Hasan ULUSOY, 1 Tülün Kaya GÜÇER, 1 Murat AKSU, 2 Şule ARSLAN, 3 Abdülkadir HABİBOĞLU, 3 Gürkan AKGÖL, 1 Ayhan BİLGİCİ, 4 Ömer KURU, 4 İlhan ÇETİN, 5 Ayhan KAMANLI, 1 Salih ÖZGÖÇMEN6

1Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Medical Faculty of Fırat University, Elazığ, Turkey
2Department of Medical Ethics and the History of Medicine, Medical Faculty of Adnan Menderes University, Aydın, Turkey
3Department of Physical Medicine and Rehabilitation, Medical Faculty of Gaziosmanpaşa University, Tokat, Turkey
4Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Medical Faculty of Ondokuz Mayıs University, Samsun, Turkey
5Department of Public Health, Medical Faculty of Gaziosmanpaşa University, Tokat, Turkey
6Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Medical Faculty of Erciyes University, Kayseri, Turkey

Keywords: Alternative medicine; complementary therapies; rheumatic diseases


Objectives: The aim of this study was to determine the prevalence of complementary and alternative medicine (CAM) use, to define the most frequently used CAM methods in rheumatic diseases, as well as to assess resources of information encouraging patients using CAM, and to evaluate the physicians' attitudes toward CAM use.

Patients and methods: We conducted face-to-face interviews with 318 patients with rheumatic diseases (212 females, 106 males; mean age 48.0±15.1 years; range 18 to 79 years) regarding demographic variables, history of CAM use, preferred CAM methods and resources of information encouraging patients using CAM. Complementary and alternative medicine methods were categorized as follows; 1- Acupuncture, 2- Biofeedback, 3- Dietary modifications, 4- Body-based practices, 5- Magnetic or copper devices, 6- Behavioural methods, 7- Others.

Results: Approximately half of the patients (46.2%) experienced at least one method of CAM previously. The most frequently used methods of CAM were dietary modifications (28.9%) and body-based practices (16.4%). Patients with non-inflammatory diseases used CAM more frequently compared to the patients with inflammatory diseases (p=0.023). While 26.5% of the users were satisfied with the benefits of CAM, 73.5% believed that CAM was inadequate or useless. Most of the patients using CAM were encouraged by their relatives and mass media, whereas only 13.6% used CAM with the recommendation of their physician. One half of the physicians were indifferent in respect of CAM use.

Conclusion: Complementary and alternative medicine methods are commonly used among patients with rheumatic disorders. However, unfortunately, the most frequent resources of information on CAM are patients' relatives or mass media, rather than a health care professional. Therefore, physicians should be equipped with sufficient knowledge to inform their patients extensively on the use of CAM methods.


Complementary and alternative medicine (CAM) has recently attracted attention due to its widespread use. Coincidently, there is considerable interest in CAM therapies among rheumatologists as well as a willingness to refer patients to providers for at least some of the CAM methods like acupuncture, behavioral medicine, biofeedback, psychotherapy, dietary prescription, and exercise interventions.[1,2] Rheumatologic diseases are chronic, and usually progressive conditions cause pain, physical disability, and dependence on medications which do not always provide full symptom relief. It is therefore not surprising that rheumatology patients might consider therapies aside from those offered by mainstream rheumatologists and primary care physicians.[3] Previous studies have revealed that the use of CAM is prevalent among patients with rheumatic diseases, with the frequency of CAM use being reported as between 22% to 95% depending on the country.[4-9]

To the best of our knowledge, the utilization of CAM in Turkish patients with rheumatic disorders has not been investigated before. Therefore, the primary objective was to determine the prevalence of CAM use and the most frequently used CAM methods among patients with rheumatic disorders in Turkey. A secondary aim was to assess the perceived effectiveness of CAM use, the sources of information which have motivated patients to use CAM, and the physicians' attitudes regarding the use of CAM.

Patients and Methods

This study was designed as a cross-sectional survey of consecutive patients with rheumatic disorders attending rheumatology clinics of three university hospitals which are located in the cities of Elazığ, Samsun, and Tokat in Turkey. A total of 318 patients (212 females, 106 males; mean age 48.0±15.1 years; range 18 to 79 years) who had been diagnosed with a rheumatic disease and had sufficient intellectual ability to understand all questions were enrolled. Written informed consent was obtained from all participants, and face-to-face interviews were performed to collect data. A questionnaire soliciting self-reported knowledge of the use of CAM was used in the study in which items related to basic demographic variables, current or previous use of CAM for their rheumatic disorders, CAM methods (using a checklist), the perceived benefits of CAM methods (none, inadequately, moderately, adequately), and the sources of information that motivated the patients to use CAM were included. To facilitate the interpretation, CAM methods were categorized as follows:

1. Acupuncture,
2. Biofeedback,
3. Dietary modifications (special diets, glucosamine ± chondroitin, fish-oil, megavitamins and minerals, specific bacterial cultures, herbal remedies, garlic tablets),
4. Body-based practices (chiropractic or nonchiropractic manipulation, massage),
5. Magnetic or copper devices,
6. Behavioral methods (psychotherapy, meditation, yoga, spiritual direction),
7. Other (hyperbaric oxygen, music therapy, bee venom, snake venom, application of leeches, salves, or peloids). The medical records of the patients were checked for diagnoses.

