clinical practice guidelines ( cpg ) are defined as follows in japan :  a clinical practice 
 guideline is a document that presents appropriate recommendations to assist patients and 
 practitioners in making decisions regarding clinical practice of high importance , based on 
 the body of evidence evaluated and integrated by systematic reviews and the balance between 
 benefits and harms.1 . using cpg improves 
 some clinical outcomes and process such as taking the evidence into practice2 . in physical therapy , because cpg are useful 
 as a means to facilitate evidence - based practice ( ebp)3,4,5 , they are expected to be increasingly used in clinical settings , 
 improving the attitudes of ebp as a spillover effect . it therefore seems important to know 
 the tendencies that physical therapists take attitudes of ebp and cpg , and some modifiable 
 basic attributes of physical therapists related to attitudes of ebp and cpg . according to the results of a survey targeting physical therapists in sweden , the local 
 attitudes of ebp were found to be high6,7,8 , 
 with most therapists using cpg . a similar tendency was observed among physical therapists in 
 the u.s . in a study showing that physical therapists highly take attitudes of ebp and 
 cpg9 . moreover , ebp knowledge and 
 behaviors among physical therapists in various countries10 and ebp barriers , enablers and interventions11 have been studied in systematic review . these results also 
 indicate that most of physical therapists in foreign countries make feel ebp to be 
 facilitated and educated . these characteristics and work environments related to attitude or behavior of implementing 
 ebp have been more reported in previous studies . in detail , foreign physical therapists , who 
 have insufficient time and organizational barriers , lack of computer and search skills , 
 appraisal and application of research findings , feel barriers to implement ebp and using 
 cpg12 , 13 . about basic attributes of physical therapists , individual 
 characteristic , which includes highest degree , age , and number of years licensed , or work 
 place environment such as number of physical therapists working at the same place and 
 recommendation to facilitate ebp and use cpg , for example , skills 
 of reading literatures and continuing ebp education course influences their ebp 
 practice16 . the percentage of physical 
 therapists learning or being educated about ebp such as searching strategy , ebp training , 
 and appraising searches is approximately 50%17 . it seems for implementing ebp that academic or clinical education 
 has important roles . on the other hand , no data have been published for japanese physical therapists . in japan , 
 continuing medical education , including both under - graduation and post - graduation , on ebp 
 and cpg is still developing compared with that in the u.s . and therefore , it is worth examining and 
 reporting the current status of japanese physical therapists with regard to ebp and cpg to 
 make the focus and goals of the medical education system clear . here we aimed to clarify the attitudes and behavior of japanese physical therapists with 
 regard to ebp and cpg , and basic attributes related to them . a cross - sectional postal mail survey was conducted using an anonymous self - administered 
 questionnaire . the eligible group comprised 2,982 of 3,465 physical therapists belonging to the chiba 
 prefecture physical therapist association as of june 2014 , excluding those belonging to an 
 educational institution , at - home members , members of this project , and the participants of 
 the preliminary investigation ( preliminary investigation has been done in order to confirm 
 the accuracy of questionnaires ) . among the eligible participants , , it was confirmed that the attributes 
 of the members of the chiba prefecture physical therapist association were not largely 
 biased compared with the national average . the collection time limit was set as 2 weeks after distribution , and reminders were sent 1 
 week after the distribution . we included questions used in previous studies6,7,8,9 
 ( appendix table 1 ) that its validation and reliability was confirmed , according to the 
 following process : forward translation by the authors into japanese , backward translation by 
 an experienced translator , and discussion and modification as appropriate to maintain 
 compatibility and adopt cross - cultural factors ( e.g certification , available database in 
 japan ) . the reliabilities were 
 examined preliminary for ten japanese participants before the survey , revealing an 
 interclass correlation coefficient of 0.890.92 for 2 weeks and 0.910.96 for 1 month , which 
 confirmed adequate reproducibility for items 1342 . the questionnaire comprised 42 items : basic attributes of the respondent ( items 112 ) , 
