125 million) had a musculoskeletal 1Significantly different from all other pain disorder categories, p < 0.05. 2Significantly different from non-arthritic joint pain or other joint conditions, neck pain or problems, sciatica, and other pain disorder in 2012 (Figure 1). Just musculoskeletal problems, p < 0.05. over 20% of U.S. adults had arthritic 3Significantly different from neck pain or problems, sciatica, and other musculoskeletal problems, p < 0.05. 4Significantly different from sciatica and other musculoskeletal problems, p < 0.05. conditions (22.1%) or lower back pain 5Significantly different from other musculoskeletal problems, p < 0.05. NOTE: The denominator used for analysis is the number of U.S. adults aged 18 and over. (20.3%). A smaller percentage of persons SOURCE: NCHS, National Health Interview Survey, 2012. reported having non-arthritic joint pains or other joint conditions (17.5%) and Figure 1. Prevalence of musculoskeletal pain disorders among adults in the past 12 months: neck pain or problems (14.3%), and an United States, 2012 even smaller percentage had sciatica (9.8%). A significant proportion of the population reported having at least one For any reason1 other musculoskeletal problem that was No musculoskeletal pain disorder 24.1 not examined independently (28.1%). Any musculoskeletal pain disorder2 41.6 Arthritic conditions 40.9 The proportion of persons with each Lower back pain 43.0 musculoskeletal pain disorder illustrated Non-arthritic joint pain or other joint conditions 44.2 Neck pain or problems 5,650.6 in Figure 1 are the subpopulations for Sciatica 41.9 subsequent analyses shown in Figures 2–6. Other musculoskeletal problems 46.2 More than 40% of adults with a For treatment1 musculoskeletal pain disorder used a Any musculoskeletal pain disorder2 13.9 Arthritic conditions 4,5,76.6 complementary health approach for Lower back pain 4,810.3 any reason in 2012 (Figure 2). This was Non-arthritic joint pain or other joint conditions 4,5,66.4 significantly higher than use among Neck pain or problems 9.2 Sciatica 11.2 persons without a musculoskeletal pain Other musculoskeletal problems 4.1 disorder (24.1%). Use of complementary health approaches for any reason among 0 10 20 304 050 60 Percent persons with neck pain or problems was 1Any complementary health approach includes acupuncture; Alexander technique; Ayurveda; biofeedback; chelation more than twice as high as use among therapy; chiropractic or osteopathic manipulation; energy healing therapy; Feldenkrais; guided imagery; homeopathic treatment; hypnosis; naturopathy; nonvitamin, nonmineral dietary supplements; massage therapy; meditation; Pilates; persons without these problems. Among progressive relaxation; traditional healers; Trager psychophysical integration; tai chi; qi gong; and yoga. Use for treatment is use specifically to treat a problem, symptom, or disease. Use for any reason includes use for treatment. adults with a musculoskeletal pain 2Includes all musculoskeletal pain disorders surveyed on the 2012 National Health Interview Survey Sample Adult section. disorder, use of any complementary health An individual may have more than one disorder but is only counted once. 3Significantly different from any musculoskeletal pain disorder, < 0.05. approach was highest among those with 4Significantly different from neck pain or problems, p < 0.05 5Significantly different from sciatica, p < 0.05. neck pain or problems (50.6%), followed 6Significantly different from other musculoskeletal problems, p < 0.05. by persons with other musculoskeletal 7Significantly different from lower back pain, p < 0.05. 8Significantly different from non-arthritic joint pain or other joint conditions, p < 0.05 problems (46.2%). The use of any NOTE: Except among those with no musculoskeletal disorder, the denominator used for analysis is the number of U.S. adults aged 18 and over with the named musculoskeletal pain disorder. complementary health approach was SOURCE: NCHS, National Health Interview Survey, 2012. significantly lower among adults with sciatica (41.9%), arthritic conditions Figure 2. Use of any complementary health approach in the past 12 months for any reason (40.9%), and lower back pain (43.0%). and for treatment among adults: United States, 2012 National Health Statistics Reports  Number 98  October 12, 2016 Page 5

Among adults with a musculoskeletal pain disorder, almost 14% used a For any reason1 complementary health approach for No musculoskeletal pain disorder 13.4 2 treatment. Persons with neck pain or Any musculoskeletal pain disorder 24.7 Arthritic conditions 26.6 problems (9.2%), lower back pain Lower back pain 23.2 (10.3%), and sciatica (11.2%) were more Non-arthritic joint pain or other joint conditions 27.7 likely to use a complementary health Neck pain or problems 27.7 Sciatica 24.1 approach to treat their disorder compared Other musculoskeletal problems 28.2 with those with non-arthritic joint For treatment1 pain or other joint conditions (6.4%), Any musculoskeletal pain disorder2 3.1 arthritic conditions (6.6%), and other Arthritic conditions 4,73.3 musculoskeletal problems (4.1%). Lower back pain 0.4 Non-arthritic joint pain or other joint conditions 2.9 In 2012, almost 25% of persons with Neck pain or problems 0.2 any musculoskeletal pain disorder used Sciatica 0.6 natural products (nonvitamin, nonmineral Other musculoskeletal problems 0.5 dietary supplements and special diets) 0 5 10 15 20 25 30 (Figure 3). This was almost twice as Percent high as use among persons without a 1Natural products include nonvitamin, nonmineral dietary supplements and special diets. Use for treatment is use specifically to treat a problem, symptom, or disease. Use for any reason includes use for treatment. musculoskeletal pain disorder (13.4%). 