What if I told you half of all middle-ear effusions (persistent fluid), known as glue ear, could be fixed by the child blowing up a balloon with his or her nose? Would you be more likely to get your child to try it than have them undergo surgery? It may sound quirky, but the technique, called autoinflation, has a solid evidence base.
There is evidence many conditions can be treated without drugs or surgery. Dangerous snoring (sleep apnea), for instance, can be relieved by a simple jaw splint. Non-drug interventions can in some cases be more effective than pharmaceutical or surgical ones. And of course, they come with few to no side effects or complications.
Doctors should be provided with the necessary instructions on how best to prescribe such treatments for patients so they can have more confidence to do so. And patients should be better informed about the options available for their health care.
Since the 1940s, drug treatments have been tested in clinical trials that prove they work for their intended purpose and are safe to take. Strong evidence for the effectiveness of non drug treatments has been slower to develop but is now available.
The research for drug treatments has been distilled and summarised for doctors in ready-reference publications such as the Australian Medicines Handbook, which supports doctors in their clinical decision-making. In some cases though, the most appropriate treatment is not a drug. It could be a recommendation for a dietary change, a specific exercise or even a phone app.
The Handbook of Non-Drug Interventions (HANDI), outlines treatments that don’t require medications or surgery. Its 54 treatments, which have been evaluated and reported to work after being tested in the same type of clinical trials as drugs, range from splints for hand pain in osteoarthritis to internet-delivered cognitive behavioural therapy for depression and anxiety.
Fluid in the ear
One treatment is for children with glue ear - persistent fluid in the middle ear resulting from infections. This can dull hearing, a particular problem for young children who are just learning to talk.
The conventional treatment for glue ear has been a surgical operation to insert ventilation tubes (grommets) through the ear drum. But HANDI references research showing the simple trick of the child blowing up a balloon with their nose fixes glue ear in 50% of cases within three months.
There is a special balloon marketed for the purpose that comes with a nose-shaped nozzle, which can be used by children over the age of three. It’s a safe and attractive option for parents that may well fix the problem in their child’s hearing while on the waiting list to see an ear, nose and throat specialist.
Other non-drug interventions can prevent conditions from occurring. For instance, over the years there has been conflicting advice on when to introduce a range of foods to infants, but there is now strong evidence that early introduction of peanut protein reduces the risk of peanut allergy.
Infants whose parents have allergies are more likely to develop peanut allergy, but this risk is reduced by 70% if babies are given peanut butter (24 grams per week in at least three meals) from the age of four months.
Another treatment is for a type of foot pain called plantar fasciitis. People with this experience pain in the soles of the feet, especially first thing in the morning.
There are several treatments available, but the simplest and safest is a stretching routine done three times a day, with the first set of ten stretches done before standing up in the morning.
Doctors may lack confidence to recommend this treatment to a patient asking for a cortisone injection into their foot. But if they have a ready reference guide with outlined evidence and guidance, they are more likely to encourage the patient to try stretching before resorting to medication.
Why don’t doctors recommend such interventions more often?
When reading research about a medication, doctors often assume that if they give the same drug in the same dose, they can expect more-or-less the same effect each time. But for non-drug treatments, the precise operational description of the intervention used in those trials becomes of paramount importance.
For instance, physical exercise to improve circulation – also known as aerobic training – has been shown to be beneficial for heart failure. It helps improve symptoms and decrease the number of heart-related hospitalisations. But how much is needed?
Before doctors can use this with their patients they will need to know how often and how intense the training should be. They will also need to know if there are patients at particular risk who should not do the training.
Recent research into publications in six leading medical journals that tested the effectiveness of non-drug interventions, found only 39% were adequately described so a reader – doctor or patient - could replicate the treatment.
Inadequate description makes it difficult to implement the treatments, which means the research findings are unusable and effectively wasted. For instance, there is a complicated exercise a doctor can do with a patient that helps resolve the most common cause of dizziness (“benign positional vertigo”), called the Epley manoeuver, after its inventor.
Unless the doctor does this often, they will not be confident in the procedure. Guidelines like HANDI appear to have filled a useful niche in the ecology of medical information as the website is getting 6000 visits per month from all over the world.