CAM MEDICINE USE COMPLEMENTARY MEDICINE

ALTERNATIVE MEDICINE (TITLE)

 The use of complementary and alternative medicine is becoming more common in people globally. Whether people are using home remedies, traditional Chinese medicine, or just taking herbal/vitamin supplements, people believe that complementary and alternative medicine is a good approach to whatever health benefits they are seeking. Some of these people that use CAM are athletes. It has been found that demographics do play a prominent role in the decision to use CAMs versus actual medical professionals. The purpose of this research is to identify the influence that demographics have on whether or not freshman athletes at Division I colleges use CAM or health professionals such as athletic trainers.

LIST OF ABBREVIATIONS

CAM- Complementary and Alternative Medicine

TCM- Traditional Chinese Medicine

CHBQ- CAM Health Belief Questionnaire

IMAQ- Integrative Medicine Attitude Questionnaire

TABLE OF CONTENTS

CHAPTER 1: INTRODUCTION

Research Question

Research Design

Independent Variables

Dependent Variable

Hypothesis (RESEARCH):

Operational Definitions

Delimitations

Limitations

CHAPTER 2: REVIEW OF LITERATURE

CHAPTER 3: METHODOLOGY

Sample

Procedures

Data Reduction and Data Analysis

REFERENCES

APPENDICES

CHAPTER 1: INTRODUCTION

According to a survey released in 2008 by the National Institutes of Health, approximately 50% of adults and children use some form of complementary and alternative medicine (CAM).¹ A variety of factors contribute to why people use CAM including cultural influences, frustrations with healthcare systems, and economic status. Some respondents perceive CAM to be safer and less expensive compared to more conventional care from medical professionals.  Others respondents use information provided through public access regarding CAM when conventional forms of care fail.  In regards to incoming intercollegiate athletes these factors contribute to their deliberation when deciding to seek medical treatment from athletic trainers or use CAM.

CAM can be defined as a group of diverse medical and health care interventions, practices, products or routines that are not generally considered a part of the conventional medicine.² India is one of many western countries known for its usage of alternative medicine.³ It is used for a variety of injuries or health complications such as cancer, cardiovascular issues, and musculoskeletal injuries. Approximately 30% of adults and 12% of children use CAM.⁴ For adults with musculoskeletal injuries, approximately 42% of adults use CAM.⁴ Athletic trainers deal with more musculoskeletal injuries than anything else in athletes, whether they are incoming freshman or veterans on the team.

When individuals who are using CAM go on to collegiate athletics, they may not be aware of the role of athletic trainers and the sports medicine model. According to statistics, 97.6% of individuals who used CAM to improve athletic performance concluded that it was helpful by boosting their physical performance and increasing their energy.⁵Since CAM is the ideal treatment for these athletes, when they advance to collegiate athletics, they rely on what they know works best for them.

Identifying what demographic factors influence the use of CAM may help in developing educational programs for these athletes so that they can maximize the available healthcare resources. Anecdotally, based on their socioeconomic status, some high school athletes do not have athletic trainers and cannot afford healthcare so as a result, they rely solely on conservative treatment. For instance, African Americans who live in areas with high poverty rates encounter significant financial barriers and usually cannot afford health insurance; therefore, it is imperative to develop educational programs for incoming freshman athletes on athletic trainers, the sports medicine model, and the healthcare profession as a whole.⁶

Since the widespread popularity of CAM, a gap in literature and lack of communication between healthcare professionals and patients has surfaced.⁷ Currently there is limited research that investigates why incoming collegiate athletes prefer CAM over medical treatment from athletic trainers and what factors may contribute to the their preference.  Based on previous studies involving CAM use in the United States, factors may include economic status, availability of healthcare, success of conventional medicine, and race.² Therefore the purpose of the project is to identify how demographic information influences the use of CAM in incoming collegiate athletes.

Research Question: How does demographic information influence the use of CAM in incoming collegiate athletes?

Research Design: Descriptive Study

Independent Variables:

• Race
  • American Indian or Alaska Native
  • Black or African American
  • Native Hawaiian or Pacific Islander
  • White
• Presence of athletic trainer at high school
  • Yes
  • No
• Type of insurance
  • Private
  • Medicaid
  • No insurance
• Parents’ income

Dependent Variable: score on the CAM Health Belief Questionnaire and the Integrative Medicine Attitude Questionnaire

Hypothesis (RESEARCH):

• We believe that race has a direct influence on the use of CAM by incoming collegiate athletes.
• We believe that the presence of an athletic trainer at the attended high school has a direct influence on the use of CAM by incoming collegiate athletes.
• We believe that having or not having insurance coverage has a direct influence on the use of CAM by incoming collegiate athletes.
• We believe the socioeconomic status of incoming collegiate athletes has a direct influence on the use of CAM.

