Medications

January/February 2013

Making non-drug interventions easier to find and use

Volume 42, No.1, January/February 2013 Pages 35-35

Non-drug interventionsPaul Glasziou MBBS, FRACGP, PhD, is Director, Centre for Research in Evidence Based Practice, Bond University, Gold Coast, Queensland.

Patients with heart failure are often anxious about any exertion as it brings on the shortness of breath that characterises their condition. But exercise for heart failure appears to be as good as the medications we use, and may be better for symptoms and quality of life. The 10 year follow up of an Italian randomised trial found that patients allocated to supervised exercise had significantly better quality of life, and around a one-third reduction in hospital readmission and cardiac mortality.1 A Cochrane review of shorter term studies supports these overall findings.2 Despite this, exercise for heart failure appears to be underprescribed, but also getting the ‘prescription’ correct – dose, duration, monitoring – is not straightforward. A non-pharmacopeia might be helpful.3

Advances in non-drug treatments in the past few decades have been substantial and diverse: exercise for heart failure and COPD, ‘mirror’ therapy for poststroke pain, the Epley manoeuvre for benign paroxysmal positional vertigo, knee taping for osteoarthritis, cognitive therapy for depression (and almost everything else!), ‘bibliotherapy’ (specific guided self-help books for some conditions), to name just a few. Indeed, nearly half the thousands of clinical trials conducted each year are for non-drug treatments. But the effective non-drug methods are less well known, less well promoted, and less well used than their pharmaceutical cousins.

This month’s issue of Australian Family Physician sees a milestone in making the effective non-drug treatments more visible and easier to use: the beginnings of the Handbook of Non-Drug Intervention (HANDI). Following a meeting at GP10 in Cairns, a team at The Royal Australian College of General Practitioners (RACGP) committed to develop the handbook which would mirror our pharmacopoeias, including indications, contraindications and ‘dosing’.3 The aim is to make ‘prescribing’ a non-drug therapy almost as easy as writing a prescription. The development process is modelled on the Pharmaceutical Benefits Scheme (PBS): the
HANDI Project Team chooses candidate treatments, a team member then reads and presents the evidence; the whole team then votes on whether the evidence about benefits and harms is sufficient to warrant an entry. If deemed sufficient, a detailed HANDI entry is then drafted and discussed at a following meeting. By the launch of the pilot handbook (in website form) at GP13 in Darwin, it is hoped there will be 20–30 entries.

The first entry – the Epley manoeuvre for benign paroxysmal positional vertigo (BPPV) – is backed by a Cochrane systematic review of several randomised trials.4 Though these trials show the Epley manoeuvre is highly effective and the first description was published in 1980, most patients with BPPV still never undergo the manoeuvre.5 Many general practitioners now seem to be aware of ‘the Epley’, but can still lack confidence in whether and how to do it. The HANDI entry therefore provides the needed details, including a step-by-step illustration and a link to an excellent video that the Cochrane ear, nose and throat group have produced to aid in learning how to perform the procedure. A GP colleague, who can never remember the precise details, keeps this video bookmarked and tells patients before performing the Epley manoeuvre: ‘I am just going to show you a video of the procedure we will do’. Neat tactic!

If you have any tips or topics for consideration, we would love to hear about them – please contact the HANDI Project Team at email HANDI@racgp.org.au.

Australian Family Physician will continue to publish selected entries on non-drug interventions, and later in 2013 the full set will be available on the RACGP website.

References

  1. Belardinelli R, Georgiou D, Cianci G, Purcaro A. 10-year exercise training in chronic heart failure: a randomized controlled trial. J Am Coll Cardiol 2012;60:1521–8.
  2. Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011 Jul 6;(7):CD001800.
  3. Glasziou PP. Promoting evidence-based non-drug interventions: time for a non-pharmacopeia? Med J Aust 2009;191:52–3.
  4. Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev 2010.
  5. Glasziou P, Heneghan C. Epley and the slow boat from research to practice. Evid Based Med 2008;13:34–5.

Correspondence afp@racgp.org.au

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