Reasons for Movement Therapy Alternatives for Older Adults from the NHIS Survey : A Guide for Practitioners

Background: Data is limited about reasons why older adults in the U.S. with chronic musculoskeletal conditions engage in movement therapy (MT), specifically yoga. Objective: To characterize older adults with a chronic musculoskeletal condition who practice yoga, and their reasons. Methods: A cross-sectional analysis was conducted using the national representative of National Health Interview Survey (NHIS), 2012 and supplemental survey on Complementary and Alternative Medicine (CAM). Adults aged 50 and above with a chronic musculoskeletal condition, those who practices yoga, were selected. Four sub-populations resulted: men and women aged 50 and older (n = 16,350) and with arthritis, rheumatoid arthritis or any joint issues that limit activities (n = 8761), who practices yoga (n = 1,637) and those at the age 50 years or older with a chronic musculoskeletal condition and practiced yoga (n = 939). Results: Women, Asians, and Whites were more likely to practice yoga. The oldest (80+) were less likely to practice yoga as compared to those aged 50 to 55. Those with a chronic musculoskeletal issues were 40% more likely to practice yoga because it was recommended a natural alternative (OR: 1.4, CI: 0.99, 1.98, p = 0.0601); almost twice as likely to practice yoga because it was recommended by a friend (OR: 1.98, CI: 1.47, 2.68, p < 0.001); 2.8 times more likely to practice yoga because it can be done on one’s own (OR: 2.75, CI: 1.97, 3.86, p < 0.001); 4.6 times more likely to practice yoga because it focuses on the whole person (OR: 4.62, CI: 3.28, 6.51, p < 0.001); women with chronic musculoskeletal issues were just over twice as likely to practice yoga as compared to men (OR: 2.17, CI: 1.68, 2.82, p < 0.001). Conversely, of those with chronic musculoskeletal issues who had yoga recommended by family members, 26% were less likely to practice yoga (OR: 0.74, CI: 0.53, 1.03, p = 0.074) and 24% less likely because it was recommended by a physician (OR: 0.76, CI: 0.58, 1.0, p = 0.0531). Conclusions: Yoga participants of 50 years and above age with a chronic musculoskeletal condition were more of whites, females, and under the age of 70. Also, the practitioners who are involved in patient care and familiar with the most common reasons for MT use can offer these alternatives more confidently.


Background
Although approximately one-third of Americans engage in some form of complementary and alternative health practices, there is still much to learn about the reasons and conditions under which these therapies are used.A recent report by the U. S. Department of Health and Human Services indicates a doubling of yoga use among adults between 2002 and 2012 [1].A systematic review by Ware NC et al. [2] suggested that yoga is an acceptable and safe intervention, which may result in clinically relevant improvements in pain and functional outcomes associated with a range of muscular skeletal conditions (MSC).
A meta-analysis of controlled and randomized clinical trials by Jeter PE et al. [1] indicated yoga has a moderate treatment effect on functional outcomes in mild to severe low back pain (LBP), rheumatoid arthritis (RA), fibromyalgia and moderate treatment effects on pain outcomes in LBP. Ward L et al. [3] using a systematic review and meta-analysis, explored the use of yoga for improvements in functional ability, pain and psychosocial outcome in those with musculoskeletal conditions.The main reasons cited for using complementary and alternative medicine (CAM) therapies were either as an adjunct to biomedical treatment or as a preferred treatment option.
Alexander and colleagues evaluated the perceived benefits of yoga in older adults in a 2013 qualitative study.Additional benefits in improved physical function, emotional state, improved sleep quality were recognized by participants following eight weeks of Lyengar yoga.The authors concluded yoga could serve as a strategy in both health promotion and management of chronic disease [4].There is limited data on reasons older adults in the U.S. with chronic musculoskeletal conditions engage in movement therapy (MT), specifically yoga [5].In light of the growing interest in the therapeutic benefits and cost-effectiveness of yoga for prevention and alleviation of symptoms related to disease, the need for more evidence has never been more compelling [1].
The purpose of this study was to assess the reasons in older Americans with chronic musculoskeletal conditions practice movement therapy, specifically yoga, and to further identify how these reasons differ between four sub-populations: 1) older Americans, 2) older Americans with a chronic musculoskeletal condition, 3) older Americans who practice yoga, and 4) older Americans with a chronic musculoskeletal condition who practices yoga.Whether or not participants benefited from their yoga practice was not available for outcome analysis.Practitioners with this information can more confidently recommend movement therapy alternatives to their patients with chronic musculoskeletal conditions.The research question was: What are the reasons older Americans with chronic musculoskeletal conditions practice movement therapy?

