The use of complementary and alternative medicine (CAM) [1] has increased significantly in Australia over the past decade and is now widespread amongst the general populations of most developed countries [2, 3]. One of the most common areas of CAM use is that of musculoskeletal care and in the context of back pain in particular, studies have illustrated that people use a wide range of therapies within and outside the conventional medical domain [4, 5].
The significance of back pain
The significance of back pain for Australian primary care delivery is evident in the fact that it is the second most common complaint in general practice consultations [6, 7] representing a key public health problem [8]. Back pain carries both high direct and indirect costs, including reduced capacity to work and participate in community life. For some back pain sufferers conventional treatments have limited therapeutic affect [8, 9] leading often to the use of various ‘alternatives’. Back pain care is delivered primarily by general practitioners (GPs), physiotherapists, chiropractors, osteopaths, acupuncturist, and massage therapists. Yet the actual usage and popularity of such modalities amongst Australians remains relatively unknown.
Studies internationally suggest that back pain sufferers often integrate a range of treatments offered by a range of different health care providers. This utilisation of multiple providers may also present difficulties in negotiating multiple and even conflicting models of care [8]. The limited research available suggests that people with back pain often lack confidence in their providers and the treatments they use [4, 10]. There is evidence suggesting confusion amongst GPs regarding the role, appropriateness, benefits and risks of the many different treatments available to treat back pain [11]. Limited exploratory research suggests that many Australian GPs are reluctant about, or reject, the assumptions underlying many treatment options for back pain (i.e. chiropractic and osteopathy) and are therefore resistant to referring beyond physiotherapy [11, 12]. GPs are more likely to suggest circumstances when patients request CAM providers such as chiropractic and osteopathy [12]. Despite the challenges of multiple providers in the context of back pain care, we know little about what treatments and practitioners Australians are utilising.
The role of CAM in back pain care
While the efficacy and use of CAM practices is debated, what is clear is that CAM therapies and therapists are playing an important role in the management and treatment of back pain [7, 9]. For example, existing Australian data shows chiropractic, acupuncture and osteopathy are frequently utilised by back pain sufferers [5, 7]. But the extent to which CAM practices are utilised in isolation from conventional practices is not well understood. While CAM use for management of back pain may be increasingly widespread there is some evidence that people are unwilling to utilise CAM as an exclusive source of CAM for their back pain [7].
The issues presented by the utilisation of competing or conflicting provider groups should not be underestimated. Studies have consistently revealed the lack of communication between patients and doctors about use of CAM [13–15]. It is often suggested that patients are reluctant to disclose their CAM use to their GP or doctor given the traditionally sceptical view of the medical community toward CAM regarding efficacy and risk [3, 13, 15]. Ultimately, consulting a range of professional groups often involves exposure to competing or conflicting claims to legitimacy and risk, leaving patients with difficult choices regarding who to consult and what advice to draw on [16].
Risk and efficacy in CAM for musculoskeletal care
In addition to issues of non-disclosure and disconnections in care provision between CAM and conventional medicine, there are concerns surrounding the potential for some CAM therapies to have adverse effects in the context of back pain [14, 17, 18]. While the level of CAM integration in back pain care has not been well documented, the simultaneous use of CAM and conventional medicine has historically been concerning for the medical community, given the varying and debated claims for legitimacy of evidence for the safety of some CAM practices. This in turn creates an environment of potential liability for general practitioners when referring to CAM providers if such adverse effects are experienced [19].
Ultimately, we know very little about the range of practitioners and practices people are using in Australia for back pain. We know CAM is widely utilised yet we acknowledge here that the broader efficacy and safety of individual CAM modalities are often ambiguous [17, 18]. The extent to which various CAM treatments constitute efficacious practices is also highly contested, and we know that acupuncture, chiropractic, osteopathy, and massage therapy are popular CAM options for women seeking back pain care [5, 7], but opinions differ on the validity, efficacy and safety of each of these CAM practices [20, 21]. Evidence from controlled trials offers little confirmation of the efficacy of individual CAM treatments in comparison to conventional care [20]. This study provides a national, representative perspective on what practices and practitioners mid-age Australian women with back pain are utilising including quality of life indicators and levels of satisfaction with conventional services.