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It has been more than 3 decades since Arthur Kleinman first reminded clinicians that individuals have more options to treat illness than just conventional biomedical approaches.1 In fact, the health care professional is often the last resort for patients, consulted only after popular remedies and traditional healing methods have been exhausted.2 To that end, it is estimated that as much as 80% of the world's health care is nonbiomedical.3
Although traditional healing is frequently integrated into the national medical system of its endemic country (eg, Ayurveda in India) and is common in places where limited access or prohibitive costs prevent the widespread adoption of biomedicine,3 traditional healing is not an integral component of the North American health care systems. This has led to its characterization as “complementary” or “alternative” medicine. The term complementary describes traditional practices used in combination with conventional biomedical approaches, whereas alternative connotes traditional practices that replace or substitute for biomedicine.4 The goal for many is integrated care in which the best treatments from conventional biomedical approaches are combined with safe and effective complementary and alternative medicine (CAM).4
The National Center for Complementary and Alternative Medicine (NCCAM), the leading federal CAM research agency in the United States, defines CAM as a variety of medical systems, healing traditions, and products not typically considered to be part of conventional biomedical approaches.4 As seen in Table 1, CAM can be broadly characterized into domains that include whole medical systems, natural products, manipulative and body-based practices, movement therapies, traditional healers, and energy field healing. Although useful for purposes of grouping, the clinician must remember that a CAM approach may overlap with several domains.
Despite growing interest in integrated care,5 much of CAM continues to be delivered outside of the North American health care systems at a considerable out-of-pocket cost.6 In fact, US adults are more likely to use CAM when conventional medical care is unaffordable.7 Despite these costs, CAM is widely used. Nationwide surveys suggest that three-quarters of US7 and Canadian adults5,8 have used some form of CAM in their lifetime. In addition, although there are no national data on CAM use in Mexico, a systematic review indicates high rates of indigenous Mexican CAM use among Mexican-American adults.9
Frequently, CAM use is reported to be highest among well-educated higher-income white adults.7 However, this is likely a function of survey questions that focus on vitamins and herb ingestion, and body-based (massage, chiropractic care) and mind-body therapies (yoga, acupuncture) to the exclusion of folk medicine and prayer, which are CAMs more commonly used by people of color and by the poor. For example, when folk medicine (defined as a “range of remedies including prayer, healing touch or laying on of hands, charms, herbal teas or tinctures, magic rituals”) was included in the 2002 National Health Interview Survey (NHIS), CAM prevalence was highest in black and Hispanic individuals and those living in poverty.10 Nonvitamin, nonmineral natural products and deep-breathing exercises were the most commonly reported CAM7 after prayer10 among US adults, whereas chiropractic care, massage, relaxation techniques, and prayer were most common among Canadian adults.5 In both groups, CAM was used for the treatment of a variety of somatic and psychiatric complaints, including neck, back, and joint discomfort; upper respiratory infections; anxiety; and depression.5,7
CAM is also frequently used by or for children. The 2006 Fraser Institute5 and 2007 NHIS7 surveys were the first comprehensive national surveys directed at understanding CAM use among North American children. Caregivers of children aged 0 to 17 were interviewed about the child's CAM use. Twelve percent of US7 and 15% of Canadian youth5 reported CAM use in the prior 12 months to treat neck and back pain, anxiety, and attention deficit and hyperactivity disorders, as well as head and chest colds.7 Children were most likely to use nonvitamin, nonmineral natural products, chiropractic care,5,7 homeopathy, and acupuncture.11 CAM use was fivefold higher in children who had a CAM-using parent compared with children who did not.7
Although CAM is commonly used to maintain wellness, national surveys have demonstrated their extensive use in treating common chronic medical conditions, including lung and digestive disorders, heart disease, hypertension, and diabetes.5,7 Lung problems generally5 and asthma and allergies specifically5,7,10 rank in the top 15 most common medical conditions for which CAM is used for both children and adults. Unfortunately, there is a lack of recent literature summarizing the rates of CAM use among children and adults with asthma. Moreover, there is a critical need to compile and summarize the growing body of evidence on the most prevalent CAM modalities used, CAM effectiveness, and its possible side effects. This summary is crucial for allopathic and CAM practitioners treating patients with asthma, as well as individuals with asthma and their families who are engaged in decision making regarding asthma self-management practices.