Movement Therapy
The National Center for Complementary and Integrative Health (NCCIH) defines Movement Therapy (MT) as a large and diverse group of procedures or techniques administered or taught by a trained practitioner or teacher.The NCCIH is a subset of the National Institutes of Health (NIH), a part of the US Department of Health & Human Sciences.The purpose of NCCIH is to define, through rigorous scientific investigation, the safety and usefulness of Complementary and Alternative Medicine (CAM).The most recent NHIS (National Health Interview Survey) completed in 2012, included yoga, Tai Chi and chiropractic manipulation among the most popular MT practices used by adults.The popularity of yoga has grown dramatically in the past 10 years, with almost twice as many U.S. adults practicing yoga in 2012 as practiced in 2002.

ISSN: 2470-1017
Likewise, the popularity of Tai Chi has also grown.For this study, yoga is the focus of Mind and Body Practices [6].

Yoga Practice
Yoga is a body of ancient Indian practices which has gained popularity in the current culture to positively influence flexibility and mobility.As such, yoga is a promising physical activity for older adults with chronic musculoskeletal conditions that diminish a patient's movement and flexibility [7][8][9].Many forms of yoga exist, with the most popular forms being Laughter Yoga, Hatha Yoga and Lyengar Yoga.These practices use properties such as bolsters, belts and chairs to adapt to an older individual's abilities [10,11].

Tai Chi Techniques
Tai chi is a centuries-old mind and body practice that involves specific postures, mental focus, breathing, and relaxation techniques.Tai Chi practitioners move their bodies with awareness, slowly and gently, while breathing deeply.While the practice of Tai Chi has increased between 2002 and 2012, its practice remains relatively small compared with yoga.Yet, as mentioned above, Tai Chi is often grouped with yoga as part of MT practices [12].
For the purpose of this study, participants were asked if they practiced yoga as a choice of movement therapy.Tai Chi is marginally included, as only one of the NHIS survey questions asked if participants "took a class or received formal training for yoga/tai chi"?Yoga is the MT focus of this paper.

Older adults and physical activity
Older adults with chronic musculoskeletal conditions are generally less physically active and are at increased risk of functional limitations, disability, and frailty [11,13,14].Physical activities shown to improve functioning in older adults include weight training, power training, walking to promote endurance, and yoga [11,15].In 2015, a study completed at John Hopkins reported that eight weeks of yoga classes improved the physical and mental well-being of people with two common forms of arthritis, knee osteoarthritis and rheumatoid arthritis [16].

Prevalence of Chronic Musculoskeletal Problems among Older Americans
Arthritis and other chronic musculoskeletal conditions are among the most common chronic diseases affecting millions of American adults [17].As the mean age of the population rises, coupled with the increase in obesity and sedentary lifestyles, chronic musculoskeletal conditions potentially play a significant role in one's quality of life due to physical disability in the future [17].In 2008, The National Arthritis Data Work group reviewed published analyses from the National Health Interview Survey and found that more than 21% of US adults (46.4 million persons) have self-reported or doctor-diagnosed arthritis [18].Of those suffering from arthritis, approximately 27 million have clinical osteoarthritis or other forms of chronic muscle, bone, or joint pain that limits the individual's activity [19].

Age Threshold for Chronic Conditions
For this study, older adults were defined as individuals age 50 and older.This definition is consistent with established approaches to defining the older population when studying health issues [20,21].The Centers for Disease Control and Prevention (CDC) defines older populations as age 50 and above because this is the decade in which many major chronic disease processes begin to manifest symptoms, including arthritis.Using age 50 to define older adults is particularly appropriate for African Americans, Hispanics, women, and people with less income, who are more likely to have chronic diseases and other challenges to health and function at earlier ages [22].

Yoga for Pain Control
The CDC has recommended three modalities for the management of arthritis; one of which involves self-management and physical or occupational therapy [19].Self-management and increased physical activity are paramount in the management of arthritis pain.Chronic pain is stressful [23].A well-known benefit of yoga is its ability to reduce stress with the combination of deep breathing and gentle movement [10,24].There is promising evidence supporting the use of yoga for both pain relief and alleviating the symptoms of arthritis [16].

