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Evidence Report/Technology Assessment Number 177 Complementary and Alternative Medicine in Back Pain Utilization Report Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 http://www.ahrq.gov Contract No. 290-02-0020 Prepared by: McMaster University Evidence-based Practice Center Hamilton, Ontario, Canada EPC Director: Parminder Raina, Ph.D. Principal Investigators: P. Lina Santaguida, B.Sc.PT., Ph.D. Anita Gross, B.Sc.PT., M.Sc. (Clin Epi) Authors: P. Lina Santaguida, B.Sc.PT., Ph.D. Anita Gross, B.Sc.PT., M.Sc. (Clin. Epi.) Jason Busse, D.C., Ph.D. Joel Gagnier, B.A., N.D., Ph.D. Kathryn Walker, B.Sc, B.Ph.E, M.Sc.P.T. Mohit Bhandari, M.D. M.Sc. F.F.C.S.C. Parminder Raina, B.Sc., Ph.D. AHRQ Publication No. 09-E006 February 2009 This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. Suggested Citation: Santaguida PL, Gross A, Busse J, Gagnier J, Walker K, Bhandari M, Raina P. Evidence Report on Complementary and Alternative Medicine in Back Pain Utilization Report. Evidence Report/Technology Assessment No. 177. (Prepared by the McMaster University Evidence-based Practice Center, under Contract No. 290-02-0020.) AHRQ Publication No.09-E006) Rockville, MD. Agency for Healthcare Research and Quality. February 2009. No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in this report. ii Preface The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-Based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of healthcare in the United States. The reports and assessments provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies. The EPCs systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments. To bring the broadest range of experts into the development of evidence reports and health technology assessments, AHRQ encourages the EPCs to form partnerships and enter into collaborations with other medical and research organizations. The EPCs work with these partner organizations to ensure that the evidence reports and technology assessments they produce will become building blocks for health care quality improvement projects throughout the Nation. The reports undergo peer review prior to their release. AHRQ expects that the EPC evidence reports and technology assessments will inform individual health plans, providers, and purchasers as well as the healthcare system as a whole by providing important information to help improve health care quality. We welcome comments on this evidence report. They may be sent by mail to the Task Order Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, or by e-mail to [email protected]. Carolyn M. Clancy, M.D. Beth A. Collins Sharp, R.N., Ph.D. Director Director, EPC Program Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality Jean Slutsky, P.A., M.S.P.H. Margaret Coopey, R.N., M.G.A., M.P.S. Director, Center for Outcomes and Evidence Task Order Officer, EPC Program Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality iii Acknowledgments We thank the representatives of our partner organization, National Center for Complementary and Alternative Medicine (NCCAM). Our thanks go to librarian Maureen Rice for her thorough management of the search terms and methodology. We would like to thank the following people who helped with screening, and the data abstraction for this review: Connie Freeborn, Rob Stevens, Lynda Booker, Solina Yoo, Kathryn Walker, and Mary Gauld. We would also like to thank Mary Gauld, Lynda Booker, and Kathryn Walker for their coordination activities. Our editorial staff, Cecile Royer, Roxanne Cheeseman, and Maureen Rice have provided invaluable input into this document. iv Structured Abstract Objectives: This systematic review was undertaken to evaluate which complementary and alternative medicine (CAM) therapies are being used for persons with back pain in the United States. Data Sources: MEDLINE®, EMBASE®, CINAHL® and Cochrane Central® and a variety of CAM specific databases were searched from 1990 to November 2007. A grey literature search was also undertaken, particularly for clinical practice guidelines (CPG) related to CAM. Review Methods: Standard systematic review methodology was employed. Eligibility criteria included English studies of adults with back pain, and a predefined list of CAM therapies. Results: A total of 103 publications were evaluated; of these 29 did not present CAM therapy use stratified for back pain. There were a total of 65 utilization studies, 43 of which were American. Four publications evaluated the concurrent use of four or more CAM therapies and these suggest that chiropractic/manipulation is the most frequently used modality followed by massage and acupuncture. A limited number of publications evaluated utilization rates within multiple regions of the back and show that CAM was used least for treating the thoracic spine and most for the low back. However, rates of use of massage were similar for neck and lower back regions. Concurrent use of different CAM or conventional therapies was not well reported. From 11 eligible CPG, only one (for electro-acupuncture) provided recommendations for frequency of use for low back pain of all acuity levels. Eighteen cost publications were reviewed and all but one publication (cost-effectiveness) were cost identification studies. There is limited information on the impact of insurance coverage on costs and utilization specific to back pain. Conclusions: There are few studies evaluating the relative utilization of various CAM therapies for back pain. For those studies evaluating utilization of individual CAM therapies, the specific characteristics of the therapy, the providers, and the clinical presentation of the back pain patients were not adequately detailed; nor was the overlap with other CAM or conventional treatments. v Contents Executive Summary........................................................................................................................ 1 Chapter 1. Introduction................................................................................................................. 11 Background............................................................................................................................... 11 What is CAM? ...................................................................................................................... 12 Who Uses CAM? .................................................................................................................. 13 What is CAM use and What are the Behavioral Models Explaining This Use? .................. 13 Evaluating the Methodological Quality of Studies Addressing Utilization of CAM ............... 14 Research Questions................................................................................................................... 15 Chapter 2. Methods...................................................................................................................... 17 Analytic Framework ................................................................................................................. 17 Scope of the Literature Search.............................................................................................. 17 Eligibility Criteria ................................................................................................................. 18 Data Collection and Reliability of Study Selection .............................................................. 23 Quality Criteria ..................................................................................................................... 23 Summarizing the Findings Descriptive and Analytic Approaches....................................... 23 Chapter 3. Results......................................................................................................................... 25 Question 1. What is the Relative Utilization for the Different CAM Therapies?.................... 27 Utilization of CAM, Data not Stratified by Back Pain or Therapy ...................................... 27 Utilization not Stratified by Back Pain Within the United States......................................... 27 Utilization not Stratified by Back Pain Within Other Countries .......................................... 28 Relative use of CAM Therapies............................................................................................ 28 Relative Utilization of CAM Therapies Within the United States ....................................... 29 Relative Utilization of CAM Therapies Outside the United States ...................................... 30 Trends in CAM Utilization ......................................................................................................
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