The aim of this systematic review was twofold. First, we aimed to quantitatively summarize the existing body of research on CAM use for asthma among children and adults. Second, we wanted to reflect on the most frequent CAM modalities used, the methodological quality and patterns presented in CAM studies, and the potential benefits and dangers of CAM use in asthma.
A systematic review of the literature12 was conducted using the following databases: PubMed, PyscINFO, and SCOPUS. The following search terms were used: “asthma” AND “complementary medicine,” “alternative medicine,” “complementary and alternative medicine,” “herbs,” “diet,” “dietary supplements,” “vitamins,” “acupuncture,” “breathing (Buteyko) exercises,” “relaxation,” “mind-body,” “homeopathy,” “ayurveda,” “traditional Chinese medicine,” “colon cleansing,” “music,” “chiropractic,” “massage,” “art therapy,” “aromatherapy,” “yoga,” “tai-chi.” Search terms were determined after reviewing existing CAM literature, reviewing information from NCCAM and compiling associated keywords and subject headings. Table 1 summarizes the different CAM domains and examples.
The place of publication was limited to North America (Canada, Mexico, and the United States). Publications were also limited to English, Spanish, and French languages. We did not limit the age of publications. Manuscripts were included if they (1) presented primary or original research and (2) were focused on CAM use among children and adults with asthma. Manuscripts were excluded if they were duplicates from different databases or did not present original research on CAM use among individuals with asthma.
The two authors (M.T. and M.G.) independently reviewed the abstracts and articles for inclusion with 100% interrater reliability. Data were extracted using a standardized template developed by the researchers to capture all relevant data. The template was reviewed by the authors and consensus reached through discussion between the authors.
A total of 1960 abstracts were identified from the initial review, of which 904 were duplicates. After a detailed review, 984 additional articles were excluded because they did not meet the inclusion criteria: 322 articles did not directly focus on CAM use among individuals with asthma; 214 manuscripts did not present original research; and 448 of the studies were conducted outside of the United States, Canada, or Mexico. As a result, 72 articles were included in the review. See Fig. 1 for the detailed description of the search process and findings and Table 2 presenting qualitative summary of the reviewed articles.
In general, there is an increasing body of research on the use of different CAM modalities among individuals with asthma. As presented in Fig. 2, the number of articles on the topic remained low until the mid 1990s and then grew steadily, especially through the past decade.
Overall, the reviewed literature includes studies conducted using diverse designs and methodological techniques, ranging from randomized controlled trials (RCTs) to qualitative research using in-depth interviews. Specifically, 42% of the reviewed articles (n = 30, see Table 2 for details) reported results of surveys, using either descriptive or correlational designs. Most of these used secondary data from large-scale, comprehensively developed and thoroughly conducted national US surveys. For example, Joubert and colleagues13 analyzed data from the National Health Interview Survey (NHIS), the principal source of information on the health of the civilian noninstitutionalized US population. The NHIS is one of the major US data-collection programs.14 Using secondary NHIS data, the researchers were able to analyze 3327 responses of individuals with asthma across the United States to identify the association between asthma episodes in the past 12 months and CAM use, controlling for comorbid conditions. Several other investigators using similar survey designs were able to identify significant patterns of CAM use and its affects in the United States15–19 and in Canada.8,11
Only one-third of the reviewed studies (n = 21) were RCTs despite RCTs being considered the “gold-standard” design when causal relationships between the treatments and health outcomes need to be established.20 Further, there were several issues related to the quality of several of the RCT studies identified from this review. One example is an application of a technique that addresses the problems associated with incomplete data because of participant withdrawal, described as “intention-to-treat” analysis (ITT). In the ITT approach, all the participants are retained in study data analyses regardless of their path through the trial and completion of the study.21,22 Participants are retained in the treatment group they are randomized to (“as randomized”), rather than being classified according to the actual treatment they received (“as treated”). In general, ITT analysis produces an unbiased estimate of treatment effectiveness.22 One fundamental assumption of the ITT method is that missing data and participant withdrawal are not related to the unobserved outcome. ITT also assumes that compliance among those who remain in the trial and those who withdraw is equivalent. Sensitivity analysis and other statistical methods were developed to validate this assumption.21 In our review, 24% of the RCT studies used the ITT approach in their analysis23–27; however, some of the researchers did not mention whether the assumptions about the missing data and adherence were validated and if sensitivity analysis was performed.23,24 This lack of information significantly limits the interpretation of the results of the reviewed RCTs.