2Includes all musculoskeletal pain disorders surveyed on the 2012 National Health Interview Survey Sample Adult section. Use of complementary health approaches An individual may have more than one disorder but is only counted once. 3Significantly different from any musculoskeletal pain disorder, p < 0.05. for any reason was more than twice as 4Significantly different from lower back pain, p < 0.05. 5Significantly different from non-arthritic joint pain or other joint conditions, neck pain or problems, and other high among persons with non-arthritic musculoskeletal problems p < 0.05. joint pain and other joint conditions 6Significantly different from other musculoskeletal problems, p < 0.05. 7Significantly different from neck pain or problems, sciatica, and other musculoskeletal problems, p < 0.05. (27.7%), neck pain or problems (27.7%), 8Significantly different from non-arthritic joint pain or other joint conditions, p < 0.05. NOTE: Except among those with no musculoskeletal pain disorder, the denominator used for analysis is the number of and other musculoskeletal problems U.S. adults aged 18 and over with the named musculoskeletal pain disorder. (28.2%) compared with those without a SOURCE: NCHS, National Health Interview Survey, 2012. musculoskeletal pain disorder. There was no significant difference Figure 3. Use of natural products in the past 12 months for any reason and for treatment among adults: United States, 2012 in the use of natural products among persons with sciatica (24.1%) and those with lower back pain (23.2%). Use of natural products was significantly lower For any reason1 among persons with lower back pain No musculoskeletal pain disorder 10.2 Any musculoskeletal pain disorder2 15.3 when compared with persons with all Arthritic conditions 12.5 other individual musculoskeletal pain Lower back pain 16.5 disorders examined, except sciatica. Non-arthritic joint pain or other joint conditions 18.0

However, few complementary health Neck pain or problems 18.9 Sciatica 14.2 users used these approaches specifically Other musculoskeletal problems 17.3 for treatment of their musculoskeletal For treatment1 pain disorder. Approximately 3% of Any musculoskeletal pain disorder2 1.8 adults with any musculoskeletal pain Arthritic conditions 1.4 disorders used natural products to treat Lower back pain 1.2 Non-arthritic joint pain or other joint conditions 0.9 one or more of these disorders. Adults Neck pain or problems 1.1 with arthritic conditions (3.3%) and Sciatica 1.6 non-arthritic joint pain and other joint Other musculoskeletal problems 0.8 conditions (2.9%) were significantly more likely to use natural products 0 5 10 15 20 25 for treatment of these conditions than Percent 1Mind and body approaches include biofeedback, energy healing therapy, guided imagery, hypnosis, meditation, individuals with other musculoskeletal progressive relaxation, Pilates, tai chi, qi gong, and yoga. Use for treatment is use specifically to treat a problem, symptom, or disease. Use for any reason includes use for treatment. pain disorders and other musculoskeletal 2Includes all musculoskeletal pain disorders surveyed on the 2012 National Health Interview Survey Sample Adult section. problems (0.5%). An individual may have more than one disorder but is only counted once. 3Significantly different from any musculoskeletal pain disorder, p < 0.05. In 2012, more than 15% of persons 4Significantly different from lower back pain, non-arthritic joint pain or other joint conditions, neck pain or problems, and other musculoskeletal problems, p < 0.05. with any musculoskeletal pain disorder 5Significantly different from sciatica, p < 0.05. used a mind and body approach such 6Significantly different from other musculoskeletal problems, p < 0.05. NOTE: Except among those with no musculoskeletal pain disorder, the denominator used for analysis is the number of as biofeedback, meditation, or yoga U.S. adults aged 18 and over with the named musculoskeletal pain disorder. for any reason (Figure 4). This was SOURCE: NCHS, National Health Interview Survey, 2012. almost one-third higher than use among Figure 4. Use of mind and body approaches in the past 12 months for any reason and for persons without a musculoskeletal treatment among adults with specific musculoskeletal pain disorders: United States, 2012 Page 6 National Health Statistics Reports  Number 98  October 12, 2016 pain disorder (10.2%). Use of mind for any reason (Figure 5). Use of Just under 