|Year : 2013 | Volume
| Issue : 1 | Page : 23-30
Evidence base for physiotherapy/physical therapy: A specialty-based quantitative trend analysis of articles
Senthil Paramasivam Kumar1, Vaishali Sisodia2, Anup Kumar3
1 Department of Physiotherapy, Kasturba Medical College (Manipal University), Mangalore, India
2 Department of Physiotherapy, Srinivas College of Physiotherapy, Pandeshwar, Mangalore, India
3 Department of Orthopaedics, Kasturba Medical College (Manipal University), Mangalore, India
|Date of Web Publication||29-May-2013|
Senthil Paramasivam Kumar
Department of Physiotherapy, Kasturba Medical College (Manipal University), Mangalore - 575 001
Source of Support: None, Conflict of Interest: None
Background: Physiotherapy or Physical therapy (PT) grew as an allied health professional specialty originally under the field of Medicine, but later took its evolution as a paramedical service - both individually and as part of Rehabilitation. Objective of Study: To quantitatively explore the existing evidence base for physiotherapy/physical therapy in PubMed through review and analysis of current scientific literature. Materials and Methods: Descriptive exploratory study through a literature search was done to identify nine time-points in the timeline from 1970-2010, with five-year intervals to identify the scientific trend. The number of obtained citations were classified and analyzed under the names of search filters of PubMed namely - text availability, publication date, species, article type, language, gender, subject areas, journal categories, and age groups. The numbers for categories and subcategories of search filters were considered for comparison and analysis. Descriptive analysis using frequencies on Microsoft Excel 2010 worksheet was done. Results: There is an exponential increase in number of articles in general over the 40 years. There was more number of 'abstract available' articles. Human studies were more than animal studies. There was more number of clinical trials and randomized controlled trials among the article types. More articles were of English language, with nearly equal gender representation. There were more number of articles on complementary medicine, and MEDLINE journals had more articles, with more in adult and middle-age for study populations. Conclusion: This study provided information on current state of evidence for physiotherapy/physical therapy in a 40-year trend. This trend was similar to overall trend for all articles indexed in PubMed.
Keywords: Evidence-based physical therapy, physical therapy evidence base, PubMed analysis, reporting trend, research analysis
|How to cite this article:|
Kumar SP, Sisodia V, Kumar A. Evidence base for physiotherapy/physical therapy: A specialty-based quantitative trend analysis of articles. Saudi J Health Sci 2013;2:23-30
|How to cite this URL:|
Kumar SP, Sisodia V, Kumar A. Evidence base for physiotherapy/physical therapy: A specialty-based quantitative trend analysis of articles. Saudi J Health Sci [serial online] 2013 [cited 2022 May 23];2:23-30. Available from: https://www.saudijhealthsci.org/text.asp?2013/2/1/23/112627
| Introduction|| |
"Published research contributes to the knowledge base that distinguishes one discipline from another. More research is now published in the physical therapy journals, but concerns with the profession's knowledge base continue."
- Robertson 
Physiotherapy or Physical therapy (PT) grew as a professional specialty originally under the field of Medicine,  but later took its evolution as a paramedical service  both individually and as part of Rehabilitation.  Now the specialty is housed under a broader term of 'Allied health' professions,  and is been globally regarded as an independent professional specialty in all aspects of practice, education, and research in a ever-changing healthcare environment.  The term 'physiotherapy', however, took its origin in only 1851 when a military physician Dr. Lorenz Gleich (1798-1865) used the term "physiotherapie" in German language. 
The World confederation for physical therapy (WCPT), an organization formed by world-wide representation and membership of national associations is the official regulatory body for PT.  The WCPT had set forth guidelines, standards, and code of conduct for PT professional practice, education, research, and administration.  The WCPT has professional subgroups based on sub-specialties of PT such as pain, spinal cord injury, women's health, manipulative physical therapy, education, journal editing, geriatrics, veterinary sciences, intensive care, acupuncture, mental health, sports, and private practice. The WCPT had its motto for developing PT as a pre-eminent healthcare specialty in the world. 