Thirteen of the reviewed studies (18%) were conducted using quasi-experimental designs (mostly a 1-group pretest posttest design). This type of studies is important, especially when experimental methods are impractical or unethical to use; however, it is challenging to make definitive causal inferences using results of these studies. Several statistical methods were recently developed to enhance the causality conclusions of quasi-experimental studies, for example propensity scoring that reduces the confounding effects of covariates. Unfortunately, we did not identify that these methods were used in the reviewed manuscripts. In addition, it was noted that the number of quasi-experimental studies has decreased over time, with only 2 articles using this methodology published since 2005.
The balance of the reviewed studies (10%) used qualitative methods for the data analysis. Application of qualitative methods helps researchers to glean important personal information that is usually inaccessible otherwise. For example, Freidin and Timmermans28 used open-ended questions to understand the experience with biomedical treatments, social influences, and concerns about adverse and long-term effects of prescription asthma medicines among mothers of children with asthma. In another study, George and colleagues29 used in-depth interviews to identify causal models of asthma and the context of conventional prescription versus CAM use in low-income African American adults with asthma. More studies using qualitative methods are needed to further understand factors related to asthma medication adherence, possible adverse effects of CAM therapies, and other issues.
High CAM prevalence rates have been reported for both children and adults with asthma. Pediatric use has been reported to be as high as 80% when folk medicine (which includes prayer) is included in the broad definition of what constitutes a CAM practice.30 Approximately one-quarter of children reported CAM use for asthma in the past year16,31 and use is highest in those children with poorer asthma control,11,32 financial barriers to conventional care,16 greater severity,16 more symptoms,30,33,34 or a CAM-using parent.7,30,31,35 As much as 80% of pediatric CAM care required an out-of-pocket expenditure.36
Similarly, CAM use for adult asthma is extremely high (96%–100%) when survey questions include folk medicine/prayer.29,37 More than 70% report CAM for symptom management in the past month33 and prevalence is higher in adults with work-related asthma,15 financial obstacles to accessing care,17,19 more symptoms,17,33 more stress,38 and more frequent attacks.13
Fig. 1 presents the reviewed articles by CAM domain. Almost half (47%) of the reviewed articles focused on multiple CAM modalities, with 30% concentrated solely on mind-body CAM approaches, 15% on natural products, and the remainder on manipulative and body-based practices (6%) or energy-field healing (2%).
As seen in Table 1, natural products encompass a wide variety of ingestible goods that include herbs, vitamins, minerals, specialized diets, dietary supplements, and botanicals. Unfortunately, much of what we know about their use is limited to prevalence surveys; few experimental studies have been conducted.
Unlike prescription drugs, manufacturers do not have to prove either the safety or the effectiveness of natural products. In fact, labels such as “safe,”“standardized,”“verified,” or “certified” do not guarantee quality or consistency.39 For example, herbal therapies may contain more than one herb, the wrong species of herb, a higher or lower dose of active ingredient than listed on the label, or contaminants, such as other herbs, prescription medicine, pesticides, and heavy metals.40 In addition, natural products are not inert and may interfere with prescription drugs to cause unintended side effects.41
Although vitamin supplementation is commonly used for pediatric asthma,16,31,35 a large longitudinal cohort survey study suggests that early vitamin supplementation may actually increase risk for asthma and food allergies in certain vulnerable populations.42 High use of herbal therapies is also reported,16,30,31,43,44 including over-the-counter (OTC) topical chest rubs made with camphor, eucalyptus oil and menthol,30 herbal teas,30 aloe plant juice, 44Echinacea,44 sweet oil (eg, olive, rapeseed, almond),44 and an herbal cough syrup sold in botanicas containing sweet almond oil, castor oil, tolu (tree resin), wild cherry, licorice, cocillana (grape bark), and honey.30 Atypical products reported include ephedra, turpentine, pine needles, and dried cow dung.44
Children with asthma also use dietary supplements,35 nutritional supplements, and elimination diets31 without scientific evaluation of their safety or effectiveness.4 In one study, Covar and colleagues24 randomized children with asthma to either a nutritional formula composed of antioxidants, omega-3 and omega-6 fatty acids, or a control formula; there were no differences in asthma-free days between groups, although inflammatory biomarkers decreased in the children receiving the nutritional formula.