 attitudes of ebp ( items 1321 ) , ebp education ( items 2223 ) , ebp - related behavior ( items 
 2428 ) , attitudes of cpg ( items 2936 ) , knowledge of ebp and cpg ( item 37 ; a j ) , cpg - related 
 behavior ( items 3841 ) , and obstacles in using cpg ( item 42 ) . some questions were also 
 included in addition to the previous studies because following questions seem to be related 
 to attitudes and behavior of ebp16 , 17 and cpg :  whether you are engaged in 
 research activities ,   whether your confidence in clinical decision making has increased by 
 the use of cpg of the treatment ,  and  whether communication with other health care 
 professionals has increased / improved by using cpgs  . the likert scale ( 3-point scale for  yes ,   partially ,  and  no  and 5-point scale for 
 answers ranging from  strongly agree  to  strongly disagree  ) was used . as for answers 
 involving frequency numbers , univariate logistic regression analysis was used to clarify the 
 relevance of related items between ebp / cpg and basic attributes and to identify . answers 
 were dichotomized according to previous studies6 , 
 9 , 16 prior to performing the logistic regression analysis . with regard 
 to the analysis of the results of the 5-point likert scale , the answers strongly agree  and 
  agree  were classified into an  agree group ,  whereas the answers  neutral ,   disagree ,  
 and strongly disagree  were classified into a  disagree group  ; with regard to the analysis 
 of the results of the 3-point likert scale , answers were divided into  yes  and  other .  as 
 for the basic attributes , an educational background of  master  or doctor  was unified as 
  master or doctor .  as for years of experience , 1620  years  and  21  years or more  were 
 grouped as i do nt know  or missing values ( not noted ) were 
 excluded from the examination . the significance level was set at 5% . for models identified as significant in the logistic 
 regression analysis , statistical significance was tested using the 95% confidence interval 
 ( ci ) of the odds ratio . the study was approved by kyoto university graduate school and faculty of medicine , ethics 
 committee ( no . e2266 ) . we explained the study using cover letter sentences , and it was 
 considered to agree if the participants anonymously responded . study on clinical 
 practice guidelines forming the base of medical care to fulfill social responsibilities  and 
 the general , incorporated association chiba prefecture physical therapist society . among the 1,000 people included , 396 responded to the questionnaire ( response rate , 39.6% ) , 
 and 384 questionnaires were available for analysis . table 1table 1.demographics and workplace characteristic ( n=384)itemvaluegendermale : 64% , female : 36%age2029 years : 43% , 3039 years : 38% , 4049 years : 16% , 5059 years : 
 3% , 60 + years : 0%highest degreecareer college : 68% , college : 29% , master degree : 2% , doctoral 
 degree : 1%primary care experience<3 years : 17% , 35 years : 26% , 610 years : 31% , 1115 years : 
 15% , 16 + years : 10%certification / specialized qualification*certification physical therapist : 3% , specialized qualification 
 physical therapist : 1%work practice ( total number)hospital : 256 , home - visit nursing station : 9 , day service / day care : 
 56 , clinic : 74 , other : 30patient care ( total number)acute care hospital : 165 , acute rehabilitation : 82 , subacute 
 rehabilitation : 141 , maintenance hospital : 216 , other : 11number of people at workplace<3 : 23 , 35 : 65 , 610 : 85 , 1115 : 54 , 15 + : 160hospital bed ( av  sd)220  172 hospital bedsav : average , sd : standard deviation . * physical therapists can be certification 
 physical therapists by clinical experiences and paper - tests in japan . moreover , 
 certification physical therapists can be specialized qualification physical therapist 
 by earning points of paper productions etc . the percentages 
 of certified physical therapists and specialized qualified physical therapists are 
 interpreted to be general in japanese physical therapists , which averages are 1% and 2% each 
 in the whole country . * physical therapists can be certification 
 physical therapists by clinical experiences and paper - tests in japan . moreover , 
 certification physical therapists can be specialized qualification physical therapist 
 by earning points of paper productions etc . table 2table 2.the percentage of ebp items ( n=384)item no.agree or yes group ( % ) disagree or other group ( % ) 1383.312.21477.115.61539.151.61674.520.61743.045.81883.313.51926.065.42013.378.92122.971.92210.489.62311.288.8249.687.52524.273.72613.584.92779.220.82880.219.8agree group :  strongly agree  and  agree  disagree group :  strongly disagree  , 
  disagree  , and neutral  yes group :  yes  , other group :  no  and  neutral  item no . 
