Handbook of Non-Drug Interventions

making effective non-drug treatments more visible and

easier to use

Paul Glasziou
Centre for Research in
Evidence-Based Practice,

Bond University
For RACGP HANDI Team
www.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 process

1.

Is there clear evidence of effectiveness?

2.

Member presents evidence to committee

Systematic review of 2+ trials or equivalent

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 Epley

1. 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 May
www.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

Some Future topics:

15+ new entries per year

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 Kings offered
me pulmonary rehabilitation.
I didnt know what that was,
so I asked and he said it was
an exercise program.
I thought the man was mad
because I couldnt 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 SymptomsBMJ 2006

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. decaffeinated 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

%Failure (new treatment)

LUTS trial: lower failure at 1 year

90
80

P<0.001

70
60
50
40

Self-Management

30

Control

20
10
0
0
3
6
12
Months after Randomization

What is the treatment?

BMJ papers 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 papers 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
Description sufficient to replicate
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

Initial
Final

Overall

Trials

Metaanalysis

Drug

Non drug

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, 700707

Chronic Fatigue Syndrome

Graded 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 COPD

Long 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 needed
A Handbook of Non-Drug Interventions

Trials of non-drug treatments in UK

Chalmers bmj.com2003;327:1017

1. Procedures
Epley for BPPV
Mothers 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 instructions
for 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