10% of adults with a and body approaches among persons practitioner-based approaches for any musculoskeletal pain disorder used a without a musculoskeletal pain disorder reason was almost twice as high among practitioner-based approach specifically was also lower than use among persons persons with any musculoskeletal pain for treatment of that disorder. Persons with individual musculoskeletal pain disorders compared with persons without with sciatica (8.9%), lower back pain disorders. a musculoskeletal pain disorder. Persons (8.9%), and neck pain or problems (7.9%) Use of mind and body approaches with individual disorders were also were more likely to use practitioner- for any reason varied among persons more likely to use a practitioner-based based approaches for treatment of these with individual musculoskeletal pain approach for any reason compared with conditions than persons with arthritic disorders. Use by persons with neck pain those with no musculoskeletal pain conditions (2.7%), non-arthritic joint or problems (18.9%), non-arthritic joint disorder. pains or other joint conditions (2.9%), pain or other joint conditions (18.0%), Almost 30% of persons with neck and other musculoskeletal problems and other musculoskeletal problems pain or problems used a practitioner- (3.1%). (17.3%) was significantly higher than use based approach such as Alexander In 2012, 5.3% of persons with any among persons with arthritic conditions technique or chiropractic or osteopathic musculoskeletal pain disorder used whole (12.5%) or sciatica (14.2%). manipulation in the past 12 months. medical systems for any reason Less than 2% of adults with a This was significantly higher than use (Figure 6). This was more than twice as musculoskeletal pain disorder used among persons with all other types of high as persons without a musculoskeletal mind and body approaches specifically musculoskeletal pain disorders. Persons pain disorder. Persons with sciatica for treatment. Use of mind and body with sciatica (19.8%), lower back pain (6.8%) and neck pain or problems approaches for treatment of these (21.7%), and other musculoskeletal (8.0%) were most likely to use whole conditions was twice as high among problems (20.8%) were significantly medical systems such as acupuncture and persons with sciatica (1.6%) compared more likely to use practitioner-based naturopathy in the past 12 months. There with persons with other musculoskeletal approaches in the past 12 months was no significant difference in use of problems (0.8%). compared with persons with arthritic whole medical systems among persons In 2012, more than 18% of persons conditions (17.4%) and non-arthritic joint with arthritic conditions (5.1%), lower with any musculoskeletal pain disorder pains or other joint conditions (16.8%). back pain (5.3%), non-arthritic joint pains used a practitioner-based approach and other joint conditions (6.0%), and other musculoskeletal problems (6.2%). Overall, less than 1% of persons with any musculoskeletal pain disorder used For any reason1 whole medical systems specifically for No musculoskeletal pain disorder 6.9 treatment. Comparatively, persons with Any musculoskeletal pain disorder2 18.2 Arthritic conditions 4,5,617.4 sciatica (1.4%) were more likely to use Lower back pain 5,721.7 whole medical systems for treatment than Non-arthritic joint pain or other joint conditions 5,616.8 persons with lower back pain (0.6%) and Neck pain or problems 6,827.8 Sciatica 19.8 neck pain or problems (0.8%). Other musculoskeletal problems 20.8 For treatment1 Any musculoskeletal pain disorder2 9.7 Discussion Arthritic conditions 4,5,82.7 Lower back pain 6,78.9 More than 50% of U.S. adults, Non-arthritic joint pain or other joint conditions 5,82.9 that is, approximately 125 million Neck pain or problems 7.9 Sciatica 8.9 Americans, suffer from one or more Other musculoskeletal problems 3.1 musculoskeletal pain disorders. The goal of is usually to 0 5 10 15 20 25 30 achieve maximum reduction in pain Percent intensity as quickly as possible, to restore 1Practitioner-based approaches include Alexander technique, chiropractic or osteopathic manipulation, Feldenkrais, massage therapy, and Trager psychophysical integration. Use for treatment is use specifically to treat a problem, an individual’s daily functioning, to symptom, or disease. Use for any reason includes use for treatment. 2Includes all musculoskeletal pain disorders surveyed on the 2012 National Health Interview Survey Sample Adult section. help the patient cope with residual pain, An individual may have more than one disorder but is only counted once. 3Significantly different from any musculoskeletal pain disorder, p < 0.05. and to assess for side effects of therapy 4Significantly different from lower back pain, p < 0.05. (5,22). Complementary approaches 5Significantly different from neck pain or problems, p < 0.05. 6Significantly different from other musculoskeletal problems, p < 0.05. are increasingly being integrated into 7Significantly different from non-arthritic joint pain and other joint conditions, p < 0.05. 8Significantly different from sciatica, p < 0.05. conventional treatment plans for some NOTE: Except among those with no musculoskeletal pain disorder, the denominator used for analysis is the number of health conditions. More than 50% of U.S. adults aged 18 and over with the named musculoskeletal pain disorder. SOURCE: NCHS, National Health Interview Survey, 2012. medical schools offer some instruction in complementary health approaches (23), Figure 5. Use of practitioner-based approaches in the past 12 months for any reason and for and a growing body of scientific evidence treatment among adults: United States, 2012 suggests that several of these approaches, National Health Statistics Reports  Number 98  October 12, 2016 Page 7