 refers to appendix . shows attitudes and behavior toward ebp . regarding the question about 
 attitudes and behavior toward ebp , proportion of respondents answering strongly agree  or 
  agree  on ebp is indicated for more than 83.3% about importance of ebp , 77.1% about 
 decision support , and 83.3% about necessity of knowledge acquisition . on the other hand , ( 39.0% ) ,  is available papers enough to support a clinical 
 question ? ( 43.0% ) . as for the question 
 regarding ebp education , 10.4% respondents answered  yes  to the question i learned the 
 foundations for ebp as part of my academic preparation .  , and 11.2% respondents answered yes  to the question  i received formal training in critical appraisal of research 
 literature as part of my academic preparation . in addition , with regard to the question 
 concerning their own confidence in ebp behavior , such as taking the view that performing 
 literature searches and reviews is important for ebp , approximately 1025% answered 
  agree . agree group :  strongly agree  and  agree  disagree group :  strongly disagree  , 
  disagree  , and neutral  yes group :  yes  , other group :  no  and  neutral  item no the relationships between ebp items and basic attributes were seen as follow . either 
  taking part in a study  ,  number of people at workplace  ,  primary care experience  , 
  certification / specialized qualification  ,  highest degree  , or  sex  was positively 
 associated with almost all questions . table 
 3table 3.attitudes and behavior of evidence - based practice ( ebp ) related to participating 
 in research activitiesitemlevelodds ratio ( 95% ci)n17 . my reimbursement rate will increase if 
 i incorporate ebp into my practice.yes1.47 ( 0.703.17)341partially0.5 ( 0.30.9)*noreference19 . at my place of work , the use of 
 current ebp is encouraged.yes6.50 ( 3.1613.57)*351partially6.45 ( 3.6911.44)*noreference21 . i feel confident in my ability to find 
 relevant research to answer my clinical questions.yes1.43 ( 0.672.91)364partially0.51 ( 0.250.96)*noreference22 . i learned the foundations for ebp as 
 part of my academic preparation.yes6.36 ( 2.6215.19)*384partially3.11 ( 1.426.77)*noreference23 . i received formal training in critical 
 appraisal of research literature as part of my academic preparation.yes5.29 ( 2.3011.93)*384partially1.72 ( 0.773.70)noreference24 . i am confident in my ability to 
 critically review professional literature.yes8.53 ( 3.7019.73)*373partially1.31 ( 0.493.20)noreference25 . i am confident in my ability to find 
 relevant research to answer my clinical questions.yes5.23 ( 2.6010.71)*376partially1.33 ( 0.732.35)noreference26 . i am familiar with the medical search 
 engines ( e.g. , ichushi , pubmed , etc.)yes7.08 ( 3.3115.14)*378partially1.22 ( 0.542.59)noreference27 . number of scientific articles related 
 to my clinical work that i read , during a typical month.yes11.77 ( 5.6625.43)*384partially2.10 ( 1.133.84)*noreference28 . number of times i use pubmed or other 
 databases to search literature that is relevant to my clinical work , during a 
 typical month.yes17.10 ( 8.0238.50)*384partially2.12 ( 1.114.00)*noreference * p<0.05 . 95%ci : 95% confidence interval , n : number of respondents shows the relationships between attitudes and behavior of ebp and whether 
 participating in research activities , which is more basic attributes related to attitudes 
 and behavior of ebp than others . yes  to questions on education and behavior of ebp compared with 
 those not engaged in research : the recommendation of ebp in the workplace ( or=6.50 , 95% 
 ci=3.1613.57 ) , education using ebp ( or=6.36 , 95% ci=2.6215.19 ) , education using critical 
 appraisal of academic literature ( or=5.29 , 95% ci=2.3011.93 ) , confidence in terms of 
 extracting a meaning of a treatise ( or=8.53 , 95% ci=3.7019.73 ) , ability to perform a 
 literature search on a clinical question ( or=5.23 , 95% ci=2.6010.71 ) , and familiarity using 
 a medicine search site ( or=7.08 , 95% ci=3.3115.14 ) . 95%ci : 95% confidence interval , n : number of respondents furthermore , as modifiable basic attributes , a higher number of people in the workplace and 
 higher educational background were positively associated with the items pertaining to the 
 attitudes of and behavior toward ebp . as not modifiable variables , number of people in the workplace significantly contributes attitudes and behavior for ebp 
