Use of the Physiotherapy Evidence Database (PEDro) in Japan

Transcription

1 SURVEY REPORT Use of the Physiotherapy Evidence Database (PEDro) in Japan Hiroshi TAKASAKI, PhD 1,MarkR.ELKINS, PhD 2,3 and Anne M. MOSELEY,PhD 3 1) Division of Physiotherapy, Saitama Prefectural University 2) Centre for Education & Workforce Development, Sydney Local Health District 3) The George Institute for Global Health; Sydney Medical School, University of Sydney ABSTRACT. 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 PE- Dro 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 ) was highest in Europe, followed by North America Carribean, South America, Asia Western Pacific, and Africa. Within the Asia Western Pacific region, -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 -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. Key words: physical therapy, evidence-based practice, clinical research (Phys Ther Res 19: 58-66, 2016) Received: May 12, 2015 Accepted: July 15, 2016 Advance Publication: December 1, 2016 Correspondence to: Mark R. Elkins, Centre for Education & Workforce Development, Sydney Local Health District, Sydney, Australia # mark.elkins@sydney.edu.au 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). Evidencebased 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. 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 1). 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

2 Use of PEDro in Japan 59 Table 1. Commonly stated obstacles to evidence-based physiotherapy and features of PEDro that can help overcome these obstacles. Obstacle Evidence may not exist to answer every clinical question 24). Physiotherapists find it difficult to judge which evidence has the highest quality and whether that quality is high enough for the results to be believable 28). Physiotherapists have limited time and money for evidence-based practice 29). Features of PEDro PEDro contains 27,066 reports of guidelines, reviews and trials evaluating physiotherapy interventions 25). PEDro has very comprehensive coverage of reports of randomised trials in physiotherapy 26, 27). Some reports (eg, Cochrane reviews) have Japanese-language abstracts. PEDro rates the quality of all trial reports. PEDro searches return higher quality trials before lower quality trials. PEDro users can see which quality criteria were met by each trial. PEDro provides Japanese-language tutorials in evidence-based physiotherapy. Reports on PEDro are categorised in many ways for easy identification with search terms. Almost all of the reports in PEDro also contain the abstract and links to fulltext versions of the article. PEDro now provides links to more sources that may provide (free) full-text copies of indexed research. PEDro can send free notifications of new evidence via Twitter, Facebook or the PEDro list. PEDro only indexes physiotherapy research, which simplifies searching. PEDro is free to search. characterise PEDro usage in Japan. Methods We sought to quantify PEDro usage with two outcomes. The first is the number of visits to the PEDro homepage. The second is the number of searches performed, expressed in absolute terms and relative to the number of registered physiotherapists and to the 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 The measures considered are detailed below. Count of visits to PEDro and location of the users 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 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). Count of searches of the PEDro database 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. Geographic areas 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. Figure 1 shows the geographic location of the prefectures. Absolute and normalised analyses Absolute usage was defined as the total number of searches from each region, country or prefecture. Data normalised by the were calculated by dividing the number of searches from each region, country or prefecture

3 60 Takasaki,etal. Figure 1. Map of the 47 prefectures in Japan showing PEDro usage relative to the number of registered physiotherapists in each prefecture in Japan (i.e., number of searches per physiotherapist). Darker shading represents higher usage. by the local ( number of searches per million ). National data were obtained from the United Nations latest updated report 12). The 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). Results Count of visits to the home-page and searches of the database in each year 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. Absolute and normalised analyses over 4 years 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 size, this ranking changed to: Europe first with 994 searches per million per year, North American Caribbean second with 734 searches per million, and South American third with 480 searches per million. Table 2 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 size, Australia was

4 Use of PEDro in Japan 61 Figure 2. ranked first ( 8,380 searches per million per year) followed by New Zealand ( 3,985 ) and Singapore ( 958 ). Table 3 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 size, however, the highest ranked prefectures were Nagano prefecture ( with 840 searches per million ), Kumamoto prefecture (556) and Aomori prefecture (503). Table 4 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,