Multivitamin use is associated with asthma in older adults45 and herbal products are widely used (93%) by the general adult asthma population.29,46 Commonly used herbal therapies include chamomile, mint, and Echinacea.19,29,47–49 In addition, OTC ephedra products, as well as coffee and tea (which contain natural methylxanthines), are widely used to supplement, or replace, short-acting β-2 agonists (SABAs) for “rescue” treatment of acute asthma.29,48,49 Adults also report the use of home remedies to augment asthma self-management, such as Hall's lozenge-infused tea (Mondelēz International Three Parkway North Deerfield, IL, USA), OTC chest rubs, and the ingestion of onion tonics, spicy foods (eg, horseradish), or cold drinks.29 Importantly, a small number of individuals report oral ingestion of topical camphor products (eg, Vicks VapoRub [Proctor and Gamble, Cincinnati, Ohio, USA]).29 Although few of these products have been scientifically evaluated, there are several studies of dietary supplements. These include studies of magnesium,50 fish oil alone51,52 or in combination with Vitamin C, and a standardized hops extract.23 Asthma quality-of-life scores improved in those who received long-term magnesium supplementation50 and the combined nutritional supplement (fish oil, Vitamin C, and hops).23 However, there was no attention control group in the combination supplement study, making it impossible to attribute improvements to the supplement.23 Other markers of asthma control, such as reduced bronchial hyperreactivity, pulmonary function, and inflammatory biomarkers improved with magnesium and fish oils.50,51
Several innocuous-appearing natural and OTC products have the potential for serious side effects, including death. For example, Echinacea (cone flower daisy) and chamomile are members of the Compositae or ragweed family. Worsening asthma may result if a ragweed-sensitive individual uses products derived from the daisy family, which includes honey made from the plants or pollens of Compositae.53 In addition, OTC natural ephedra (found in ma huang, a Traditional Chinese Medicine herb), can have a synergistic cardiovascular effect when used with albuterol.54 Black licorice made from the glycyrrhiza root can prolong the half-life of cortisone, potentiating systemic steroid effects.55 Further, the recommended dose of Hall's is 1 to 2 lozenges every 2 hours, which delivers a total dose of 6 to 20 mg of menthol; some adults used large quantities of lozenges (10) in a single serving of tea,29 which may be harmful.56
Of greatest concern, however, were the reports of turpentine oil and Vicks VapoRub ingestion29,44 and risky behaviors associated with natural product use. First, ingesting turpentine oil57 and OTC topical chest rubs can be fatal in children and may pose some risk for adults.58 Second, even when natural product use is not in and of itself harmful, its use may contribute to risky health behaviors. For example, herbal product use is associated with decreased inhaled corticosteroid adherence.59 Further, substituting caffeinated products (tea and coffee) for SABAs translates to the use of less potent natural therapies for more rapid-acting and effective prescription therapies during acute asthma episodes.37 This may lead to less effective reversal of bronchospasm and contribute to delays in seeking appropriate medical intervention, placing the individual at increased risk for near-fatal or fatal asthma.41
Mind-body medicine encompasses a wide variety of practices that seek to use the mind to enhance physical functioning and health and are generally considered safe in healthy people when practiced.90 Table 1 provides detailed information about many mind-body practices.
Breathing exercises (59%),16 prayer (70%–80%),33,60 and relaxation (85%) are the most popular mind-body approaches used by children with asthma.33 Relaxation training may be taught as a stand-alone therapy61,62 or paired with biofeedback63,64 or guided imagery.65–67 Although early studies suggested that relaxation might improve lung function,62 these findings were not replicated in larger trials.61 However, in several small feasibility studies without a control condition, biofeedback-induced relaxation was associated with improvement in lung function,63,65,68 stress,63 depression,63 and anxiety,65 whereas relaxation coupled with guided imagery improved lung function and anxiety.66,67 Although one small RCT of biofeedback and relaxation demonstrated improved pulmonary function, anxiety, and attitudes toward asthma, there was no difference between groups in asthma medication use, number of asthma attacks, or self-concept.64
Hypnosis has also been examined in 2 pediatric asthma studies using a pre-post design. Reductions in symptoms69 and severity scores without concomitant improvement in the number of asthma episodes or in pulmonary function tests were reported.70 Further, a small RCT of an art therapy intervention (compared with a wait-list control) reported decreased anxiety and increased quality of life,71 whereas music therapy (singing) was associated with maintenance or improvement of lung function compared with relaxation.72
Mind-body approaches are very popular among adults with asthma, including qi gong, tai chi,11 prayer, humoral balance, and relaxation.29,37 Intervention studies of relaxation have demonstrated improvement in well-being and pulmonary function, as well as reduced symptoms73 without a reduction in cortisol after training.74 Subjects enrolled in biofeedback27 or guided (mental) imagery75 interventions required less asthma medicine27,75 and demonstrated improved lung function without concomitant improvement in the number of asthma flares27 compared with a control group.