Practice of physiotherapy started its history from the application of manipulative therapy techniques by Hippocrates in 400 BC, to the use of passive movements and manual muscle testing after the First World War.  Now PT includes in its therapeutic armamentarium a range of exercise, electrical/thermal and manual therapy modalities that had been to be effective either individually or as an adjunct thus establishing its role along a symptom control-quality of life benefits for all ages among both healthy subjects and patients alike.  Practice autonomy and direct access PT services are available in most parts of developed countries,  thus enabling immediate and appropriate therapeutic interventions and cost-effectiveness.  Now, PTs are recognized as inherent team members in a multidisciplinary biopsychosocial rehabilitation 'out of the box' framework. 
Education in PT is the second domain in which schools and institutions began their instruction that later on got accredited for their curricular content and credentials by professional regulatory bodies in respective countries. Educational qualifications in PT include part-time and full-time courses of certification programs, undergraduate degree, post-graduate degree, and doctoral degree (both Doctor of Physical Therapy and Doctorate of Philosophy).  Recent developments in PT education include problem-based learning,  advanced pedagogical methods, and articulated curricula. 
Research in PT despite its academic inadequacies  evolved with its first published clinical trial in by on. The first systematic review was on in the steady increase in number of randomized clinical trials in PT from in to in warrant an evidence-based or evidence-informed paradigm shift  that ensued in a continuum of struggle for existence to survival of the fittest.  There is a growing emphasis on multidisciplinary collaborative research with a shift towards mixed-methods research models. 
Evidence informed practice (EIP) within the context of Evidence-based practice (EBP) requires professionals to keep abreast with the latest developments in the field of research and scientific evidence.  PubMed is the largest and most widely searched database for evidence retrieval, with 22 million citations, and analyses of PubMed have provided valuable information on existing evidence base in many previous reports. Kumar and Sisodia  performed an exploratory review on PubMed per se, but there is a need to explore the evidence base for PT to establish an evidence benchmark for specialty-based professional representation for PT in PubMed.
Objective of study
To quantitatively explore the existing evidence base for physiotherapy/physical therapy in PubMed through a descriptive review and analysis of current scientific literature.
| Materials and Methods|| |
Descriptive exploratory study.
The study methodology was a replication of previously used method as described by Kumar and Sisodia.  Two reviewers performed an independent blinded search of PubMed using specific search strategy and they independently extracted and synthesized the data from the selected studies using a structured checklist. At all stages of the review process, all disagreements were solved by mutual consensus before proceeding to the subsequent stages of the review.
A combination of using Medical subject heading (MeSH) and search filters in PubMed was used for this study. "Physiotherapy or Physical Therapy [MeSH Major Topic]" was entered into search tab through advanced search option of PubMed.  A thorough literature search was done to identify nine time-points in the timeline from 1970-2010 in a 40-year period, with five-year intervals to identify the scientific trend. The search was performed in the month of November 2012, and retrieved numbers of citations were then used as data for extraction and synthesis.
Data extraction and synthesis
The number of obtained citations were classified and analyzed under the names of search filters of PubMed namely - text availability, publication date, species, article type, language, gender, subject areas, journal categories, and ages. The numbers for categories and subcategories of search filters were considered for comparison and analysis.
All data were entered in Microsoft Excel 2010 worksheet and computed descriptively using their respective frequencies - numbers and percentiles. All comparisons were done visually to obtain an overall appearance and trend.
The total number of articles under "Physiotherapy/Physical Therapy [MeSH Major Topic]" were 80,261 articles (on 15 th November 2012) and 62,447 articles indexed during the search period (1970-2010), which were identified by searching through publication dates in search filters of PubMed.