5 62 Takasaki,etal. Table 2. Estimated number and percentage of PEDro searches from 2010 to 2013 for each World Confederation for Physical Therapy (WCPT) region. WCPT region in Percentage of searches 2010 per million Absolute number of searches per (n) (n) (%) ( 1,000,000) (n) (rank) (rank) Europe 2,730, , North America Caribbean 1,098, , South American 979, , Asia Western Pacific 1,347, , , Africa 55,188 13, No WCPT region 68,380 17, , Total 6,280,072 1,570, , Table 3. Estimated number and percentage of PEDro searches from 2010 to 2013 for each country in the Asia Western Pacific region. Country in Percentage of searches 2010 per million Absolute number of searches per (n) (n) (%) ( 1,000,000) (n) (rank) (rank) Australia 750, , , New Zealand 69,636 17, , Singapore 19,464 4, South Korea 125,249 31, Fiji 2, Taiwan 49,517 12, Macau Hong Kong 12,459 3, Oman 3, Japan 118,550 29, Saudi Arabia 24,021 6, Malaysia 21,414 5, Bahrain United Arab Emirates 4,312 1, Kuwait 1, Philippines 37,341 9, Thailand 14,379 3, Pakistan 14,521 3, Iran 6,196 1, Cambodia Indonesia 13,395 3, Sri Lanka 1, India 52,345 13, , Nepal Bangladesh 2, Afghanistan Total 1,347, , , followed by Tokyo and Aomori prefectures with 1.0 search per physiotherapist each. The prefectures that were ranked among the lowest for absolute and/or relative usage were the Kagawa, Kagoshima and Iwate prefectures. Figures 1and 2 shows the results for the analysis of searches per registered therapist by prefecture.

6 Use of PEDro in Japan 63 Table 4. Estimated number and percentage of PEDro searches from 2010 to 2013 for each prefecture in Japan. Prefecture in Percent age of searches registered PTs per million Absolute number of searches per Number of searches per registered PT (n) (n) (%) ( 1,000,000) (n) (n) (rank) (rank) (rank) Nagano Prefecture 7,162 1, , Akita Prefecture 2, Tokyo 22,914 5, , Aomori Prefecture 2, Gunma Prefecture 3, , Hokkaido 9,865 2, , Kumamoto Prefecture 4,020 1, , Okayama Prefecture 2, , Saitama Prefecture 5,558 1, , Aichi Prefecture 7,257 1, , Hiroshima Prefecture 3, , Miyagi Prefecture 1, , Osaka Prefecture 9,053 2, , Ishikawa Prefecture 1, Niigata Prefecture 1, , Tochigi Prefecture 1, Chiba Prefecture 4,177 1, , Ibaraki Prefecture 1, , Toyama Prefecture Wakayama Prefecture Fukuoka Prefecture 4,559 1, , Kanagawa Prefecture 3, , Gifu Prefecture , Shizuoka Prefecture 1, , Kyoto Prefecture 1, , Nara Prefecture Hyogo Prefecture 2, , Fukushima Prefecture Tottori Prefecture Fukui Prefecture Yamanashi Prefecture Yamagata Prefecture Shimane Prefecture Mie Prefecture Shiga Prefecture Nagasaki Prefecture , Miyazaki Prefecture Ehime Prefecture , Saga Prefecture Yamaguchi Prefecture , Oita Prefecture , Tokushima Prefecture Kochi Prefecture , Iwate Prefecture Okinawa Prefecture , Kagoshima Prefecture , Kagawa Prefecture Total 118,550 29, , PT = physiotherapist

7 64 Takasaki,etal. Discussion 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 ). 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, which is slightly lower than usage in Brazil (0.95 PEDro searches per physiotherapist 16) ) and markedly lower than in Australia (7.5 PEDro searches per physiotherapist ; 187,743 searches divided by 25,152 registered physiotherapists in ) ). 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. (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. This may reflect the fact that entrylevel 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 38 th 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

