Chiropractic + Naturopathic Doctor • December 2015 • Topical Interest

The clinical market is flooded with new, overthe- counter products and equipment. Every day we are bombarded with emails, phone calls, company reps and pamphlets, telling us in breathless detail about the amazing properties and qualities of this or that tool, cream or stretch band. In recent years, we have found ourselves starting to turn a blind eye to the deluge, as have many of you. This is a real pity, as there are some products out there that can make a substantial contribution to our evolving clinical practice.

For some time now, private clinics and allied health professionals have played an increasingly important role in the delivery of primary, complex and long-term care. Every day we meet patients who, in the past, would have gone to their doctor or local emergency department. People with serious conditions and acute pain arrive looking for the kind of support we are often not fully equipped to provide. We need better tools, and the right tools, to adequately care for our increasingly complex case load.

The medical and complementary health industry has responded to our need, by designing a diverse array of better equipment and products. However, within the storm of marketing we all receive, the many great products out there can often escape our attention. Being very busy clinicians, as most of us are, we have had to learn how to quickly evaluate products, and to focus our attention on those with the highest potential return for our practice. Let’s take a look at topical analgesics, as an example.

The development of advanced clinical allopathic and over-the-counter topical analgesics to manage pain is an area where product advancement has been particularly marked. In the last 10 years we have seen dozens of products enter (and often leave) the market. As the number, diversity and types have grown, so has our potential to effectively treat acute and chronic pain in primary care and long-term rehabilitation.

When a patient presents him/herself with serious musculoskeletal pain we assess and start a treatment regime that may include mobilization, pain relieving modalities, remedial exercise, behaviour modification, or referral to the appropriate health-care provider within our multidisciplinary clinic. These treatments usually have great outcomes, but do not always resolve to our satisfaction. Sometimes, the pain a patient arrives with, is not the one they leave with. Sending a patient home with a sore back, inflamed joints, and an appointment for next week doesn’t sit well with us, ethically, morally or clinically.

Many products we see on the market claim to be able to help these patients. But with so many products in front of us how do we know which ones are suited to the challenges we face? Do they work? How do they work? Is there evidence to support their claims? What are the downsides? How do we sort through the knot of product types, claims and counterclaims?

As clinicians responsible for chiropractic and rehabilitation in private practice we are concerned with evidence- based treatments – ones that we know work, that can be used within our regulated scope of practice, that deliver value for money, and that can turn a profit (or at least not lose money) if sold to patients. However reluctantly, we feel we must set aside practices and products whose value are debated or unproven.

Health Canada regulates topicals under two distinct regulatory systems: drug products and licensed natural health products, with their respective DIN or NPN number. We do not evaluate any new products that are not registered with Health Canada. Surprisingly, that eliminates a large number of products on the market today.

Drug products and their various medical and pharmacological implications, we leave to physicians and pharmacists. Looking at the natural health product side of the market, we do our own due diligence. We always check the Health Canada Drug database to compare a product’s marketing to its Health Canada registered active ingredients. We want to know that a product contains what it says it does, and at the concentrations claimed.

After establishing that a product is registered, legal and contains actives, we look at efficacy. We rely a lot on PubMed, the U.S. National Library of Medicine online collection of global research, to give us a sense of the landscape. Search an active ingredient and you’ll find out all you really need to know about the claims being made by product marketers.

Amongst natural health topical products for instance, research points to the efficacy of the double-punch of methyl salicylate (MS) combined with menthol (Clinical Therapeutics 2010 Jan;32(1):34-43 “Efficacy and safety profile of a topical methyl salicylate and menthol patch in adult patients with mild to moderate muscle strain: a randomized, double-blind, parallel-group, placebo-controlled, multicenter study.” Higashi Y, Kiuchi T, Furuta K.), and the great results from clinical trials of menthol on chronic pain related to joint injury related to repetitive tasks (Rehabil Res Pract. 2014; “Acute effect of topical menthol on chronic pain in slaughterhouse workers with carpal tunnel syndrome: triple-blind, randomized placebo-controlled trial.” Sundstrup et al).

If a claim made by a product’s marketing is not reflected in PubMed research abstracts, then it’s a good sign the product’s treatment value is unproven, and we set it aside.

Apart from all these criteria we must Consider strength, mode of delivery and patient needs. We like the metaphor of helping a thirsty patient. The treatment is water. But a single drop of water in the eye won’t do, when what they need is a whole refreshing glass of water to drink. A drop of five per cent menthol won’t quench the thirst of a patient that needs a glass of 16 per cent menthol. A field-side chiropractor who requires quick pain relief for her injured athletes needs a potent handheld 22 per cent spray, not a two-litre tub of four per cent gel back in the change room. Using a 46 per cent MS and menthol combination applied pre-game, which does not sweat off and lasts for hours, will deliver a much different result to a professional hockey player than an eight per cent water-based menthol cream that sweats off within minutes. Conversely, a patient on a blood thinner, with certain allergies or low levels of pain may benefit greatly from the five per cent products.

The modalities used and treatment choices we make as allied health professionals are critical to our decision making about new products. Are we using topical products in-clinic or out-ofclinic, alone or in combination with other products or treatments, applied by us or by the patient, as preventative or restorative care? Every modality affects choices for the best product. Sprays are great for field-side spot treatment; high strength solids manage pain over an entire workday; gels and creams are great for patients to self-apply. Personally, we don’t care to rub in any product with our hands. Doing so with products that have high concentrations of actives may be dangerous for you over time. Besides, if a product is highly effective then it doesn’t need to be rubbed in.

There are, of course, many other considerations when looking at the many products available to us. Using topicals again as our example, we also need to consider cost per ml/actives, cost per volume, clinic demographics, regional variations in injury prevalence, insurance coverage, and customer service and support. What really matters is that we do our due diligence, so we can make informed assessments of the clinical value of products in treatment, and the commercial value to our businesses.

When considering new products – when you try to sort the wheat from the chaff – we encourage you to consider the indicators of value we’ve outlined. Is it registered and legal? Does it contain what it says it does and at high enough concentrations to be clinically effective? Is it supported by research? Do you like it? Do patients respond positively to it? Find the answers to these questions and you will find the amazing products out there that deliver the clinical and business results you want.

HANA VEPRIKOVA is a physiotherapist trained in Canada and Europe, a runner and active mother of two teenage boys. She is the head of rehabilitation at the Rosedale Wellness Clinic in Toronto.

DR. BRYAN SHER, DC, plays the trombone in a swing band and is an avid water skier. He is the owner and director of the Rosedale Wellness Clinic.