Trend for number of 'physical therapy' articles
The number of 'physical therapy' articles per year increased gradually from 1970 to 2000, and sharply afterwards until 2010 [Figure 1].
|Figure 1: 40-year trend for number of 'physical therapy' articles based upon year of publication|
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Text availability of 'physical therapy' articles
There was greater number of 'abstract available' than 'full text available' articles and 'free full text available' articles [Figure 2]. The increase in number of 'full text available' and 'abstract available' articles were more rapid after 1995, and was more than that of 'abstract available' articles [Figure 3].
|Figure 2: Relative prevalence of sub-categories for text availability among 'physical therapy' articles|
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|Figure 3: Comparison of 40-year trend between the three subcategories of text availability among 'physical therapy' articles|
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Species studied in 'physical therapy' articles
The number of articles and the trend of increase were more in human studies than on other animals' studies [Figure 4] and [Figure 5].
|Figure 4: Relative prevalence of sub-categories for species among "physical therapy' articles|
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|Figure 5: Comparison of 40-year trend between the two subcategories of species among 'physical therapy' articles|
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Types of 'physical therapy' articles
Clinical trials, randomized controlled trials, and review articles were more in number than other article types [Figure 6]. The rapid increase in number of clinical trials followed by randomized controlled trials on physical therapy occurred from 1995 onwards [Figure 7].
|Figure 6: Relative prevalence of sub-categories for article types among 'physical therapy' articles|
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|Figure 7: 40-year trend for number of articles among 'physical therapy' articles based upon article types|
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Language of 'physical therapy' articles
The number of articles and the trend of increase was more for studies on English language than on other languages [Figure 8] and [Figure 9].
|Figure 8: Relative prevalence of sub-categories for language among 'physical therapy' articles|
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|Figure 9: 40-year trend for number of English language articles among 'physical therapy' articles|
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Gender studied in 'physical therapy' articles
The relative prevalence of number of articles and the corresponding trend was equal for 'female' gender' and 'male gender' amongst the 'manual therapy' articles [Figure 10] and [Figure 11].
|Figure 10: Relative prevalence of sub-categories for gender among 'physical therapy' articles|
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|Figure 11: Comparison of 40-year trend between the subcategories of gender among 'physical therapy' articles|
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Subject categories of 'physical therapy' articles
A prominently large number of 'physical therapy' articles were indexed under the subject category of 'complementary medicine', followed by 'cancer' and 'toxicology' [Figure 12]. The trend analysis for 'physical therapy' articles indexed under subject category of 'complementary medicine' showed a rapid increase in number of articles from the year 1995 onwards, followed by cancer [Figure 13].
|Figure 12: Relative prevalence of sub-categories for subject areas among 'physical therapy' articles|
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|Figure 13: 40-year trend for number of articles under subject categories among 'physical therapy' articles|
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Journals publishing 'physical therapy' articles
Maximum articles on 'physical therapy' were indexed in MEDLINE journals, and some articles in core clinical journals, dental, and nursing journals [Figure 14]. The trend analysis for 'physical therapy' articles indexed in MEDLINE and nursing journals showed a rapid increase in number of articles from the year 1995 onwards [Figure 15].
|Figure 14: Relative prevalence of sub-categories for journals among 'physical therapy' articles|
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|Figure 15: Comparison of 40-year trend for number of 'physical therapy' articles in four journal categories|
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Age of study population in 'manual therapy' articles
The relative prevalence of number of articles and the corresponding trend was more for 'physical therapy' articles indexed under 'adult age' and 'middle age' than 'child' and 'old age' [Figure 16] and [Figure 17].
|Figure 16: Relative prevalence of sub-categories for ages among 'physical therapy' articles|
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|Figure 17: Comparison of 40-year trend between the subcategories of ages among 'physical therapy' articles|
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| Discussion|| |
This study aimed to descriptively explore the existing evidence, which forms the base for PT in PubMed, and the number of articles indexed under medical subject heading of PT and their increase in number over the 40-year period from 1970-2010 with sudden increase after 1995 was witnessed. This study's findings were very much in line with overall growth in evidence provided by PubMed, as demonstrated by Kumar and Sisodia. 
The overall proportion of articles for PT in PubMed is merely inadequate. This may be attributed to inherent problems in PT research.  Understanding of the role of research in PT as a philosophy, overcoming the barriers to involvement in research, and use of research by physical therapists determines the extended scope of PT research into EBP.  The profession of PT depends on research and publication in its efforts to further professionalization and professional autonomy  as a result of fight for professional survival.  Research should be emphasized as a subspecialty under PT and training in multidimensional practice settings are essential  to move the way forward  into the future  for effective organization of physiotherapy. 