Methods
Data was obtained from the 2012 National Health Interview Survey (NHIS) and its Complementary and Alternative Medicine supplement [5].The NHIS is a nationally representative, crosssectional, multistage household survey of the non-institutionalized, civilian U.S. population.The survey has been conducted annually since 1957 by the National Center for Health Statistics.The NHIS is one of the major data collection programs of the National Center for Health Statistics, part of the Centers for Disease control and prevention (CDC).This survey collects information about the use of medical services, health status, and other health measures.It is a principal source of health information representing the civilian, non-institutionalized populations of the U.S. Survey details are publically available on the CDC's website [25].The analysis focused on the 16,350 total respondents who used CAM and were ages 50 and older.
A cross-sectional analysis was conducted using the 2012 NHIS data for adults aged 50 and over who had a chronic musculoskeletal condition and reported practicing yoga.For the purposes of this study, a "chronic musculoskeletal condition" was identified as a composite of six survey questions regarding individuals having arthritis, rheumatoid arthritis or any joint issues that limit activities.Respondents' answering 'yes' to any of these items were included for analysis.These conditions involve a disorder or condition that potentially limits motion.NHIS survey sections selected for analysis included the Sample Adult Core, Person Public Use, and the Alternative Health/ Complementary and Alternative Medicine supplement.Merging of these sections produced a database including adults 50 years and older, adults with musculoskeletal disorders, adults who used CAM and the reasons for CAM use.
The resulting database produced four sub-populations: men and women who were at the age of 50 and older (n = 16,350) and were told they had arthritis, rheumatoid arthritis or any joint issues that limit activities (n = 8761), who practiced yoga (n = 1,637) and who were age 50 and older with a chronic musculoskeletal condition and practiced yoga (n = 939).
The research protocol was approved by the Institutional Review Board at Western Carolina University in Cullowhee, North Carolina.

Dependent Variable
The dependent variable of this study is "practiced yoga", a dichotomous variable with three components.The NHIS asked participants (1) if you "did yoga, past 12 months"; (2) if you "ever did yoga"; and (3) if you "took a class or received formal training for yoga/tai chi".A positive response to any of these questions indicated that the participant had done some form of yoga.To simplify the presentation of results, the authors refer to this combined variable as "practiced yoga."

Independent Variables
The independent variables were the 13 reasons for doing CAM.These thirteen reasons were: it was recommended by a medical doctor, it was recommended by a family member, it was recommended by a friend, it was recommended by a co-worker, medical treatments were too expensive, therapy combined with medical treatment would help, medical treatments did not work, medications caused side effects, it can be practiced/done on your own, it is natural, it focuses on the whole person, mind, body, and spirit, it treats the cause and not just the symptoms, it was part of your upbringing.

Exposure Variable
The variable 'chronic musculoskeletal condition' is a dichotomous variable combined with multiple components.Chronic musculoskeletal condition was set to "yes" if any of the following were true: had a fracture, bone or joint injury causing difficulty with activity, had muscle/bone pain in the past 12 months, ever been told you had arthritis or rheumatoid arthritis, or had activity limited due to arthritis or joint symptoms.

Demographic Characteristics
The descriptive variables were age, and race/ethnicity.Age was coded into five-year ranges, with referent category of 50 to 54 years of age.This categorization limited the possibility of confounding by age while permitting identification of nonlinear results [26].Ethnicity was represented with five groups: non-Hispanic African American (hereafter African American), non-Hispanic White (hereafter White), Hispanic, Asian, and other.White was chosen as the referent category because it represented the largest number of participants.This categorization limits the possibility of residual confounding while permitting the identification of any notable nonlinearities in the results.

Statistical Analysis
Analyses included logistic frequency statistics for the descriptive variables for everyone at the age of 50 and older, everyone at the age of 50 and older with yoga practice, everyone at the age of 50 and older with a chronic musculoskeletal condition and everyone age 50 and older who practiced yoga and had a chronic condition.
Logistic regression models were estimated for yoga use.This model predicted the adjusted likelihood that a participant who had chronic musculoskeletal issues report having done yoga.Variables were assessed for multicollinearity, of which there was no notable evidence.All analyses were weighted for national representation [5].Data were analyzed using SAS 9.4 (Cary, NC) to account for the survey design.In order to obtain accurate prevalence estimates for use of health care practices, data was weighted per the NHIS survey description document [5].These data reflect a portion of the population Sharma M, et al. [19] reported as suffering from clinical arthritis or other forms of activity-limiting chronic muscle, bone or joint pain.While men reported using CAM at a higher percentage than women (53.34% vs 46.66%), when asked about the presence of a chronic musculoskeletal condition, women reported a higher use of CAM as compared to men (42.51% vs 57.49%).Women reported practicing yoga at a higher rate than men regardless of the presence of a chronic musculoskeletal condition (without chronic musculoskeletal 26.98% vs 73.02%; with chronic musculoskeletal 25.95% vs 74.05%).