Operational Definitions:

• CAM- a group of diverse medical and health care interventions, practices, products, or routines that are not generally considered a part of conventional medicine
• Incoming collegiate athletes- freshman athletes entering into their first year of college athletics and academics

Delimitations: 17-20 year old male or female incoming freshman athlete at The University of Alabama participating in any one of the following sports: Track and Field, Basketball, Football, Baseball, Softball, Gymnastics

Assumptions: participants of the survey will be honest

Limitations: results of the survey are self reported

CHAPTER 2: REVIEW OF LITERATURE

According to a survey released in 2008 by the National Institutes of Health (NHIS), approximately 50% of adults and children use some form of complementary and alternative medicine (CAM).¹In 2007, NHIS collected data from literature reviews spanning 20 years and responses from over 29,000 households using questionnaires. The majority of the population surveyed used CAM as a prevention mechanism for overall health or relief of symptoms associated with chronic or terminal illnesses. Common therapeutic interventions include natural products, meditation, home remedies, yoga, traditional Chinese medicine, acupuncture, massages, and chiropractic care used to treat common colds, musculoskeletal conditions, and even cancer.⁸

To understand complementary and alternative medicine, one must also understand what conventional medicine is. The National Institute of Cancer defines conventional medicine as the system that medical doctors and healthcare professionals use to treat symptoms and diseases using drugs, radiation, and surgeries. A lot of times, CAM and conventional medicine are used collectively; CAM does not replace conventional medicine completely.⁹ CAM is becoming more widely used in the United States. The National Cancer Institute spends approximately $120 million dollars annually on CAM research.¹⁰ In other European countries such as China and India, CAM is a part of the tradition and culture.¹¹

With India being one of the most renowned countries for its use of CAM and traditional medicine, other countries are starting to integrate some of its practices into their own practices.¹² India incorporates spirituality into their healthcare systems as well as plants and herbs.¹³ In the Chinese culture, different formulas of herbs and holistic therapies are also used to treat syndromes and diseases. Over the years, more research has been done to support the use of traditional CAM.

Varieties of factors contribute to why people use CAM including cultural influences, frustrations with healthcare systems, and economic status. Alternatives to conventional medicine is not a new phenomenon. It dates back to ancient times for some cultures, which inherently explain why some people trust cultural influences over the expertise of healthcare professional and their conventional forms of therapy. Specifically in American society, first generation immigrants and the cultural melting pot may heavily influence how decisions are made. When physicians prescribe supplements along with medications, some patients may be more inclined to use CAM because of the cost efficiency it provides. When conventional forms of treatment fail, patients begin to divert from them and take complete control with a more holistic approach.

Another reason people use complementary medicine is due to the fact that the advancements of conventional medicine have resulted in increased incurable diseases. These patients expect conventional medicine to cure them so when it fails, they focus on self-treatment. Individuals also use complementary medicine based on their cultural differences. Society includes various cultures and athletes who prefer complementary medicine based on what is routine with their spirituality, what they can afford, and what practices have been passed down through generations.¹⁴

During the duration of 2007, 4 out of 10 adults used some form of CAM in the previous 12 months.  The survey identified 17.7% of the adults used natural products, 12.7% used deep breathing exercises, and 9.4 % used meditation. Moreover, 1 out of 9 children used CAM in the past 12 months.  Children commonly used 3.9% of natural products and 2.8% of chiropractic and osteopathic practices.  Two similar studies conducted in 2002 and 2012, showed children and adults alike tend to use natural products the most. Out of 30% of adults, a great number of them also teach their children how to use the same methods. For example, a home remedy that may be passed down and taught for sore and scratchy throat is a mixture of apple cider vinegar and honey. If children have the impression that it works, they may continue to use it when they move out on their own rather than buying over the counter medicine. Anecdotally, a lot of adults and children believe in a sense of spirituality and use prayer as a form of healing similar to Indian culture.¹⁵

In a technologically advanced society, the public now has access to public information compared to that of the past. As a result, patients are decreasingly becoming less tolerant of traditional forms of medicine.¹⁶ With the amount of public access available, patients now see paternalistic practices as ineffective, costly, and dissatisfying.¹⁴ Furthermore, groups who have private healthcare insurance and parents with at least a high school education were more likely to use complementary medicine.¹,¹² In a survey done by NHIS in 2012, Americans spent $14.7 billion out of pocket on complementary visits, whereas, Americans only spent $12.8 billion on complementary medicines like natural products.