 as follows : less than 3 physical therapists in workplace was more prone to disagree number 
 of scientific articles related to my clinical work that i read , during a typical month . ( or=0.01 , 95%ci=0.000.28 ) , and  number of times i use pubmed or other databases to search 
 literature that is relevant to my clinical work , during a typical month . ( or=0.01 , 
 95%ci=0.000.32 ) . from three to five physical therapists in workplace was more prone to 
 disagree  ebp improves the quality of patient care . number 
 of scientific articles related to my clinical work that i read , during a typical month . ( or=0.35 , 95%ci=0.140.77 ) . from three to five and from six to ten physical therapists in 
 workplace were more prone than more than 15 physical therapists to disagree  at my place of 
 work , the use of current ebp is encouraged  ( 35 physical therapists : or=0.20 , 
 95%ci=0.070.45 , 610 physical therapists : or=0.40 , 95%ci=0.210.76 ) , ( 35 physical therapists : or=0.08 , 
 95%ci=0.000.36 , 610 physical therapists : or=0.17 , 95%ci=0.040.51 ) , and i received formal 
 training in critical appraisal of research literature as part of my academic preparation . ( 35 physical therapists : or=0.01 , 95%ci=0.050.15 , 610 physical therapists : or=0.42 , 
 95%ci=0.160.97 ) . from six to ten physical therapists in workplace were more prone than more 
 than 15 physical therapists to disagree i am familiar with the medical search engines 
 ( e.g. , ichushi , pubmed , etc . )  . similarly , a higher educational background such as whether what last degree is and what 
 sort of school participants graduated is significantly associated with attitudes and 
 behavior for ebp as follows ( all p<0.05 ) :  i received formal training in critical 
 appraisal of research literature as part of my academic preparation .  ,  current research 
 helps me make decisions about patient care .  ,  at my place of work , the use of current ebp 
 is encouraged . ,  i am confident in my ability to critically review professional 
 literature .  ,  i am confident in my ability to find relevant research to answer my clinical 
 questions .  ,  i am familiar with the medical search engines ( e.g. , ichushi , pubmed , etc . )  , 
  number of scientific articles related to my clinical work that i read , during a typical 
 month .  , and  number of times i use pubmed or other databases to search literature that is 
 relevant to my clinical work , during a typical month .  . then , attitude and behavior toward cpg and obstacles in using it was resulted below . moreover , 13.3% respondents agreed to the clinical usefulness of cpg ( table 4table 4.the percentage of cpg items ( n=381)item no.agree or yes group ( % ) disagree or other group ( % ) item noagree or yes group ( % ) 2940.159.142a38.83029.270.142b45.330 ( 1)26.372.942c23.430 ( 2)18.880.542d43.83154.935.442e41.73276.315.142f38.33313.372.942g39.83445.344.342h16.13556.033.142i15.63615.164.842j11.237a5.270.837b7.669.337c8.666.137d4.272.737e6.860.437f6.365.637g0.354.737h3.156.337i6.870.337j11.769.83870.129.73962.837.04022.177.3agree group : , other group :  no  and  neutral  item no . refers to appendix . ) . yes group :  yes  , other group :  no  and  neutral  item no the relationship between the questions on cpg and basic attributes of the respondents has 
 been shown about almost items . table 
 5table 5.attitudes and behavior of clinical practice guidelines ( cpg ) related to 
 participating in research activitiesitemlevelodds ratio ( 95% ci)n29 . i am aware that evidence - based 
 guidelines for diagnoses relevant to my work exist.yes2.34 ( 1.194.72)*381partially1.04 ( 0.631.72)noreference30 . i can integrate the patients 
 preferences with evidence - based guidelines.yes2.93 ( 1.316.43)*307partially0.45 ( 0.181.00)noreference38 . i have the ability to access relevant 
 databases and the internet at my facility.yes1.33 ( 0.603.27)347partially2.68 ( 1.355.83)*noreference39 . i have the ability to access relevant 
 databases and the internet at home or locations other than my facility.yes3.22 ( 1.2211.11)*335partially0.62 ( 0.361.10)noreference40 . i know how and where to find 
 evidence - based guidelines related to my work on the internet.yes2.75 ( 1.325.61)*380partially1.58 ( 0.882.78)noreference * p<0.05 . 95%ci : 95% confidence interval , n : number of respondents shows the relationships between attitudes and behavior of ebp and whether 