Other mind-body approaches studied included yoga, meditation, and music therapy. In a small controlled trial of yoga instruction that included postures (yogasanas), breathing exercises (pranayamas), and meditation, intervention subjects reported enhanced relaxation and less SABA use compared with control subjects, although objective measures of lung function remained unchanged.76 Further, a randomized, controlled, double-masked clinical trial of Iyengar yoga failed to demonstrate any between-group differences in asthma quality of life, SABA use, spirometry, symptoms, or health care utilization for asthma.26 In addition, small intervention studies of transcendental meditation,77 music therapy, and progressive muscle relaxation27 improved lung function, although the small increases in function were not considered to be of clinical significance.27
Two studies used multiple CAM interventions. In the first RCT, yoga, journaling, and nutritional manipulation (elimination diet coupled with supplements of fish oil, Vitamin C, and a standardized hops extract) were given to the intervention group with subsequent improvements in their asthma quality of life scores. These results should be viewed cautiously, however, because of the lack of a control group and the confounding of multiple interventions.23 In the second study, patients with asthma received training on multiple mind-body approaches, including deep-breathing relaxation, a cognitive-behavioral intervention, and journaling. When compared with an attention control group, the intervention group experienced improved lung function.78
Single studies of Buteyko breathing and hypnotic susceptibility in adults have also been conducted. In an RCT of Buteyko, intervention subjects demonstrated improved asthma control with less medication use up to 6 months after training compared with the control condition.79 Moreover, a correlational study identified that higher hypnotic susceptibility scores were associated with less airway hyperreactivity.79
Finally, several RCTs of acupuncture have been conducted in adults with asthma with mixed results. Treatment was associated with improved asthma quality of life25 and reports of improved asthma80 although acupuncture did not demonstrate improved lung function,80,81 reduced need for medications,25,81 or reduced symptoms.81
NCCAM classifies most of the mind-body interventions as “safe”; however, there is small risk associated with some approaches. For example, progressive muscle relaxation has been associated with decreased airflow82–84 and increased heart rate variability82,83 in patients with asthma. In addition, there are case reports of untoward effects of mind-body therapies in the general population. For example, case reports describe complications related to yogic postures, including nerve or spinal damage,85 worsened glaucoma,86 and stroke.87 There are also reports of yoga breathing causing pneumothorax.88 Rare but serious complications may also result from acupuncture, including blood-borne illnesses, punctured organs, and vascular damage.89 There are also reports of intensification of mania and distress after meditation90 and hypnosis91 in patients with mental illness.
Spinal manipulation and massage are the 2 primary manipulative and body-based approaches. As described further in Table 1, practitioners manipulate joints and massage soft tissue to reduce pain and stress and to facilitate relaxation.
There are very few studies of manipulative and body-based practices despite a high rate of use by children with asthma.35 A small RCT demonstrated that massage therapy reduced anxiety and cortisol levels immediately after treatment and improved attitudes toward asthma and lung function over time compared with the control condition (progressive muscle relaxation). These findings were more pronounced in younger children compared with older children.92 In a study by Bronfort and colleagues,93 chiropractic spinal manipulative therapy improved asthma quality-of-life scores but failed to demonstrate any important changes in lung function or airway hyperreactivity compared with a sham chiropractic treatment. In an RCT of a spinal manipulation intervention, chiropractic care provided no additional benefit over usual medical care in children with mild to moderate asthma.94
Only one study of manipulative therapy (craniosacral treatment) for adults with asthma was identified in this review.25 In this investigation, 89 subjects were randomized to 1 of 5 groups: acupuncture alone, craniosacral therapy alone, acupuncture and craniosacral therapy together, attention control, or usual care/wait list. Asthma quality-of-life scores improved in all 3 of the active intervention groups, although the combination of acupuncture and craniosacral treatment was not superior to either therapy alone. Medication use and pulmonary function were unchanged.25
When provided by a trained therapist, there are relatively few serious risks associated with massage or spinal manipulation for children or adults with asthma. Before massage therapy is initiated, a health care professional should provide medical clearance for individuals with concomitant conditions, such as pregnancy, propensity for bleeding (bleeding disorders, anticoagulant therapy), solid tumor cancers, blood clots, fractures, open wounds, skin infections, osteoporosis, or recent surgery.95 Most serious side effects associated with spinal manipulation involve treatment of the cervical area and may include vertebrobasilar artery stroke and cauda equine syndrome.96
Whole medical systems are complete systems of theory and practice that have evolved over time in different cultures and apart from Western medicine.4 They include Traditional Chinese Medicine from China, Ayurveda from India, and homeopathy and naturopathy from Europe (see Table 1). Although these systems are widely used for asthma, no adult or pediatric studies were identified in this review.