In both Indian and Chinese cultures, CAM has been used to treat cancer and hypertension.¹⁷CAM can also be used to treat musculoskeletal injuries. At some point, one will most likely experience some form of pain or discomfort, especially if active. One of the most common musculoskeletal issues people experience is back pain. Back pain can come from a bad night of sleep, a long day of work, or being an athlete. In a recent study, researchers found that between 64 and 93% of dentists struggle with musculoskeletal injuries. This stems from circumstances such as sitting for long periods of time, holding awkward positions, and or having bad posture.¹⁸ This same study also suggests that CAM such as yoga, acupuncture, massage, and prayer were effective in treating musculoskeletal pain.¹⁸ If CAM assists professionals such as dentists with their musculoskeletal pain, it may also be effective in athletes with musculoskeletal pain and injuries as well.

Children that may go on to play sports at the collegiate level may also want to continue using whatever form of CAM they used growing up. The trend of athletes using CAM is increasing in amateur and professional athletes. Athletes utilize CAM when: they want to improve their performance, they want to shorten the amount of time they will be out of participation, and when they become frustrated with recurring injuries and how they are managed. A lot of times, athletes’ peers have some influence on encouraging others to try new methods of CAM. In the athletic setting, one of, if not the most commonly used form of CAM is massage. More athletes are starting to use Chinese methods of CAM such as acupuncture and cupping.

Cupping therapy is a part of Chinese traditional therapy and has been around for approximately 2000 years.¹⁹ It was originally used by folk healers.²⁰ There are two methods for cupping: dry cupping or wet cupping. The main difference in dry and wet cupping lies in the fact that dry cupping is noninvasive while wet cupping is invasive. Both will elicit some bruising of the skin as the skin is vacuumed into the cups.¹⁹ Informally, cupping has been used on men and women track athletes at The University of Alabama to help with sore muscles after a strenuous day of practice. Another form of CAM used on track athletes at The University of Alabama is the Graston Technique. Graston is considered an “instrument assisted soft tissue mobilization.” Anecdotally, it is used to dismantle adhesions and scar tissues to create an increase in short-term joint range of motion.¹⁵ Cupping therapy and Graston technique are both becoming more popular in the athletic training room as more evidence-based research develops.

Incoming freshman athletes may not be aware of the role of athletic trainers and the sports medicine model. These athletes grow so accustomed to their own remedies that they don’t seek the healthcare that is provided for them by medical professionals. The repetitive use of complementary medicine is primarily due to the fact that the athletes are taking control of self-treatment.This is problematic because adverse reactions and improper treatment of medical issues may arise.²¹ Considering all of these factors, it is extremely important for incoming collegiate athletes to know and understand the role of athletic trainers and the sports medicine team. These healthcare professionals perform clinical evaluations, provide therapeutic interventions, and create rehabilitation protocols to ensure that the athletes are able to compete at their maximum potential; therefore, initiatives should be taken to educate these incoming athletes on the importance of medical professionals.

According to statistics, 97.6% of individuals who used complementary medicine to improve athletic performance concluded that it was helpful by boosting their physical performance and increasing their energy.⁵As athletic training students, we were taught that if an athlete thinks a particular therapeutic intervention works for them, we continue to use it on that athlete. Since the athletes believe that complementary medicine is useful for them, when they advance to collegiate athletics, they rely on what they know works best for them. This is why these individuals find it difficult to consult athletic trainers when they are injured.¹⁴

Identifying what demographic factors influence the use of complementary medicine may help in developing educational programs for these athletes so that they can maximize the available healthcare resources.²² Whether or not the incoming collegiate athlete has insurance plays a significant role in the use of complementary medicine. Statistics show that athletes who aren’t insured and athletes who are insured but have low incomes experience financial barriers. Although the uninsured athletes are more likely to have trouble paying for healthcare, the athletes who are insured with low incomes also avoid care because they cannot afford the costs.²³

Whether or not the incoming athlete had an athletic trainer present at their high school also plays a role in the use of complementary medicine. Anecdotally, based on their socioeconomic status, some high school athletes do not have athletic trainers and cannot afford healthcare so as a result, they rely solely on complementary medicine. Since the athletes had to partake in self-treatment in high school due to the absence of an athletic trainer, they continue to use complementary medicine when they go to college.