 participating in research activities , which is related to many of attitudes and behavior of 
 ebp . physical therapists engaged in research activities were more prone to answering  yes  
 to the items related to the attitudes of and behavior toward cpg than those not engaged in 
 research : being aware of cpg ( or=2.34 , 95% ci=1.194.72 ) , using cgp ( or=3.02 , 95% 
 ci=1.476.32 ) , integrating patients preferences with cpg ( or=2.93 , 95% ci=1.316.43 ) , being 
 able to access clinical databases at their workplace ( or=3.22 , 95% ci=1.2211.11 ) , and 
 knowing how to search for cpg on the internet ( or=2.75 , 95% ci=1.325.61 ) . 95%ci : 95% confidence interval , n : number of respondents in addition , a higher number of people at the workplace and a higher educational background 
 were positively related with the attitudes of and behavior toward cpg as modifiable 
 variables , and sex and years of experiences as not modifiable variables . number of people in the workplace significantly contributes attitudes and behavior for ebp 
 as follows : less than 3 physical therapists in workplace was more prone to disagree  i have 
 the ability to access relevant databases and the internet at my facility . ( or=0.20 , 
 95%ci=0.070.54 ) . from three to five physical therapists in workplace was more prone to 
 disagree  i am aware that evidence - based guidelines for diagnoses relevant to my work 
 exist . ( or=0.50 , 95%ci=0.270.91 ) ,  i use evidence - based guidelines in my work .  ( or=0.49 , 
 95%ci=0.240.97 ) ,  i have the ability to access relevant databases and the internet at my 
 facility .  ( or=0.23 , 95%ci=0.110.47 ) , and  i know how and where to find evidence - based 
 guidelines related to my work on the internet . were more prone than more than 15 physical therapists to 
 disagree  i am aware that evidence - based guidelines for diagnoses relevant to my work 
 exist . ( or=0.38 , 95%ci=0.210.66 ) , and  evidence - based guidelines are important so that 
 patients receive equal treatment . ( or=0.32 , 95%ci=0.180.57 ) . a higher educational background such as whether what last degree is and what sort of school 
 participants graduated is significantly associated with attitudes and behavior for ebp as 
 follows ( all p<0.05 ) : i am aware that evidence - based guidelines for diagnoses relevant 
 to my work exist . i know how and where 
 to find evidence - based guidelines related to my work on the internet . this is the first survey on the attitudes and behavior toward ebp and cpg of japanese 
 physical therapists . we found that thoughts on ebp are partially shared , but appropriate use 
 of cpg is not shared among these therapists and that only few of the study individuals 
 received ebp education . the attitudes of ebp and cpg among japanese physical therapists are low compared with that 
 among foreign therapists6,7,8,9 . this may be because ebp education systems have not been developed 
 in japan . in fact , the results of the present study indicate that physical therapists that 
 have mastered or doctoral degree and certified / specialized qualification ( japanese physical 
 therapists first graduate school and qualified . after that , they proceed to gradable 
 certified system , certified physical therapists , and specialized physical therapist . ) . at 
 only bachelor degree , students are not almost taught what is evidence or how to use 
 guideline . moreover , there are not physical therapists in clinical setting who can teach 
 what ebp is or spend time to teach it . in order to spend time to teach , number of people in 
 workplace needs to be increased , that is indicated by the present study which less number of 
 people in workplace do not facilitate attitudes and behavior toward ebp or cpg . also , 
 previous studies have reported that postgraduate ebp education improves the conviction and 
 attitudes of ebp9 , 16 , 19 . therefore , postgraduate 
 ebp education is important for physical therapists to be able to implement ebp . however , the 
 present study showed that only 10% of the respondents received ebp education . was 
 related to most questions on ebp and cpg . to put research evidence into practice , we need to 
 know the existing evidence and how to use it in reality13 , 20 , 21 . because the educational systems of physical therapists in japan 
 are not established , the one way to know and use the evidence may be to take part in 