Mind-body medicine, manipulative approaches, and natural products are often essential components of whole medical systems approach to treating asthma. Therefore, the previous caution about their use is operative when patients seek such treatment; however, a particular point should be made about homeopathy. Because homeopathic treatments traditionally involve the ingestion of natural products, clinicians may be concerned about interactions or adverse side effects. Generally, plant material used in the preparation of homeopathic products is diluted to such infinitesimally small doses that not even one single active biologic molecule may remain in the “mother tincture,” thus rendering the product harmless.97 However, nasal zinc is an exception to this rule. Reports of permanent loss of smell forced the Food and Drug Administration to recall this homeopathic cold remedy, which was not neither dilute nor orally ingested.98
As described in Table 1, magnets, Reiki, and therapeutic touch are the most commonly used energy-field healing practices. No adult or pediatric studies of energy healing were identified in this review.
There is no known risk in the use of energy field healing practices such as Reiki or therapeutic touch.99 Magnets are also safe when applied to the skin and are contraindicated only for individuals with medical devices affected by strong magnetic fields, such as pacemakers, implanted defibrillators, and insulin pumps.100
Pilates, Rolfing, and Alexander are common movement therapies (see detailed in Table 1). No adult or pediatric studies examining movement practices were identified in this review.
Although only one scholarly article on the safety of movement therapies was located (a single case report of a spontaneous diaphragm rupture attributable to Pilates),101 it is likely that some of the same concerns about massage may be applicable to Rolfing and that the Alexander technique might cause minor fatigue or muscle tenderness.
Mexican Curandera, Native American shaman, Puerto Rican santeros, and Voudoun houngans and mambos are among the many traditional healers that practice healing arts in North America (see Table1). No adult or pediatric studies examining traditional healers were identified in this review.
The use of natural products in traditional healing may cause drug-herb interactions, as previously described. In addition, some herbal preparations may be smoked as a treatment for asthma.102 Alternatively, individuals may visit a smokehouse where poor indoor air quality has been identified as a health risk for individuals with respiratory disorders, including asthma.103 Other potential dangers of traditional healing have not been reported.
This review uncovered important information, not only about the types and patterns of CAM use, but also about the influence of CAM on asthma self-management decisions and behaviors in children and adults with asthma. For instance, a large qualitative study found that mothers considered their child's daily asthma therapy to be optional despite it being prescribed for daily use, were strongly influenced by their social network to use CAM for their child's asthma, and were not demographically distinguishable from mothers who used conventional prescription treatment.28 Most (77%) caregivers considered herbal therapies to be safe and did not believe that herbs interacted with medication; only 1% could correctly name a drug-herb interaction.44 Further, research demonstrated that adolescents were familiar with culturally relevant CAM104 and believed CAM to be an effective part of their asthma armamentarium.30,60 Conversely, 71% of children and their caregivers voiced concerns about the safety of prescription therapies.43 However, self-reported adherence to daily asthma therapies did not change with the initiation of CAM.105
Despite the high rates of CAM use, only one-third of pediatricians asked about CAM.106 Importantly, if asked, caregivers disclosed at relatively low rates ranging, from 36%31 to 54%.107 Caregivers were more comfortable disclosing yoga and dietary interventions than prayer or guided imagery.33 As a result of this reluctance to divulge CAM use, partial disclosure was more common (62%).35 However, 80% of caregivers reported that they wanted to tell their provider about their child's CAM use.31
Most adults (84%) preferred an integrated approach for asthma self-management that included CAM and prescription therapies.37 Nurses and CAM practitioners were more likely to ask about CAM use than allopathic physicians,108 although there are no disclosure rates available specific to adults with asthma. CAM use was associated with low rates of adherence to daily prescription medicines37,59 and increased rates of hospitalization for life-threatening asthma.49,59 These high rates of acute health care utilization were independent of disease severity, suggesting that the use of less potent CAM for the home management of acute asthma may unnecessarily delay professional treatment and contribute to higher hospitalization rates.49 This is supported by qualitative studies in which patients reported that CAM was safe and effective for the initial treatment of severe attacks,29 was safer than SABAs, worked quickly and synergistically with SABAs,37 and allowed for the customized treatment the patients desired.37,109