Race and socioeconomic status are two of the major demographic factors that play a significant role in the use of complementary medicine. For instance, African Americans who live in areas with high poverty rates encounter significant financial barriers and usually cannot afford health insurance.⁶Although African Americans are the primary user, complementary medicine is also used by various other ethnicities. The most common types of complementary medicine used are expressive therapies, faith healing and prayer, home remedies, massage therapy, special exercises, and herbal remedies. Whites are more likely to use herbal remedies and environmental changes, African Americans are more likely to use faith healing or prayer and home remedies, and Hispanics are more likely to use spinal manipulation in comparison to other ethnicities.²¹Therefore, it is imperative to develop educational programs for incoming freshman athletes on athletic trainers, the sports medicine model, and the healthcare profession as a whole.

Since the widespread popularity of CAM, a gap in literature and lack of communication between healthcare professionals and patients have surfaced .¹⁴ Although the NHIS sampled a large enough population that gathered sufficient data, the study still has limitations. The accuracy of the answers provided to the questions are in contingent upon respondents’ memory and ability to self report without biases. Moreover, when sampling CAM usage in children accuracy is dependent upon parents knowledge of the CAMs their child is using. Another limitation is the lack of communication between patients and healthcare professionals about CAM. Since insufficient evidence has surfaced in regards to the effectiveness and safety of CAM many physician are reluctant to advise the use of alternative medicine. Furthermore, in not having practical evidence physician have very little understanding of the effects of CAM.

CHAPTER 3: METHODOLOGY

Sample

75 athletes (50 men and 25 women) from the University of Alabama are being recruited for this specific study.  Athletes will be included based on the following criteria:

• Freshman in college
• Participating in the following varsity sports:
  • Track and Field (Men’s and Women’s)
  • Basketball (Men’s and Women’s)
  • Football
  • Baseball
  • Softball
  • Gymnastics
• Identify as a male or female
• Are 17-20 years of age

The above sports were chosen because typically at Division I schools, these sports are highly recruited for when athletes are in high school. Athletes will be excluded if they are still living with their parents or if they have a previous diagnosis of a life-threatening illness such as cancer.

Procedures

This descriptive study employs data retrieved directly from the participants of this study. The surveys will both be completed on the same day, following official enrollment and arrival on campus. The surveys will be completed in the athletic training room in one of the athletic trainer’s offices.  First, the participants will take a survey strictly referring to their own personal demographics prior to their arrival at college. The demographic survey will provide information pertaining to race, whether or not they had an athletic trainer at their high school, as well as the type of health insurance they had (private, Medicaid, or no insurance at all; Appendix 1). Once this survey is completed, they will complete the 10 item CAM Health Belief Questionnaire (CHBQ, Appendix 2) followed by the 29 item Integrative Medicine Attitude Questionnaire (IMAQ). (Appendix 3). These surveys will provide information in regards to the participants’ use of complementary and alternative medicine as well as their belief in its effectiveness.

Data Reduction and Data Analysis

In order to score the results of both the CHBQ and IMAQ surveys, the scoring criteria provided for each will be used. The questionnaires uses a seven point Likert scale:  1 corresponds with “Strongly Disagree” and 7 corresponds with “Strongly Agree”. A sum of all rated items will be taken to get a total scale score. The higher scores suggest a greater advocacy toward CAM and lower scores suggest a lesser advocacy toward CAM. Descriptive statistics will be calculated for all dependent variables and demographic information. SPSS software will be used for all data analysis.

REFERENCES

1. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008(12):1-23.

2. Black LI, Clarke TC, Barnes PM, Stussman BJ, Nahin RL. Use of complementary health approaches among children aged 4-17 years in the United States: National Health Interview Survey, 2007-2012. Natl Health Stat Report. 2015(78):1-19.

3. Pandey MM, Rastogi S, Rawat AK. Indian traditional ayurvedic system of medicine and nutritional supplementation. Evid Based Complement Alternat Med. 2013;2013:376327.

