Handbook of Non-Drug Interventions making effective non-drug treatments more visible and easier to use

Paul GlasziouCentre for Research in Evidence-Based Practice,

Bond University

For RACGP HANDI Teamwww.racgp.org.au/handi

A brief history The Pharmacopoeia

Chinese edition 3000 BC Nuovo Receptario, 1498 Pharmacopeia, Occo 1564

The Non-Pharmacopoeia Patterson Lecture GP10 RACGP initiates 2011 Pilot version 2013

Nuovo Receptario Composito Florence in 1498

What about didgeridoo playing?

Rx

Didgeridoo t.d.s(1)

Dr Paul Glasziou

The HANDI Committee

4 GPs, Physiotherapist, Occupational Therapist, Physician,and RACGP staff

HANDI development process1. Is there clear evidence of effectiveness?

Member presents evidence to committee Systematic review of 2+ trials or equivalent

2. Draft Entry with details of practicalities Detailed descriptions Handouts, links, etc Videos for some processes

HANDI Entries in AFP, Jan/Feb

Handbook of Non-Drug Interventions

www.racgp.org.au/handi/

Learning the “how to” of Epley1.Bookmark the video (on YouTube)2.Tip: watch with patient first!!

Exercise – for chronic illnesses COPD (“pulmonary rehab”) Claudication

Future topics? Heart Failure Chronic Fatigue Depression? Anxiety?

1-day conference, 1st Maywww.exerciseastreatment.net.au/

Pulmonary Rehabilitation is effective

Great – but what is pulmonary rehabilitation??

Some treatments with “dramatic effects” also included

Where now? Three years funding from BUPA

15+ new entries per year Some Future topics:

insomnia intervention, Mediterranean diet, pelvic floor exercises, sleep intervention for infants, FODMAP diet for IBS, exercise for ….

Your ideas, tips, and comments please!

Found: a good description of pulmonary rehabilitation

My consultant at King’s offered me “pulmonary rehabilitation”. I didn’t know what that was, so I asked and he said it was an exercise program. I thought the man was mad because I couldn’t get out of a chair.

(Later interview – she is much improved)

http://www.youtube.com/watch?v=cthKnGK6Gzs

3. Information & Self-Management Depression

BeyondBlue; several books LUTS Irritable Bowel Syndrome Weight loss tips

Lower Urinary Track Symptoms 60 year old man with symptomatic BPH

asks about pros and cons of surgery “What things have you tried so far?”

Lower Urinary Tract Symptoms Advise a daily fluid intake of 1500-2000ml (minor

adjustments made for climate and activity), avoid inadequate or excessive intake on the basis of a frequency / volume chart

Advise fluid restriction when symptoms are most inconvenient e.g. long journeys or when out in public

Avoid caffeine by substituting with alternatives e.g. de-caffeinated or non-caffeinated drinks

Avoid alcohol in the evening if nocturia is bothersome Advise bladder retraining. Using distraction techniques

(predetermined mind exercise, perineal pressure or pelvic floor exercises) aim to increase the minimum time between voids to 3 hours

BMJ 2006

LUTS trial: lower failure at 1 year

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ilure

(n

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reat

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Months after Randomization

Self-ManagementControl

P<0.001

What is the treatment?

BMJ paper’s description of sodium reduction "Individual and weekly

group counseling sessions were offered initially, with less intensive counseling and support thereafter, specific to sodium reduction."

???????

TOHP Study BMJ, Apr 2007; 334: 885

What is sodium reduction? The paper’s description

"Individual and weekly group counseling sessions were offered initially, with less intensive counseling and support thereafter, specific to sodium reduction."

Previous reference (i) an individual session followed by 10 weekly group 90

minute sessions with a nutritionist, followed by a transitional stage of some additional sessions

(ii) Topics in the weekly sessions included Getting Started, sodium basics, the morning meal, midday sources of sodium, the main meal, planning ahead, creative cooking, eating out, food cues, and social support,

(iii) the sessions included sampling of foods, discussion of articles on sodium reduction, and problem-solving,

(iv) patients kept diaries at least 6 days per week, and urine sodiums were measured.

What do the guidelines say?

Descriptions in 80 treatment studies selected for EBM were inadequate

0%10%20%30%40%50%60%70%80%90%

100%

Overall Trials Meta-analysis

Drug Non drug

Description sufficient to replicate

Initial

Final

Glasziou et al BMJ, 2008

HANDI overview Evidence-Based non-drug treatments Include sufficient details of treatment

Handouts Video links to show processes

HANDI some issues Work needed to get full descriptions and

written up clearly Poor descriptions in trials But authors will often hand over

Intellectual property Need a public access repository where authors

can put FREE materials RACGP can build handbook from this

Leaflet: 10 tips for weight loss 104 adults BMI 31;

randomized to Leaflet & weekly weigh Leaflet & monthly weigh Control

International Journal of Obesity (2008) 32, 700–707

Chronic Fatigue SyndromeGraded Exercise improves fatigue

Cochrane Review 2004

Exercise for CFS

Prescription for graded exercise Exercise every 2nd day Target RPE of 11-14 -> Every 2 weeks increase duration

by 2-5 minutes

Wallman. Med J Aust. 2005 Aug 1;183(3):142-3.

Example: a patient with COPDLong term smoker with chronic

obstructive airways disease has recently quit smoking.

Has tried medications but does not like any.

Asks: are any “breathing exercises”I can recommend?

Pulmonary rehabilitation integrates

3 excepts from the Description of Included Studies

The (missing) guidebook for IBS TRIAL: Self-help interventions in patients with a primary

care diagnosis of irritable bowel syndrome. Gut 2006.

At one year, patients in the guidebook group had a 60% reduction in primary care consultations (p,0.001) and a reduction in perceived symptom severity (p,0.001) compared with controls.

PROBLEM: Missing details of guidebook. No response from author to 3 emails Colleague said booklet was on sale Google search found the book

Price: £8.99

Diet & Nutrition Weight loss tips Cranberry for UTI Salt for Blood Pressure Oral rehydration

Cranberry Juice for UTIs?

Cranberries for preventing urinary tract infections Main results: Ten studies (n = 1049) were included.

Cranberry products significantly reduced the incidence of UTIs at 12 months (RR 0.65, 95% CI 0.46 to 0.90) compared with placebo/control.

Cranberries for treating urinary tract infections Main results: No studies were found which fulfilled all of

the inclusion criteria. Two studies are currently being undertaken.

Non-pharmacological interventions Procedures Exercise – particularly for the ill Information / self-management Diet & Nutrition

Update: By GPs for GPs

Common Cold and physical methods

Alexander technique

CBT self-help

Repository of intervention descriptions is neededA “Handbook” of Non-Drug Interventions

Trials of non-drug treatments in UK

Chalmers bmj.com2003;327:1017

1. Procedures Epley for BPPV Mother’s Kiss Knee taping for OA Alexander Technique Counterpressure for

syncope Nit combs for lice Light box for SAD

The Epley for BPPV (Vertigo)

STUDY: Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal. Neurology 2005.

TREATMENT: “Each head position has to be maintained for more than 30 seconds. Patients received illustrated instructionsfor the specific maneuver …”

All agreed “useful” 3 months later

only 2 doctors did it Put video in intranet

Another 3 months later Still only 2 doctors Trained each person to do

HANDI Entries in AFP, Jan/Feb