that have evolved independently from, For any reason1 or parallel to, conventional medicine No musculoskeletal disorder 2.5 (32). However, although whole medical Any musculoskeletal pain disorder2 5.3 Arthritic conditions 4,55.1 systems share a number of common Lower back pain 5.3 elements with conventional medicine, Non-arthritic joint pain or other joint conditions 6.0 use of these approaches for any reason Neck pain or problems 8.0 or for treatment of musculoskeletal pain Sciatica 6.8 disorders was less popular than other Other musculoskeletal problems 6.2 types of approaches. 1 For treatment This report adds to evidence Any musculoskeletal pain disorder2 0.7 regarding the use of complementary Arthritic conditions * Lower back pain 5,60.6 approaches to treat or manage pain in Non-arthritic joint pain or other joint conditions * the U.S. population. The high level of Neck pain or problems 0.8 use of practitioner-based approaches Sciatica 61.4 identified in this report adds to previous Other musculoskeletal problems *0.1 research that has shown that some 0 2 4 6 8 10 U.S. adults use complementary health Percent approaches for treatment despite a lack * Estimates are considered unreliable. Data have a relative standard error (RSE) greater than 30% and less than or equal to 50% and should be used with caution. Data not shown have an RSE greater than 50%. of health insurance coverage for their 1Whole medical systems include acupuncture, homeopathy, naturopathy, and traditional healers. Use for treatment is use complementary health practitioner visits specifically to treat a problem, symptom, or disease. Use for any reason includes use for treatment. 2Includes all musculoskeletal pain disorders surveyed on the 2012 National Health Interview Survey Sample Adult section. (33). As such, the information in this An individual may have more than one disorder but is only counted once. 3Significantly different from any musculoskeletal pain disorder, p < 0.05. report may be useful to clinicians and 4Significantly different from neck pain or problems, p < 0.05. 5Significantly different from sciatica, p < 0.05. researchers interested in the types of 6Significantly different from other musculoskeletal problems, p < 0.05. complementary health approaches most NOTE: Except among those with no musculoskeletal pain disorder, the denominator used for analysis is the number of U.S. adults aged 18 and over with the named musculoskeletal pain disorder. frequently used for musculoskeletal SOURCE: NCHS, National Health Interview Survey, 2012. pain management, and in implementing the 2016 National Pain Strategy, which Figure 6. Use of whole medical systems in the past 12 months for any reason and for lays out a plan for better addressing pain treatment among adults: United States, 2012 issues in the United States (5). including chiropractic manipulation, persons with any musculoskeletal pain acupuncture, massage, and yoga, may disorder (18.2%) was almost three times References help to manage some painful conditions as high as among persons without a 1. National Institutes of Health. Research (24–31). musculoskeletal pain disorder (6.9%). portfolio online reporting tools (RePORT). In 2012, 41.6% of adults with a Regarding treatment of musculoskeletal Pain management. Available from: musculoskeletal pain disorder used one or pain disorders, the prevalence of use of https://report.nih.gov/nihfactsheets/ more complementary health approaches. practitioner-based approaches (9.7%) ViewFactSheet.aspx?csid=57. This is significantly higher than the use was more than three times that of use 2. Institute of Medicine Committee on among adults without a musculoskeletal of other types of complementary health Advancing Pain Research, Care, and pain disorder (24.1%). An even higher approaches among persons with any Education. Relieving pain in America: prevalence of use was seen among musculoskeletal pain disorder. Use A blueprint for transforming prevention, care, education, and research. Washington, persons who had neck pain and problems of practitioner-based approaches was DC: National Academies Press. 2011. (50.6%) and other musculoskeletal more than five times the use of other Available from: http://www.nap.edu/ problems (46.2%). approaches among persons with neck catalog/13172/relieving-pain-in-america- Natural products were the most pain or problems, lower back pain, a-blueprint-for-transforming-prevention- common complementary health approach sciatica, and other musculoskeletal care. used among U.S. adults with one or problems. 