4. Cohen EM, Dossett ML, Mehta DH, Davis RB, Lee YC. Factors associated with complementary medicine use in pediatric musculoskeletal conditions: Results from a national survey. Complement Ther Med. 2017;31:53-58.

5. Weinick RM, Byron SC, Bierman AS. Who can’t pay for health care? J Gen Intern Med. 2005;20(6):504-509.

6. Jacobs EA, Rolle I, Ferrans CE, Whitaker EE, Warnecke RB. Understanding African Americans’ views of the trustworthiness of physicians. J Gen Intern Med. 2006;21(6):642-647.

7. Ventola CL. Current Issues Regarding Complementary and Alternative Medicine (CAM) in the United States: Part 3: Policies and Practices Regarding Dietary Supplements In Health Care Facilities. P T. 2010;35(10):570-576.

8. Adams D, Schiffgen M, Kundu A, et al. Patterns of utilization of complementary and alternative medicine in 2 pediatric gastroenterology clinics. J Pediatr Gastroenterol Nutr. 2014;59(3):334-339.

9. Thomson P, Jones J, Browne M, Leslie SJ. Psychosocial factors that predict why people use complementary and alternative medicine and continue with its use: a population based study. Complement Ther Clin Pract. 2014;20(4):302-310.

10. Li X, Yang G, Li X, et al. Traditional Chinese medicine in cancer care: a review of controlled clinical studies published in chinese. PLoS One. 2013;8(4):e60338.

11. Ramakrishnan P, Dias A, Rane A, et al. Perspectives of Indian traditional and allopathic professionals on religion/spirituality and its role in medicine: basis for developing an integrative medicine program. J Relig Health. 2014;53(4):1161-1175.

12. Bhalerao MS, Bolshete PM, Swar BD, et al. Use of and satisfaction with complementary and alternative medicine in four chronic diseases: a cross-sectional study from India. Natl Med J India. 2013;26(2):75-78.

13. Lucchetti G, Ramakrishnan P, Karimah A, et al. Spirituality, Religiosity, and Health: a Comparison of Physicians’ Attitudes in Brazil, India, and Indonesia. Int J Behav Med. 2016;23(1):63-70.

14. Ventola CL. Current Issues Regarding Complementary and Alternative Medicine (CAM) in the United States: Part 1: The Widespread Use of CAM and the Need for Better-Informed Health Care Professionals to Provide Patient Counseling. P T. 2010;35(8):461-468.

15. Cheatham SW, Lee M, Cain M, Baker R. The efficacy of instrument assisted soft tissue mobilization: a systematic review. J Can Chiropr Assoc. 2016;60(3):200-211.

16. Adams D, Dagenais S, Clifford T, et al. Complementary and alternative medicine use by pediatric specialty outpatients. Pediatrics. 2013;131(2):225-232.

17. Xiong X, Yang X, Liu Y, Zhang Y, Wang P, Wang J. Chinese herbal formulas for treating hypertension in traditional Chinese medicine: perspective of modern science. Hypertens Res. 2013;36(7):570-579.

18. Gupta D, Batra R, Mahajan S, et al. Comparative Evaluation of the Complementary and Alternative Medicine Therapy and Conventional Therapy Use for Musculoskeletal Disorders Management and Its Association with Job Satisfaction among Dentists of West India. J Tradit Complement Med. 2014;4(4):263-267.

19. Mehta P, Dhapte V. Cupping therapy: A prudent remedy for a plethora of medical ailments. J Tradit Complement Med. 2015;5(3):127-134.

20. Roberti di Sarsina P, Iseppato I. Traditional and non-conventional medicines: the socio-anthropological and bioethical paradigms for person-centred medicine, the Italian context. EPMA J. 2011;2(4):439-449.

21. Wilson KM, Klein JD, Sesselberg TS, et al. Use of complementary medicine and dietary supplements among U.S. adolescents. J Adolesc Health. 2006;38(4):385-394.

22. Ghildayal N, Johnson PJ, Evans RL, Kreitzer MJ. Complementary and Alternative Medicine Use in the US Adult Low Back Pain Population. Glob Adv Health Med. 2016;5(1):69-78.

23. Stussman BJ, Black LI, Barnes PM, Clarke TC, Nahin RL. Wellness-related Use of Common Complementary Health Approaches Among Adults: United States, 2012. Natl Health Stat Report. 2015(85):1-12.

APPENDICES