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Background: The Physiotherapy Evidence Database (PEDro) may help users to overcome some obstacles to evidence-based physiotherapy. Understanding the extent to which Japanese physiotherapists access research evidence via the PEDro website may suggest strategies to enhance evidence-based physiotherapy in Japan. Objectives: To quantify usage of PEDro in Japan, to compare this to usage in other countries, and to examine variations in PEDro usage within Japan. Design: An observational study of PEDro usage with geographic analysis. Methods: Data about visits to the home-page and searches of the database were recorded for 4 years. These data were analysed by each region of the World Confederation for Physical Therapy, each country in the Asia Western Pacific region, and each prefecture in Japan. Results: From 2010 to 2013, users of PEDro made 2.27 million visits to the home-page and ran 6.28 million searches. Usage (ie, number of searches normalised by population) was highest in Europe, followed by North America Carribean, South America, Asia Western Pacific, and Africa. Within the Asia Western Pacific region, population-normalised usage was highest in Australia, then New Zealand and Singapore. Japan ranked 10 among the 26 countries in the region. Within Japan, the highest population-normalised usage was in the Nagano, Kumamoto and Aomori prefectures, which was ten-fold higher usage than in some other prefectures. Conclusions: Although Japan has higher PEDro usage than many other countries in the Asia Western Pacific region, some prefectures had very low usage, suggesting that evidence-based practice may not be being adopted uniformly across Japan.
The principle of ‘evidence-based practice’ involves the clinician using his/her experience to apply high-quality evidence about the effects of interventions to achieve the treatment goals that are a priority for the patient 1). Evidence-based practice is important because it guides professionals to provide patients with the most effective interventions.
When evidence-based practice is recommended in physiotherapy, several obstacles to achieving these practical steps are often raised 2). These obstacles are outlined in Table 1.1. However, a resource called the Physiotherapy Evidence Database (3) (PEDro) may help overcome these obstacles. PEDro is an online resource of published evidence about the effects of physiotherapy interventions and it has several features that can assist users to overcome the common obstacles to evidence-based practice (Table (Table11).
PEDro has been recommended by many people as an important tool for evidence-based physiotherapy 4-6). Studies have examined usage of PEDro as a way of comparing the extent of evidence-based physiotherapy occuring in different geographic regions 7-9) in order to consider strategies to facilitate evidence-based physiotherapy. However, such an analysis for Japan has not been performed yet. Understanding how Japanese physiotherapists access research evidence will facilitate the development of strategies to enhance evidence-based physiotherapy. For example, marked differences in usage of PEDro between Japan and other countries or between prefectures may indicate where campaigns to encourage greater use of evidence could be targeted. Therefore, the overall purpose of the study was to quantify and characterise PEDro usage in Japan.
We sought to quantify PEDro usage with two outcomes. The first is the number of visits to the PEDro home-page per year. The second is the number of searches performed per year, expressed in absolute terms and relative to the number of registered physiotherapists and to the population size. We sought to then analyse these usage statistics geographically for each region of the World Confederation for Physical Therapy, for each country in the Asia Western Pacific region of the World Confederation for Physical Therapy, and for each prefecture in Japan. Usage data collection occurred over a 4-year period, between 1 January 2010 to 31 December 2013. The measures considered are detailed below.
Visits to the PEDro home-page were identified using Google Analytics 10). Data extraction and analysis have been reported elsewhere 7). The data we extracted for the years 2010-2013 were the number of visits and the location of each visit hosted. The count of visits was calculated as the number of individual sessions initiated by a user of the home-page. An individual session occurs when a user opens and navigates around the home-page 10). The location of the user who made each visit was derived by mapping internet protocol (IP) addresses 10).
Searches of the database are performed using the PEDro search function. The software that supports the database (FileMaker Pro 12, FileMaker, Inc, Santa Clara, CA, USA) logs the time and date of each new search performed. To calculate the number of searches performed each year, the date data were exported to an Excel spreadsheet (Microsoft Office 2007, Microsoft Corporation, Redmond, WA, USA). The proportion of visits from each region was also estimated in each geographic region of interest.