3. National Institute for Occupational Safety more musculoskeletal pain disorders; The use of the selected and Health. NIOSH program portfolio: 24.7% of adults with musculoskeletal complementary health approaches Musculoskeletal disorders. Available pain disorders used natural products. examined varied among persons with from: http://www.cdc.gov/niosh/programs/ This was almost twice the use among arthritis and non-arthritic joint pain and msd/. persons without a musculoskeletal pain other conditions. However, these persons 4. Centers for Disease Control and Prevention. Disability and health: disorder (13.4%). However, use of were consistently more likely to treat Musculoskeletal disorders. Available natural products specifically for treatment their conditions with natural products and from: http://www.cdc.gov/ncbddd/ among adults with musculoskeletal pain practitioner-based approaches than with disabilityandhealth/relatedconditions.html. disorders was less than 4%. mind and body approaches. 5. National Institutes of Health. National The use of practitioner-based Whole medical systems involve pain strategy: A comprehensive population approaches for any reason among complete systems of theory and practice health-level strategy for pain. Available Page 8 National Health Statistics Reports  Number 98  October 12, 2016

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Technical Notes Practitioner-based approaches— Includes Alexander technique, Definition of terms chiropractic or osteopathic manipulation, Feldenkrais, massage therapy, and Trager Arthritic conditions—Based on a psychophysical integration. positive response to “Have you ever Sciatica with back pain—Based on been told by a doctor or other health a positive response to “During the past professional that you have some form of 3 months, did you have low back pain?” arthritis, rheumatoid arthritis, gout, lupus, and “Did this pain spread down either or fibromyalgia?” leg to areas below the knees?” Only Lower back pain without sciatica— respondents who answered “yes” to both Based on a positive response to “During questions were defined as having sciatica. the past 3 months, did you have low Persons with sciatica were distinct from back pain?” However, persons who those with lower back pain without subsequently responded “yes” to a sciatica. question about lower back pain spreading Somatic pain—Pain caused by the down to the legs and areas below the activation of pain receptors in either the knees were excluded from this subgroup. body surface or musculoskeletal tissues. Mind and body approaches— Visceral pain—The pain felt when Includes biofeedback, energy healing internal organs are damaged or injured. therapy, guided imagery, hypnosis, Visceral pain is caused by the activation meditation, progressive relaxation, of pain receptors in the chest, abdomen, Pilates, tai chi, qi gong, and yoga. or pelvic areas. Natural products—Includes Whole medical systems—Includes nonvitamin, nonmineral dietary Ayurveda, acupuncture, homeopathy, supplements and special diets. naturopathy, and traditional healers. Neck pain—Based on a positive response to “During the past 3 months, did you have neck pain?” Respondents were instructed to refer to pain that lasted a whole day or more, and not report aches and pains that were fleeting or minor. Neuropathic pain—Pain caused by injury or malfunction to the spinal cord and peripheral nerves. Non-arthritic joint pain or other joint conditions—Based on a positive response to “During the past 30 days, have you had any symptoms of pain, aching, or stiffness in or around a joint?” Respondents were instructed to exclude back or neck pain. Persons with a positive response who subsequently responded “yes” to ever being told by a doctor or other health professional that they have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia were excluded from this subgroup. Other musculoskeletal conditions— Includes a positive response to “During the past 3 months, did you have facial ache or pain in the jaw muscles or the joint in front of the ear?,” “During the past 12 months, have you had any severe or strains?,” and “During the past 12 months, have you had other muscle or bone pain?”

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Suggested citation Copyright information National Center for Health Statistics Clarke TC, Nahin RL, Barnes PM, Stussman All material appearing in this report is in Charles J. Rothwell, M.S., M.B.A., Director BJ. Use of complementary health approaches the public domain and may be reproduced Jennifer H. Madans, Ph.D., Associate for musculoskeletal pain disorders among or copied without permission; citation as to Director for Science adults: United States, 2012. National health source, however, is appreciated. statistics reports; no 98. Hyattsville, MD: Division of Health Interview Statistics National Center for Health Statistics. 2016. Marcie L. Cynamon, Director Stephen J. Blumberg, Ph.D., Associate Director for Science

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