Summary of Sample
Whites report a much higher use of CAM (75.81%) than any The percentage of those using CAM between the ages of 50 and 69 are range from 21.84% to 13.51%.Beginning at age 70, the range declines in the percentage in the use of CAM (9.67% -4.64%).

Prevalence of Reasons for Participation in Yoga
Table 2 displays the prevalence of the 13 reasons for using CAM by four sub-populations: 1) of Americans age 50 and older, 2) of Americans age 50 and older with chronic musculoskeletal conditions, 3) of Americans age 50 and older who practiced yoga, and 4) of Americans age 50 and older with chronic musculoskeletal conditions who have done yoga.
In the population of Americans age 50 and older, the lowest prevalence was 1.02% (n = 666) and the highest prevalence was 18.64% (n = 3048).For Americans age 50 and older with chronic musculoskeletal conditions, the lowest rate was 1.55% (n = 136); the highest rate was 20.99% (n = 1839).For the sample of Americans age 50 and older who practiced yoga, the lowest prevalence was 3.18% (n = 52); the highest was 61.76% (n = 1011).The final population including Americans age 50 and older with chronic musculoskeletal condition and practiced yoga, the lowest rate was 4.26% (n = 40); the highest rate was 63.26% (n = 594) (table 2).Although prevalence rates varied among the four sub-populations of this study, the higher prevalence rates, despite the sub-population is consistent with Moonaz SH et al. [16] evidence supporting the use of yoga for pain relief and improved arthritis symptoms.
Upon examination of the four sub-populations, three distinct groupings emerged as reasons regarding the use of CAM, specifically yoga.The first group centers on cost and failure of conventional medicine (n = 5).The second group focuses on formal and informal sources of recommendations (n = 4).The third group concentrates on autonomy, mind, body and spirit (n = 4).
The reasons for the lowest and highest prevalence rates were the same for all four sub-populations.The lowest was 'medical treatments were too expensive' and highest was 'it is natural'.These findings are consistent with the work of Ward L et al. [3] and colleagues on the use of CAM therapies, such as yoga, either an adjunct to biomedical treatment or as a treatment option of choice.

Reasons for Doing Yoga
Multivariate logistic analysis was performed to show the weighted, adjusted results from the nationally representative results from the 2012 NHIS of Americans age 50 and older.Each category shows the estimated odds ratio (OR) and the 95% Confidence Interval (CI) (table 3).Of the 13 reasons, four had significant (p < 0.001) results.Those with chronic musculoskeletal issues were almost twice as likely to practice yoga because it was recommended by a friend (OR: 1.98, CI: 1.47, 2.68, p < 0.001).Women with chronic musculoskeletal issues were over twice as likely to practice yoga as compared to men (OR: 2.17, CI: 1.68, 2.82, p < 0.001).Those with chronic musculoskeletal issues were 2.8 times more likely to practice yoga because it can be practiced or done on one's own (OR: 2.75, CI: 1.97, 3.86, p < 0.001).Those with chronic musculoskeletal issues were 4.6 times more likely to practice yoga because it focuses on the whole person, mind, body, and spirit (OR: 4.62, CI: 3.28, 6.51, p < 0.001).
Three reasons had significant results between 95% and 90% CI (p < 0.10) results, one of which was "more likely" and two of which were "less likely".Those with chronic musculoskeletal issues were 40% more likely to practice yoga because it was natural (OR: 1.40, CI: 0.99, 1.98, p = 0.060).Those with chronic musculoskeletal issues were 26% less likely to practice yoga because it was recommended by a family member (OR: 0.74, CI: 0.53, 1.03, p = 0.074).Those with chronic musculoskeletal issues were 24% less likely to practice yoga because it was recommended by a doctor (OR: 0.76, CI: 0.58, 1.00, p = 0.053).The remaining seven reasons had no significant findings.
In the Race/Ethnicity categories, non-Hispanic was the only category with no significant findings as compared to Whites.The other three categories had significant findings between 95% and 90% CI (p < 0.10), two of which were "less likely' and one "more The age categories, ages 55 to 79 showed no significant findings as compared to those aged 50 to 54.The oldest age categories had highly significant results.Those aged 80 thru 84 with a chronic musculoskeletal condition were just over 60% times less likely to practice yoga as compared to those aged 50-54 (OR 0.392, CI: 0.23, 0.67, p < 0.001).Those aged 85 and older with a chronic musculoskeletal condition were just under 70% times less likely to practice yoga as compared to those aged 50-54 (OR 0.304, CI: 0.15, 0.61, p < 0.001).