Global analysis was conducted using five regions (Africa, Asia Western Pacific, Europe, North America Caribbean, and South American). The countries that constitute each region are available on the World Confederation for Physical Therapy website 11). Regional analysis of the Asia Western Pacific region was conducted using 26 countries (Afghanistan, Australia, Bahrain, Bangladesh, Cambodia, Fiji, Hong Kong, India, Indonesia, Iran, Japan, Korea, Kuwait, Macau, Malaysia, Nepal, New Zealand, Oman, Pakistan, Philippines, Saudi Arabia, Singapore, Sri Lanka, Taiwan, Thailand and United Arab Emirates). National analysis of Japan was conducted using 47 prefectures. Fig. Fig.11 shows the geographic location of the prefectures.
Absolute usage was defined as the total number of searches from each region, country or prefecture. Data normalised by the population were calculated by dividing the number of searches from each region, country or prefecture by the local population (number of searches per million population). National population data were obtained from the United Nations latest updated report 12). The population of each prefecture was obtained from Official Statistics of Japan 13). In addition, for the Japanese prefectures only, data normalised by the number of local physiotherapists were calculated by dividing the number of searches from each prefecture by the number of registered physiotherapists in that prefecture. The number of registered physiotherapists in each prefecture of Japan in June 2012 was obtained from the Japanese Physical Therapy Association 14).
Between 1 January 2010 and 31 December 2013, there were 2,271,047 visits to the PEDro home-page globally. A total of 6,280,072 searches of the database were performed over the 4-year period.
The global analysis demonstrated that the region with the highest absolute usage was Europe (43.5% of all searches), followed by Asia Western Pacific (21.4%) and North American Caribbean (17.5%). When the usage was normalised for the population size, this ranking changed to: Europe first with 994 searches per million population per year, North American Caribbean second with 734 searches per million population per year, and South American third with 480 searches per million population per year. Table Table22 lists the absolute and relative usage of PEDro for each region of the World Confederation for Physical Therapy.
The regional analysis in the Asia Western Pacific region demonstrated that the three countries with the highest absolute usage of PEDro were Australia (55.7% of all searches), South Korea (9.3%) and Japan (8.8%). When usage was normalised for the population size, Australia was ranked first (8,380 searches per million population per year) followed by New Zealand (3,985) and Singapore (958). Table Table33 lists the absolute and relative usage of PEDro for each country in the Asia Western Pacific region.
In Japan, the three prefectures with the highest number of PEDro searches in absolute terms were Tokyo (19.3%), Hokkaido (8.3%) and Osaka prefecture (7.6%). When the data were normalised for the population size, however, the highest ranked prefectures were Nagano prefecture (with 840 searches per million population per year), Kumamoto prefecture (556) and Aomori prefecture (503). Table Table44 lists the absolute and relative usage of PEDro for each prefecture in Japan.
When the data were normalised for the number of registered physiotherapists, Nagano prefecture and Akita prefecture each had 1.2 searches per physiotherapist per year, followed by Tokyo and Aomori prefectures with 1.0 search per physiotherapist per year each. The prefectures that were ranked among the lowest for absolute and/or relative usage were the Kagawa, Kagoshima and Iwate prefectures. Fig. Fig.11 and and22 shows the results for the analysis of searches per registered therapist by prefecture.
This study assessed the usage of PEDro globally and in Japan. The study was successful in obtaining data for over 2 million visits to the home-page and over 6 million searches of the database. The usage of PEDro is likely to reflect positive attitude of physiotherapists to seek research evidence to guide clinical decision-making.
Europe had the highest absolute and relative usage of PEDro across the five regions of the World Confederation for Physical Therapy, with the Asia Western Pacific region ranked second in absolute terms and fourth in relative terms. The high PEDro usage in Europe is not surprising. A previous study found eight European countries among the twelve countries with the highest number of searches 7). Europe is the region with the highest number of countries affiliated to the World Confederation of Physical Therapy, which has been supporting dissemination and implementation of evidence-based practice since 2001 15).