The development of research in PT could extend its role into all domains of specialty of PT and its subspecialties, in aspects of clinical practice, education and administration.  Such an integrated model should be specialty per se. incorporated in PT curricula, which has the four following aspects as outlined by Darra et al. (1) The concept that theory, research, and clinical practice are interdependent and inform each other; (2) the importance of client-centered practice; (3) the terminology and philosophical framework of the World Health Organization's International Classification of Functioning, Disability, and Health; and (4) the importance of evidence-based practice.
Whilst there are many other databases available, previous studies have analyzed Physiotherapy evidence database (PEDro)  for its content  and other reports had analyzed RCTs of PT interventions in multiple databases.  PEDro is the main resource for EBP in PT,  with quality scores available for indexed abstracts of RCTs.  PEDro quality scale was also widely used in development of many systematic reviews and practice guideline recommendations on PT interventions.  PT-specific analysis would be appropriate to be done for PEDro, while a multidisciplinary focus such as this study's requires a database such as PubMed.
The large numbers of 'abstract available' articles show a positive demonstration for EBP since they provide an outline of scientific information essential for use by developing country researchers. Quality criteria for abstracts are essential prior to such use, and abstract quality was a definitive indicator for study quality in RCTs and, hence, future quality assessments of abstracts in PT would be indicated.
The increase in number of articles after 1995 could be due to inclusion of more PT journals either into PubMed, PubMed central or Medline. However, this is one of the acceptable limitations for this study, and PubMed-indexation was nevertheless a quality indicator for Journals since open-access archiving provides huge opportunities for non-indexed journals to be included into PubMed.  Future analyses should address these issues by being performed on PT journals for their contribution to EBP through PubMed. Such analyses were previously reported for ethical issues  and reporting trend analyses for individual PT journal ,, as well as combined. , Such analyses of PT journals could be focused on levels or hierarchy of evidence of published articles. 
More articles on human than other animals as study species shows the development and transformation from basic laboratory studies to clinical case-oriented studies in an effort of EBP in knowledge generation and translation from 'bench to bedside'. 
More studies were original articles (clinical trials and RCTs) which are associated with many methodological and reporting issues  such as trial registration,  which may be the impending policy change required by the PT journals.  The intervention studies could also be evaluated and grouped based on International classification of functioning, disability, and health (ICF) model.  The maximum number of RCTs indexed in PubMed reflected the previously reported high prevalence of PT RCTs in PubMed at 91%  compared to other databases, with only PEDro and CENTRAL at higher rates (98% and 99%, respectively).
Evidence for effectiveness and adverse events thus facilitate an informed clinical decision making, in turn leading to development of clinical practice guidelines. 
Lesser prevalence of evaluation studies poses a threat to diagnostic EBP since both diagnosis and therapy requires measurement methods which need validation and reliability research to support their use.  Sim and Arnell  said, "First, it is argued that validity is often poorly distinguished from the allied concept of reliability and that purported claims for validity often only demonstrate reliability. Second, it is claimed that validity is too often neglected in favor of reliability, and specific examples relating to gait analysis are put forward to support this argument. Third, some of the methodological difficulties that may occur when attempts are made to demonstrate validity are considered."
Karin et al., outlined the obstacles for EBP implementation as; "Important obstacles to the implementation of EBP include physiotherapists' lack of autonomy and authority to decide on patients' treatments or to negotiate with government. In addition, the lack of evidence, inaccessibility and inapplicability of scientific evidence, the economic parameters influencing government and physicians, the expectations from patients and a lack of motivation."
Effective implementation of EBP in PT requires formative evaluation strategies,  such as interdisciplinary training  to address the challenges as mentioned by Maher et al., as; "facilitating the publication of all research, use of an optimum format for reporting research, maximizing the efficient use of electronic databases, improving physical therapists' skills in critical appraisal of published research, and fostering consumer access to evidence."
Identification and strategization of national research priorities by professional associations would be a key step in global initiative towards improving research and EBP in the health specialty of PT.  Periodic reflective analyses such as this study is essential to explore the growth and development of PT as an effective professional specialty. 
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]