Limitations
The prevalence of CAM use by older Americans with chronic musculoskeletal issues in this study cannot be associated to actual yoga participation.The NHIS data provides statistical percentages and frequencies based on the data collected in the survey.Large datasets, such as the NHIS, can provide correlations, but the predictive abilities are less certain.Other limitations of using big datasets are the potential bias of population representation and issues of data quality including assessment of accuracy.However, the analysis of inexpensive, accessible and timely data by scholars should be valued as the springboard for future targeted research.

Conclusion
A cross-sectional analysis was conducted using the 2012 NHIS data for adults aged 50 and over who reported practicing yoga and had a chronic musculoskeletal condition.This study focused on the 16,350 respondents who used CAM and were ages 50 and older.Yoga participants aged 50 and older with a chronic musculoskeletal condition were more likely to be white, female, and under age 70.Possible reasons for this finding may include women's notable tendency for 'help-seeking', their informal role as family health advocates and frequent compliance with suggested or recommended therapies than their male counterparts.Three distinct groupings emerged among the 13 reasons regarding the use of CAM, including yoga.The first centered on the cost and failure of conventional medicine.The second group focused on formal and informal sources of recommendations.The third concentrated on autonomy, mind, body and spirit.Individuals in this sample were more likely to practice yoga because it was a natural alternative, could be practiced on one's own, and most likely because it focused on the whole person (mind, body, and spirit).Individuals are less likely to practice yoga because it was recommended by a friend or physician.
Hootman et al. [17] asserted that as the mean age rises in the older population, chronic musculoskeletal conditions would significantly affect quality of life secondary to physical disability in the future.Understanding the reasons why those with chronic musculoskeletal issues choose movement centered CAM's (such as yoga or Tai Chi) is important to all those involved in the care of older adults.Input from clinicians, family, and friends may assist individuals in making treatment decisions.Practitioners involved in patient care and familiar with the most common reasons for MT use can more confidently offer these alternatives.Patients for whom conventional or pharmacological approaches have been unsuccessful may be more receptive to MT use as part of their treatment plan based on these findings.

Author Contributions
Elizabeth M. Tait developed the concept and design of research, planning methods to generate results, data collection and processing of NHIS survey components and analysis, initial interpretation of results, initial writing of manuscript and critical review of statistical content of final manuscript.Marianne Hollis was oversighted in project and manuscript organization and preparation; secondary interpretation of results and presentation within the manuscript; results and conclusion writing; critical review of final manuscript.Brian Raming was oversighted in

Table 1
displays the weighted descriptive, nationally representative results from the 2012 National Health Interview survey of Americans age 50 and over.Those who are at the age of 50 and older and use CAM have a sample size of n = 16,350; N = 102,379,202.Adults age 50 and older who use CAM and who have a chronic musculoskeletal condition have a sample size of n = 8,761 N = 53,848,056.Respondents with age 50 and older regardless of the presence of a chronic musculoskeletal condition and who used yoga have a sample size n = 1,637; N = 10,518,855.Adults with age 50 and older who have a chronic musculoskeletal condition who practiced yoga have a sample size of n = 939; N = 5,810,892 million.

Table 1 :
Summary of sample.( a sample size, b population size, c Confidence Interval).Data source: 2012 National Health Interview Survey.of the other race/ethnicities.African Americans report 10.27%, Hispanic 9.11%, Asian 4.17% and all others 0.63% for all four groupings.

Table 2 :
Prevalence of reasons older adults use CAM specifically Yoga.

Table 3 :
Multivariate Logistic Analysis predicting the likelihood of practicing yoga for those with a chronic musculoskeletal condition, men and women ages 50 and older, 2012 a .(+p < 0.1, *p < 0.05, **p < 0.01, ***p < 0.001) and manuscript organization, preparation, writing and editing throughout manuscript versions, critical review of final manuscript. project