Data was analyzed using descriptive statistics, Student’s t-test for continuous variables, and the chi-square test for categorical variables. A twotailed p value of <0.05 was considered statistically significant.


A total of 318 patients with rheumatic disorders completed the questionnaire. The demographic and clinical characteristics of the patients are summarized in Table 1. Approximately one half (46.2%) of the patients had experience with at least one type of CAM method. There was no difference in the frequency of CAM methods used among patients from the three different cities (data not shown). The mean age of CAM users and non-users was similar (p=0.156). There was no significant difference in terms of gender between CAM users and nonusers. However, the frequency of CAM use tended to be higher among females compared with males (50.5% versus 39.6%, respectively; p=0.095). Patients with a higher education level (more than 11 years of education) tended to use CAM more frequently than patients with a lower education level, but the difference did not reach a statistically significant level (64% and 44.7%, respectively; p=0.063). The patients with non-inflammatory or degenerative disorders, including osteoarthritis, fibromyalgia, chronic low back pain, and chronic neck pain, experienced CAM more frequently than the patients with inflammatory disorders, such as rheumatoid arthritis, spondyloarthropathies, connective tissue diseases, vasculitis, and familial Mediterranean fever (p=0.023).

The percentages of each CAM category ranged from 28.9% for dietary modifications to 0% for biofeedback in all of the study population. Body-based practices were the second most frequently used method of CAM (16.4%). Behavioral therapies, acupuncture, and magnetic or copper devices were less frequently preferred methods (Table 2). The most frequently used CAM methods were vitamin ± mineral supplements in 15.4%, herbal remedies in 13.2%, massage in 12.9%, and fish-oil supplements in 9.4% (Table 3).

Most of the users were motivated to use CAM by their friends and family members (41.5%) or by other patients (17.7%), and by mass media and advertising (12.9%) (Table 4). The percentage of patients who decided to use CAM on their own was 14.3%. Only 13.6% of the users had been referred by their physicians to use CAM therapies. Most of the users (60.5%) did not desire to talk about their CAM use with their physicians. The rest of the users (39.5%) expected to receive information about CAM from their physicians and talked about it with them. However, their physicians were frequently (50%) incurious about the patients’ CAM use, with 37.9% being in favor of it and 12.1% against the use of CAM therapies.

Only 26.5% of the patients who had used at least one CAM method considered these therapies to be adequate or moderately effective whereas 73.5% considered them to be inadequate or not beneficial.


The results of this study showed that the use of CAM was common among patients with rheumatic disorders. The prevalence of CAM use was higher in non-inflammatory rheumatic disorders than inflammatory ones. Dietary modification was the most frequently used type of CAM. The next frequent type of CAM was body-based practices. The most frequent source of information on CAM came from patients’ relatives or media rather than a healthcare professional. A small proportion of patients were motivated to use CAM by their physicians. Only one-fourth of the CAM users perceived that it had beneficial effects whereas the rest of the users thought it was either inadequate or not useful at all. Our results also indicated that female patients as well as patients with higher education levels were more keen to use CAM.

In the present study 46.2% of patients with rheumatic disorders reported they had used CAM. This finding is in line with the results of previous studies from different countries. The percentage of rheumatology patients reporting CAM use varies from between 22% to 95% in different studies. In Canada, a study showed that 22% of people with self-reported arthritis had used CAM in the past year.[4] In an Israeli study, 42% of patients with defined rheumatic diseases attending rheumatology clinics reported the use of CAM.[6] In a Swedish study of patients with rheumatic diseases, it was found that 65% of the patients had used CAM at least once in their lives.[7] Over 80% of patients with rheumatoid arthritis in Korea and 70% in Australia reported the use of CAM therapies.[8,9] A study from the United States showed that 92% of patients with rheumatic diseases had used CAM methods for their arthritis.[10] In a recent study on CAM use among patients with ankylosing spondylitis in Australia, 95% of the patients reported previous or current CAM use.[5] This wide range in the frequency of CAM use in studies from different countries may be related to cultural differences, availability of CAM providers, advertisements in the lay press, or methodologies used in these studies. For example, some of the studies used self-administered questionnaires with telephone or mail contact whereas others conducted face-toface interviews. Moreover, some studies focused only on one specific disease or used self-definition of rheumatic diseases while others used physician-based diagnoses and assessments.

Patients with inflammatory rheumatic diseases were less likely to use CAM than patients with noninflammatory rheumatic diseases. This finding is consistent with the results of previous studies.[6,11] The availability of effective combination therapies for inflammatory rheumatic diseases, especially for rheumatoid arthritis, is a possible reason for these patients not seeking alternative therapies. Another hypothesis may be the fact that patients with inflammatory rheumatic diseases can be anxious due to possible interactions between conventional medical therapies and CAM therapies.

