handbook of non-drug interventions -...
TRANSCRIPT
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
0102030405060708090
0 3 6 12
%Fa
ilure
(n
ew t
reat
men
t)
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