Compiled by the Royal Australian College of General Practitioners, HANDI is the world’s premier compendium of drug-free medical treatment.
In 2017, while traveling through rural India, Rae Thomas’ teenage daughter began to feel dizzy and nauseous for several hours. Rae recalled hearing that the forward spin procedure can help fight the most common cause of persistent dizziness.
Using her cell phone, she found a description of the Epley maneuver (or canalith repositioning) on the Handbook of NonDrug Interventions (HANDI) website, watched the linked video a few times, and performed the procedure.
Her daughter’s relief was immediate – though it needed to be repeated over the next few days. Rae was only aware of this option because she worked at the same university as the developers of HANDI. The Epley maneuver is just one of dozens of effective “non-drug” treatments that are underused by doctors and patients. Some have substantial research-supported effects: exercise (as part of “pulmonary rehabilitation”) for patients with chronic airway disease can prevent 70% of hospital readmissions and deaths; daily sunscreen can reduce invasive melanoma rates by 50%; and the “external cephalic version,” transforming a baby in utero by pushing on the mother’s abdomen, can prevent 50 percent of unsafe breech births. If there were equally effective drugs, doctors and patients alike would cry out for their access; companies would set high prices. But unlike their pharmaceutical brethren, these non-drug treatments are less researched, poorly described in this research, weakly regulated, and unmarketed – especially when they are free or cheap. One explanation for their relative neglect has been the lack of a respected compendium, equivalent to pharmacopoeias (drug manuals) that physicians consult when prescribing.
Instead, trials of effective non-drug treatments are widely scattered across the vast oceans of scientific literature.
There is no regulatory body (like the TGA in Australia or the FDA in the United States) to rule on which ones are effective. And generally, no company has an interest in marketing them. Non-drug treatments fall into several generic classes: exercise (general and specific), diet, cognitive behavioral therapy, physical maneuvers, and a wide range of others. Perhaps the most overlooked non-drug “treatment” is exercise for chronic illnesses – lung disease, heart failure, cancer fatigue, diabetes, depression, and so on. While exercise is often promoted for prevention in healthy people, sick people stand to gain the most but are often afraid of exercise.
Exercise can cause symptoms such as shortness of breath and fatigue, but with persistence it will improve function and quality of life, often reduce relapses, and improve survival. Over the past decade, we have recognized that specific exercises can often overcome functional deficits. Some of them are described in Norman Doidge’s popular book, The Brain that Changes Itself, which outlines the discovery and impact of brain plasticity for rehabilitation.
A clinical example is “mirror therapy” – where patients perform activities via feedback from a mirror – used successfully to treat phantom limb pain and regional pain syndromes after stroke.
To address the lack of a compendium, in 2013 the Royal College of General Practitioners (RACGP) in Australia began compiling effective non-drug interventions relevant to primary care.
Based on the format of modern drug manuals, each HANDI entry includes indications, contraindications and ‘dosages’. The goal is to make “prescribing” non-drug therapy almost as easy as writing a prescription for a drug.
It allows clinicians to offer a greater choice of interventions to a patient, who may wish to avoid medications and the risks and lifestyle changes often associated with drug treatment regimens.
Since its launch in 2015, HANDI has grown in popularity with Australian GPs and has been incorporated into many local ‘clinical pathways’, but it is underutilized compared to drug-based options. HANDI is a step towards improving non-drug interventions, but other issues still need to be addressed.
One problem is how poorly described non-drug treatments are in current medical trials – one study found less than half are clearly enough described to allow replication in follow-up studies; it also creates problems for reviewing the evidence and making recommendations. Another obstacle is the lack of inclusion in medical education – pharmacology is taught but not as much in ‘non-pharmacology’. But perhaps the most important problem is that many of these non-drug treatments are free or cheap and have no copyright, so there is no one to benefit from them except the patient. . The pandemic has taught us the important role of non-drug interventions – such as social distancing, crowd avoidance, better ventilation and masks. Hope this lesson is not forgotten.
The HANDI Development Process The RACGP HANDI Working Group meets six times a year, collecting possible topics from a variety of sources. Each potential HANDI entry then goes through a three-step process before being published.
Step 1: Evidence and Suitability Assessment The group assesses the proposed non-drug intervention by examining two questions: 1. Is the evidence strong enough? 2. Is the intervention relevant and practical for general practitioners? Treatment should be supported by at least two positive, good-quality randomized controlled trials (RCTs) with patient-relevant results, or one RCT with strong evidence to support the causal relationship under study.
Step 2: Writing the HANDI Entry Next, a group member works with a medical writer to develop a detailed ‘how-to’ guide for using the non-drug intervention that includes indications, contraindications, precautions, side effects, availability and description of intervention, and consumer resources.
Step 3: Final review and publication The entry draft is reviewed at a subsequent committee meeting before being finalized and published on the HANDI website.
(This story was not edited by Devdiscourse staff and is auto-generated from a syndicated feed.)