Within the Asia Western Pacific region, Japan accounted for the third highest absolute usage (nearly 9% of searches) and was ranked tenth for relative usage. However, Japanese physiotherapists performed an average of 0.4 searches per year, which is slightly lower than usage in Brazil (0.95 PEDro searches per physiotherapist per year 16)) and markedly lower than in Australia (7.5 PEDro searches per physiotherapist per year; 187,743 searches per year divided by 25,152 registered physiotherapists in 2013 17)). Although the relative usage per number of physiotherapists was very low regardless of the prefecture, PEDro usage in Japan is not equally distributed across the country, with more than a 10-fold difference between the prefectures with the highest and lowest number of searches per registered physiotherapist per year. (A post-hoc analysis of the number of searches corrected by the number of graduating physiotherapy students annually instead of the number of registered physiotherapists also showed high variability between prefectures, with Akita and Nagano still having the highest ranks. Data are available on request from the authors.) It is interesting that Akita prefecture and Nagano prefecture have the greatest relative usage per number of physiotherapists and Akita prefecture is outstanding in terms of the relative usage per number of physiotherapists graduating per year. This may reflect the fact that entry-level education in Akita prefecture is performed in Akita University only, which is a 4-year university degree with post-graduate courses being offered, and relatively few physiotherapists are trained. Higher education such as 4-year university degree with post-graduate courses may be a key to facilitate evidence-based practice. One reason for greater use of PEDro in the Nagano prefecture may be that the topic of the 38th Congress of Japanese Society of Physical Therapy, which was organised by the Nagano Physical Therapy Association, was “evidence-based physiotherapy". This may have raised the awareness of evidence-based practice in the Nagano prefecture.
Dissemination of the evidence-based practice concept often starts at the university level and this practice should continue throughout the clinical career. In Japan, strategies to promote evidence-based competencies targeting students at an undergraduate or postgraduate level seem to be a reasonable approach. Integration of evidence-based practice and information literacy early into undergraduate programmes is effective 18,19). Thus, schools and universities for physiotherapists may need to further enhance students' attitude towards seeking information from the international literature and to let students know global standards.
There is one barrier to the widespread usage of PEDro in current clinical practice in Japan. The search functions on the PEDro website and the majority of abstracts are only available in English although the PEDro home-page is available in 12 languages, including Japanese. It may be difficult for many Japanese physiotherapists who do not speak English 20) to quickly read each abstract. The Japanese Physical Therapy Association also has established a tutorial of evidence-based physiotherapy on a website in Japanese 21) but the actual search of the literature written in other languages is not performed in Japanese. Therefore, another strategy to foster evidence-based practice would be to make PEDro more accessible, by providing the search function in other languages such as Japanese. This would require a significant investment of money by the global physiotherapy community because of the costs involved in translation. Alternatively, evaluation of emerging technologies like automated translation of webpages is warranted.
The usage of PEDro per physiotherapist in Japan is limited but it may be argued that Japanese physiotherapists might use other online resources (e.g. Ichushi 22) and J-stage 23)) to search for evidence rather than PEDro. However, this would also apply to physiotherapists in other countries and regions. It is also doubtful that general physiotherapists use Ichushi, which could be one of the most common online database for Japanese articles, because it is costly to use Ichushi personally (¥2000/8h). Abstracts of Japanese papers can also be seen in J-stage for free but most of free abstracts in Japanese academic papers are written in English. Therefore, the lower usage of PEDro in Japan is still a concern. However, there is some uncertainty about how well the usage of PEDro reflects the implementation of evidence-based practice, so this could be investigated further. Surveys of Japanese physiotherapists might help to understand the factors associated with evidence-based practice behaviours and identify targets to effectively promote the uptake of evidence-based practice across the nation.
A limitation of our analysis is that we could not calculate usage normalised by the number of physiotherapists for countries and regions outside Japan because data on the number of physiotherapists in each country are not easily accessible. This makes it impossible to compare PEDro usage relative to the number of physiotherapists between different countries. Establishing a common data set would benefit the physiotherapy profession globally. To achieve this, the physiotherapy community in each country needs only to submit the number of registered and unregistered physiotherapists to the World Confederation of Physical Therapy's data collection project 24).
Another limitation of the study is that the profession of the users could not be assessed. Usage of PEDro in Japan may be undertaken by other healthcare practitioners or patients. Also, usage may be influenced by frequent usage bysome sections of the physiotherapy workforce - for example, academic physiotherapists.
Our findings revealed that although Japan has higher PEDro usage than many other countries in the Asia Western Pacific region, usage normalised by number of physiotherapists is very low across Japan. Future education of physiotherapy needs to further enhance students' attitude towards seeking information from the international literature to facilitate evidence-based practice in Japan.
There are no conflict of interest
Mark Elkins and Anne Moseley are developers of the Physiotherapy Evidence Database (PEDro). PEDro is funded by the Australian Physiotherapy Association; the Transport Accidents Commission (Victoria, Australia); the Motor Accident Insurance Commission (Queensland, Australia; the Chartered Society of Physiotherapy and the World Confederation for Physical Therapy member organisations of 39 countries.