In this study, dietary modification was the most frequently favored (62.6%) category of CAM for rheumatic diseases. The next most common (35.4%) category of CAM was body-based practices, such as massage, manipulation and traction. In North American studies, chiropractic medicine was the most commonly used CAM method (from 31% to 59%) in rheumatic diseases whereas acupuncture and homeopathy were less common.[4,12,13] In Israel, the most frequently used CAM therapies by patients with rheumatic diseases were acupuncture and homeopathy (44% and 41%, respectively), and the frequency of dietary modifications was 26%.[6] In Sweden, most of the patients with rheumatic diseases (51.5%) preferred to use dietary CAM methods with omega-3 fatty acids being the most frequently utilized type of dietary CAM. Acupuncture and manual therapies (massage, homeopathy, chiropractics) were preferred less frequently (22.5% and 29.5%, respectively) in the same study.[7] In Britain, dietary modifications were the most common type of CAM method.[14] Disease-specific studies showed that 23% to 72.1% of patients with ankylosing spondylitis used dietary modifications.[5,15] Lee et al.[8] reported that 70.4% of patients with rheumatoid arthritis in Korea used products derived from plants or animals. The different frequency of use of each CAM method among different countries may reflect to some extent the availability of CAM providers, ethnic familiarity with some modalities, or coverage by public health insurance. For example, CAM has been accepted as a major form of healthcare and is partially covered by the medical insurance systems in some of the eastern countries.[16]

We found that CAM users were principally informed and motivated by their friends, family members, other patients, or mass media rather than by a healthcare professional. This is similar to the results of previous studies assessing the use of CAM.[6,8,17] Only 13.6% of the users had been referred by their physicians in our study. On the other hand, less than half (39.5%) of the users had discussed the use of CAM with their physicians, who were frequently indifferent toward the use of CAM by their patients. Previous studies revealed that patients are reluctant to report or discuss their CAM use with their physicians, and some discontinue prescribed treatments without consulting their physician.[13,18,19] Rao et al.[13] reported that 45% of patients with rheumatic diseases who had used CAM previously informed their physicians about their CAM use. In a study from the United States, only 54% of patients with rheumatic diseases discussed their CAM use with their rheumatologist.[10] Because chronic musculoskeletal disorders are the leading indication for the use of CAM, rheumatologists should inform their patients regarding its use.[20] More patients are likely to inform their rheumatologist about their CAM use if their doctors prefer to use treatment methods which were shared and discussed with the patients.[10]

In our study, most of the users perceived the efficacy of CAM to be either deficient or ineffectual. Only one-fourth of the users were satisfied with the benefits of CAM therapies. In previous studies, less than half of the patients with rheumatic diseases reported symptomatic benefits of CAM use.[5,8] In a recent study, half of the patients who had experienced at least one CAM drug stated that the drug had positive effects on their health.[7]

Previous studies have indicated that female gender, advanced education level, and younger age are associated with a higher prevalence of CAM use in rheumatic diseases.[4-7,9,21,22] Similarly, female gender and higher education levels (more than high school) were also associated with more frequent use of CAM in our study. On the other hand, a lower education level was found to be associated with a greater use of CAM in different study.[23]

A notable strength of this study is the representative sampling of patients with rheumatic diseases from the three clinics in different cities of Turkey. The number of surveyed patients was sufficient compared with previous studies which assessed CAM use. On the other hand, this study had a number of limitations. The results of the study depended on self-reported data. The benefical effects of each of the CAM modalities were also obtained from patient-reported data. We should underscore that the benefits of CAM modalities have to be assessed by using evidence-based methods. In addition, there is always a question mark regarding what does or does not constitute a CAM therapy. For example, current Osteoarthritis Research Society International (OARSI) guidelines list acupuncture and glucosamine, either with or without chondroitin, as non-pharmacologic treatments for hip and knee osteoarthritis.[24] However, we selected to include these therapies under CAM. The American College of Rheumatology defined CAM as therapies “outside of the prevailing scientific mainstream but [which] still may be safe and effective, unsafe and ineffective, or questionable”.[25] The concept of CAM has changed over time. Currently, for example, exercise interventions and balneotherapy are considered as integral parts of mainstream medical treatments.[25-27] Therefore, we decided not to include these therapies in CAM and to consider them as conventional therapies.

It is clear that patients’ use of CAM is an important clinical issue; this is especially true for rheumatologists and primary care physicians who treat rheumatologic disorders. Unfortunately, the most frequent sources of information about CAM are derived from patients' relatives or mass media rather than healthcare professionals. Because the use of CAM may negatively affect patients by causing an interaction with prescribed medications or a deferral of effective therapy, physicians should be ready to extensively inform their patients about the use of various CAM methods.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

The authors received no financial support for the research and/or authorship of this article.


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