Transcriptional control of Pi-starvation responses

WEB SITE SPONSORING ORGANIZATION CONTENT

EBM Resource Center Web Page The New York Academy of Medicine in The Web page contains references, bibliographies, www.ebmny.org/ partnership with the Evidence-Based tutorials, glossaries, and online databases to

Medicine Committee of the American guide those embarking on teaching and practicing College of Physicians, New York chapter, evidence based medicine. It offers practice tools has received a grant from the National to support critical analysis of the literature and Institutes of Health to develop an evidence MEDLINE searching as well as links to other based medicine resource center. sites that help enable evidence based medical care.

Centre for Evidence-Based The Centre for Evidence-Based Medicine CATmaker is a software tool that helps you create Medicine CATmaker (CEBM) was established in Oxford, UK, as Critically Appraised Topics (CATs) for the key www.cebm.net/index. the first of several UK centers having the articles you encounter about therapy, diagnosis, aspx?o=1216 aim of promoting evidence based health prognosis, etiology/harm, and systematic reviews

care. The CEBM provides free support and of therapy. The site includes a form you may resources to doctors, clinicians, teachers, download to assist you in the CAT process.

and others interested in learning more about EBP.

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Beginning BestBETs

an anterior talofibular ligament sprain. You prescribe a double-tubigrip bandage and advise him to follow rest, ice, compression, and elevation (RICE) instructions. You wonder whether it is worthwhile referring him to the physiotherapist in addition to this, to speed up his return to normal activity.

Search strategy

Medline 1966-week 3/09/04 using the OVID interface.

[exp ankle injuries OR (ankle.mp AND {exp soft tissue injuries OR exp “sprains and strains”})] AND [exp Physical Therapy Techniques OR physiotherapy.mp OR manipulation.mp] AND [controlled clinical trial.pt OR randomized controlled trial.pt OR review, academic.pt] LIMIT to human AND English.

Search outcome

Altogether 38 papers were found, of which 32 were irrelevant to the study question. An additional paper was found via reference checking. The remaining 6 papers and one systematic review are shown in the table here.

D I G G I N G D E E P E R 1 1 . 1 E X A M P L E C O M M U N I C A T I O N

“Physiotherapy in acute lateral ligament sprains of the ankle”

n Report By: Jonathan Shaw—SpR in Emergency Medicine

n Search checked by Simon Clarke—Consultant in Emergency Medicine and Health

Protection

n Institution: Wythenshawe Hospital, Manchester

n Date Submitted: 15th January 2001

n Last Modified: 18th February 2005

n Status: Yellow dot (Internal BestBET edit)

In [patients with an ankle sprain] is [physiotherapy a useful adjunct to simple RICE instructions] at [speeding time to recovery]?

Clinical scenario

A 20-year-old man attends the emergency department, having sustained an inversion injury slipping off a curb. Clinical exami-nation by an emergency nurse practitioner in the minor injuries unit reveals tenderness to the lateral malleolus, and you suspect

Relevant paper(s)

Author, Date, Study Type

and Country Patient Group (level of evidence) Outcomes Key Results Study Weaknesses

Pasila et al

C H A P T E R 1 1 Communicating Evidence for Best Practice 151

Continued

D I G G I N G D E E P E R 1 1 . 1 E X A M P L E C O M M U N I C A T I O N — cont’d

Author, Date, Study Type

and Country Patient Group (level of evidence) Outcomes Key Results Study Weaknesses

Holme et al

92 patients 5 days post-injury 72 hours of injury randomized to RICE or RICE + pas-sive manipulation every 2/7 for 2/52

Total of 572 pa-tients (5 trials) — placebo or “sham ultrasound”

40 patients all within 36 hours of acute injury, of re-injury (7% vs.

29%, n =65) in fol-lowing 12 months No significant dif-ferences found

1.5 days quicker to return to normal walking. 0.7 days quicker to return to running. 1.2 days quicker to re-turn to sport No significant dif-ferences found for any outcome measure at 7 to 14 days of follow-up. Pooled relative risk for general improvement was

Four of the trials were “of modest -sures not taken beyond 3 days post-injury

Comment(s)

A number of different techniques are described, all of which pur-port to be of benefit in therapy for acute ankle sprains. These in-clude passive manipulation, ultrasound, short-wave diathermy, and wobble-board training, among other exercise regimes. There does appear to be a paucity of evidence concerning the effective-ness of any of these methods at the present time. In addition, there is no clear demarcation concerning their effectiveness

according to the three grades of injury that help to classify muscle and ligament damage equivalent to any loss of function, strength, fiber damage, and instability of the affected joint.

Clinical bottom line

Based on the current best evidence, home mobilisation facilitated by simple written instructions is suitable for the management of ankle sprains, and active physiotherapy offers no additional benefit.

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References

1. Pasila M, Visuri T, Sundholm A. Pulsating shortwave diathermy: value in treatment of recent ankle and foot sprains.

Arch Phys Med Rehabil. 1978;59(8):383-386.

2. Wester JU, Jespersen SM, Nielsen KD, et al. Wobble board training after partial sprains of the lateral ligaments of the ankle: a prospective randomised study. J Orthop Sports Phys Ther. 1996;23(5):332-336.

3. Karlsson J, Eriksson BI, Sward L. Early functional treatment for acute ligament injuries of the ankle joint. Scand J Med Sci Sports. 1996;6(6):341-345.

4. Holme E, Magnusson SP, Becher K, et al. The effect of super-vised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports. 1996;9(2):104-109.

5. Green T, Refshauge K, Crosbie J, et al. A randomised control trial of a passive accessor joint mobilisation on acute ankle in-version sprains. Phys Ther. 2001;81(4):984-993.

6. Van Der Windt DA, Van Der Heijden GJ, Van Den Berg SG, et al. Ultrasound therapy for acute ankle sprains [Cochrane Review]. Cochrane Libr 4. Oxford: Update Software.

7. Wilson DH. Treatment of soft-tissue injuries by pulsed electri-cal energy. BMJ. 1972;2(808):269-270.

D I G G I N G D E E P E R 1 1 . 1 E X A M P L E C O M M U N I C A T I O N — cont’d

S U M M A R Y

practice. Educating our patients to improve their health literacy involves an understanding of their communication and com-prehension abilities and requires time for listening during ther-apy sessions. Both a technology profile and a method of storing and retrieving appraised research evidence will increase the efficiency and effectiveness of physical therapy practice.

Integration of research, clinical expertise, and the patient’s val-ues and circumstances is the goal of an evidence based physical therapy practitioner. Communicating evidence to patients, fam-ilies, colleagues, and all stakeholders for physical therapy is a crucial skill for evidence based physical therapy practice. Un-derstanding the health literacy of our patients is crucial to best

1.State three ways to improve health education. 2.How can CATs be useful to your practice?

R E V I E W Q U E S T I O N S

R E F E R E N C E S

4. Fuhrmans V. Withdrawal treatment: a novel plan helps hospital wean itself off pricey tests—it cajoles big insurer to pay a little more for cheaper therapies. Wall Street Journal. January 12, 2007:A1.

5. Korthals-de Bos IB, Hoving JL, van Tulder MW, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ.

2003;326:911.

1. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International. 2000;15:259-267.

2. Knowledge brokers: a model to support evidence-based changes in practice. Teleconference summary: McMaster University, Centre for Childhood Disability Research, 2010. http://canchild.ca/en/resources/

Participant_InBrief_Apr20_10.pdf. Accessed September 7, 2010.

3. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B.

Gross Motor Function Classification System for cerebral palsy. Dev Med Child Neurol. 1997;39:214-223.

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Technology and Evidence