Gold Coast (Australia), September 16 (360info) Compiled by the Royal Australian College of General Practitioners, HANDI is the world’s first collection of drug-free medical treatments.
In 2017, while traveling in rural India, Rae Thomas’ teenage daughter began feeling dizzy and nauseous for several hours.
Rae remembers hearing that a head rotation procedure could help treat the most common cause of persistent dizziness.
Using her cell phone, she found a description of the Epley maneuver (or canalith repositioning) on the HANDI (Handbook of NonDrug Interventions) website, watched the linked video a few times, and performed the procedure.
Her daughter’s relief was immediate – although it had to be repeated over the next few days. Rae was only aware of this option because she worked at the same university as the HANDI developers.
The Epley maneuver is just one of dozens of effective “non-drug” treatments that are underused by doctors and patients.
Some have substantial effects, backed by research: exercise (as part of “pulmonary rehabilitation”) for patients with chronic airway disease can prevent 70 percent of hospital readmissions and death; daily sunscreen can reduce rates of invasive melanoma by 50%; and ‘external cephalic version’, which involves turning a baby in utero by pressing on the mother’s abdomen, can prevent 50% of unsafe breech births.
If there were such effective drugs, doctors and patients would clamor for access; companies would set high prices. But unlike their pharmaceutical brethren, these nondrug treatments are less intensively researched, poorly described in that research, weakly regulated, and unmarketed, especially when they’re free or cheap.
One explanation for their relative negligence has been the lack of a respected compendium, equivalent to the pharmacopoeias (drug manuals) that physicians consult when prescribing.
Instead, trials of effective non-drug treatments are widely scattered across vast oceans of research literature. There is no regulatory body (like the TGA in Australia or the FDA in the US) to judge 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, but also a wide range of others.
Perhaps the most overlooked non-drug “treatment” is exercise for chronic conditions – lung disease, heart failure, cancer fatigue, diabetes, depression, etc.
While exercise is often promoted for prevention in healthy people, sick people have the most to gain, but are often fearful of exercise.
Exercise can cause symptoms such as shortness of breath and fatigue, but with persistence it improves function and quality of life, often reduces relapses and improves survival.
Over the past decade we have recognized that specific exercises can often overcome functional deficits. Some of these 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 mirror feedback – 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 medication manuals, each HANDI entry includes indications, contraindications and “dosage”.
The goal is to make “prescribing” a 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 become increasingly popular with Australian GPs and has been integrated into many local ‘clinical pathways’, but 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 showed that less than half are described clearly enough to allow replication in follow-up studies; it also creates problems when reviewing the evidence and making recommendations.
Another obstacle is the lack of inclusion in medical training – pharmacology is taught but not so much “non-pharmacology”.
But perhaps the biggest problem is that many of these non-drug treatments are free or cheap and have no copyrights, so there’s no one else to benefit from them but the patient.
The pandemic has taught us the important role of non-drug interventions – such as social distancing, crowd avoidance, better ventilation and masks. Let’s hope this lesson is not forgotten.
The Disability Development Process The RACGP Disability 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: Assess the evidence and relevance The group assesses the proposed non-drug intervention, considering 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 outcomes, or one RCT with strong evidence supporting the causal relationship to the 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 the intervention , and general public resources.
Step 3: Final review and posting The draft entry is reviewed at a subsequent committee meeting before finalization and posting on the HANDI website. (360info.org) PY PY