8 Use of PEDro in Japan 65 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. Conclusion 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. Acknowledgements: 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. Conflict of Interest: There are no conflict of interest References 1) Sackett DL, Straus SE, Richardson WS, Rosenberg W and Haynes RB: Evidence-based medicine: how to practice and teach EBM. 2nd ed, Edinburgh, Churchill Livingstone, ) Herbert RD, Sherrington C, Moseley AM, Maher C and Elkins M: Evidence-Based Physical Therapy. JJPTA. 2003, 30: ) Physiotherapy Evidence Database (PEDro). [cited 2015 Nov. 1]; Available from: 4) Bizzini M: VIP for PT, or very important PEDro for physiotherapy. Brit J Sports Med. 2013, 47: ) Fitzpatrick RB: PEDro: A Physiotherapy Evidence Database. Med Ref Serv Q. 2008, 27: ) Giglia E: PEDro: this well-known, unknown Physiotherapy Evidence Database. Eur J Phys Rehabil Med. 2008, 44: ) Campos TF, Beckencamp PR and Moseley AM: Usage evaluation of a resource to support evidence-based physiotherapy: the Physiotherapy Evidence Database ( PEDro). Physiother. 2013, 99: ) Elkins MR, Moseley AM, Sherrington C, Herbert RD and Maher CG : Growth in the Physiotherapy Evidence Database (PEDro) and use of the PEDro scale. Brit J Sports Med. 2013, 47: ) Sherrington C, Moseley AM, Herbert RD, Elkins M and Maher C: Ten years of evidence to guide physiotherapy interventions: Physiotherapy Evidence Database (PEDro). Brit J Sports Med. 2010, 44: ) Google: Google analytics. [cited 2014 Jan. 13]; Available from: 11) World Confederation for Physical Therapy. [cited 2015 Nov. 1]; Available from: 12) United Nations Population Division (Department of Economic and Social Affairs ) : World prospects : the 2010 revision-, both sexes. [cited 2012 Oct. 24]; Available from: 13) Official Statistics of Japan: Online data report via e-stat: portal site of the Government Statistics for Japan. [cited 2012 Oct. 1]; Available from: ) Japanese Physical Therapy Association : Online data report. [cited 2012 Oct. 1]; Available from: _jpta/about_jpta/05_index.html 15) World Confederation for Physical Therapy : Evidence based practice - an international perspective: report of an expert meeting of WCPT member organizations. [cited 2013 Nov. 2]; Available from: eport_2001.pdf 16) Elkins MR, Moseley AM and Pinto RZ: Usage evaluation of the Physiotherapy Evidence Database ( PEDro ) among Brazilian physical therapists. Braz J Phys Ther. 2015, 19: ) Physiotherapy Board of Australia: Registrant Update, Issue 8 - March [cited 2014 Apr. 22]; Available from: hysiotherapyboard.gov.au/documents/default.aspx?record=wd1 4%2F13496&dbid=AP&chksum=x2O26pfhgf8U2QkG1usfw Q%3D%3D 18) Boruff JT and Thomas A: Integrating evidence-based practice and information literacy skills in teaching physical and occupational therapy students. Health Info Lib J. 2011, 28: ) Education First. English Proficiency Index (3rd Edition). [cited 2015 Nov. 1]; Available from: ds/ 20) Japanese Physical Therapy Association: Tutorial of evidencebased physical therapy. [cited 2015 Nov. 1]; Available from: htt p:// 21) World Confederation of Physical Therapy: Data collection project. [cited 2015 Nov. 1]; Available from: ode/ ) Ichushi. [cited 2015 Nov. 1]; Available from: or.jp/about.english.html 23) J-stage. [cited 2015 Nov. 1]; Available from: jst.go.jp/browse 24) Bithell C : Evidence-based physiotherapy : some thoughts on best evidence. Physiother. 2000, 86:

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