There is a growing body of evidence on the use of CAM by individuals with asthma, particularly in the domains of natural products, mind-body medicine, and manipulative and body-based practices. Natural products were the most common CAM used by both children and adults with asthma. Unfortunately, much of what is known about the effectiveness of these treatments is based primarily on prevalence surveys and a few methodologically weak intervention studies that reported mixed results. Of note, several natural OTC products have the potential for serious side effects, including death. Use of natural products was also associated with risky asthma self-management behaviors, such as decreased adherence to allopathic treatments.59 Mind-body medicines were also frequently used for asthma with one-third of the reviewed literature focused uniquely on this CAM approach. There were also several trials of spinal manipulation and massage, examples of manipulative and body-based practices. Again, weak study designs, mixed results, and the possibility of serious side effects are concerning. Most importantly, CAM use was rarely discussed in the clinical encounter.
Many clinicians assume that patients turn to CAM only when they have received a cancer diagnosis or develop cancer treatment-related symptoms.110,111 However, CAM is a popular treatment for asthma as well as a number of other chronic medical conditions, including diabetes,5,6,111,112 hypertension,5,6,113 and heart disease.5,6,114 The desire to use CAM as a way of personalizing treatment has also been noted by other researchers.115,116 Perhaps one of the most underappreciated risks of CAM is the failure of health care providers to inquire about CAM and patients' reluctance to disclose CAM use.117
There are several clinical implications of this review. First, it is important for clinicians and patients to discuss the risks associated with CAM use that include, but are not limited to, use of adulterated natural products, drug-herb interactions, and rare but serious events associated with innocuous-appearing therapies. Second, all CAM self-management strategies must be assessed for their timeliness and appropriateness, and negotiated through a shared decision-making model. For example, this review identified the risky behavior of substituting CAM for both “rescue” and daily asthma therapies. Perhaps a jointly developed plan that promotes the use of both CAM and prescription therapies at each of these events would be useful as a means of addressing patient preferences while also reducing the risk of an untoward event.
To be successful in this endeavor will require the provider to become better educated about CAM, to take the initiative in inquiring about CAM at each office visit, and to create a safe environment in which disclosure is facilitated. With this comes responsibility on the part of the health care professional to respond respectfully and professionally to disclosure. If the patient perceives that the provider is dismissive, derisive, or unsupportive, then a disruption to the therapeutic alliance can result.118 Health care professionals need help to successfully meet these expectations. The construction and validation of research instruments that address the integral role of CAM in asthma self-management decisions is a critical first step in the systematic collection of data about patient perceptions and preferences for care.119 Engaging in continuing education is also of paramount importance, as this training will facilitate a deeper appreciation for the reasons patients prefer CAM and will promote the acquisition of the enhanced communication skills needed to support integrative treatment as a cornerstone of patient-centered care.
In summary, this review provides clinicians with important new information: (1) CAM is widely used by both children and adults with asthma; (2) relatively little is known about the safety or effectiveness of CAM for asthma, owing to the paucity of well-designed studies; (3) patients use CAM to create a tailored asthma self-management plan; (4) CAM influences patients' prescription medication–taking behaviors, which, in turn, produces other health risks; and (5) patients and health care professionals do not talk about, or participate in, shared decision making concerning CAM use. Most importantly, this review identifies knowledge gaps that can be addressed by future research. Taken together, this new knowledge may help narrow the divide between what patients want, and what providers currently offer, for asthma self-management.
Funding Sources: Mr Topaz: None; Dr George: This study was supported by the National Center for Complementary and Alternative Medicine (National Institutes of Health) 1K23AT003907-01A1. Conflict of Interest: None.