 research activities , which may improve practice in turn . this study revealed that 
 approximately 10% of the respondents engaged in research activities , a figure increasing to 
 approximately 30% if those who are only partly engaged in are included . this suggests that 
 that patients have been provided the quality of physical therapy becomes uniform unless 70% 
 of physical therapists who are not engaged in research activities do not raise their 
 attitudes of ebp and cpg . thus , education that includes research activities appears critical 
 to raising attitudes toward ebp and cpg . first , there may be bias due to the nature of the 
 self - administered questionnaire survey . second , comparison of the present results with those from other 
 countries should be performed with caution because the validation of the questionnaire has 
 not been completed ; validation is important , despite the careful translation process . third , 
 any causality of the relation between research experience and a positive attitude toward ebp 
 can not be determined because our findings are based on a cross - sectional survey , and high 
 motivation of the clinicians may confound the relationship between attitude toward ebp and 
 research experience . fourth , the present findings are not likely to be seriously biased because the 
 respondents were randomly sampled in a single prefecture ; however , generalizability needs 
 attention across other prefectures . this study gain approximately 40% response , and this rate is less than other 
 countries ( e.g. 73% in american physical therapists15 and 81% in canadian physical therapists16 ) . it may influence the present results at the point that 
 participants who have already been aware of ebp or using cpg respond to these 
 questionnaires . from the above , first , in order to 
 facilitate ebp and using cpg , work environment needs to be established such as increasing 
 number of physical therapists in the workplace , recommending ebp , and making times to spend 
 searching relevant research evidences . of course , establishing these environments is hard to 
 implement , organizations need to consider for physical therapists . may make 
 physical therapists be aware of necessity to have attitudes toward ebp and using cpg . education guideline from 
 japanese physical therapy association indicated that we need to teach ebp and how to adjust 
 cpg for patients in clinical settings or academic preparation , but these statements are not 
 implemented . we expect that these three policies are developed . as for the future problems to be tackled , it can be pointed out that an intervention 
 program should be developed to improve the attitudes , behavior , and education of ebp and cpg 
 and that ebp promotion and cpg expansion are necessary .
[ purpose ] this study aimed to investigate japanese physical therapists attitudes of 
 evidence - based practice and clinical practice guidelines . 
 [ subjects and methods ] in 2014 , 
 a cross - sectional postal mail survey using a self - administered questionnaire was 
 conducted . 
 of 2,982 physical therapists belonging to the chiba prefecture physical 
 therapist association , 1,000 were randomly selected . 
 the questionnaire comprised 42 items 
 pertaining to the attitudes of and behavior toward evidence - based practice and clinical 
 practice guidelines . 
 it was investigated to reveal the relationship between clinical 
 practice guidelines / evidence - based practice and therapist characteristics . 
 [ results ] the 
 response rate was 39.6% , and 384 questionnaires were available . 
 the main results were as 
 follows : 83.3% participants agreed to the importance of evidence - based practice , 77.1% 
 agree to that evidence - based practice supports clinical decision of physical therapists , 
 and about 11% agreed to have been educated about evidence - based practice . 
 then , 29.2% 
 used , 54.9% agreed to the importance of , and 13.3% agreed to the utility of clinical 
 practice guidelines . an important factor related mostly to a positive attitude , knowledge 
 and behavior of evidence - based practice and clinical practice guidelines was participating 
 in research activities . 
 [ conclusion ] many of physical therapists do not use and understand 
 the importance of clinical practice guidelines . participating in research activities may 
 partially contribute to improving these conditions .