Healthcare spending continues to rise, with a significant portion directed toward wasteful practices, particularly low-value care. Low-value care includes diagnostic tests, procedures, and treatments that offer no benefit to patients and, in some cases, may even cause harm.1 To reduce low-value care practices, several initiatives have been developed such as the “Choosing Wisely” and “Less is More” campaigns.

The Choosing Wisely Campaign (CWC) (http://www.choosingwisely.org) was launched by the American Board of Internal Medicine (ABIM) Foundation in 2012 to challenge the “more-is-better” mindset in healthcare practices. It aims to reduce low-value care by encouraging conversations between healthcare professionals and patients about commonly used tests and treatments that may not be necessary.2 Although rising healthcare costs are a global issue, the CWC emphasizes the value of care and potential risks to patients, rather than focusing on cost as the primary motivating factor.3

The CWC has gained worldwide attention and has been adopted by over 80 healthcare specialty societies in more than 30 countries. In physical therapy, several authors have published CWC recommendation lists endorsed by associations such as the American Physical Therapy Association,4 the Australian Physiotherapy Association,5 the Brazilian Orthopedic Physical Therapy Association,6 and the Brazilian Association of Physical Therapy in Women's Health.7 However, CWCs have been published only on associations websites. Considering the potential of the CWC to reduce low-value care in physical therapy, this study aimed to: (i) identify physical therapy associations participating in the CWC and (ii) characterize the content of their recommendations.

At the time of our analysis, we identified 127 physical therapy associations that were members of World Physiotherapy. Out of 127 physical therapy associations, seven (5.5 %) confirmed having Choosing Wisely recommendations. These associations were from Brazil, the USA, Norway, Italy, Australia, Spain, and Switzerland (Fig. 1).

Fig. 1.

A world map representing the current World Physiotherapy member associations. Countries with an association were shaded in blue, while those without remained uncolored. Red dots represent the countries with a Choosing Wisely initiative in the physical therapy field (data were collected between October and November 2023).

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A total of 62 recommendations were identified, with the following distribution: 30 (48.4 %) related to musculoskeletal physical therapy, 17 (27.4 %) covering mixed themes, 9 (14.5 %) focused on women's health, 4 (6.4 %) on cardiorespiratory physical therapy, and 2 (3.2 %) on neurological physical therapy. Choosing Wisely recommendations related to musculoskeletal physical therapy were related to low back (10; 33.4 %), neck (7; 23.4 %), shoulder (6; 20 %), knee (5; 16.7 %), and ankle and foot (2; 6.7 %). Brazil presented the highest number of recommendations (20; 32.2 %), followed by Norway (15; 24.1 %), Australia (6; 9.7 %), Switzerland (6; 9.7 %), Italy (5; 8.0 %), the USA (5; 8.0 %), and Spain (5; 8.0 %). Table 1 presents all identified Choosing Wisely recommendations.

We aimed to identify physical therapy associations participating in the CWC and characterize the content of their recommendations. We identified 127 physical therapy associations listed on the World Physiotherapy website. Of these, seven associations from Brazil, the USA, Norway, Italy, Australia, Spain, and Switzerland confirmed having a CWC. A total of 62 recommendations were identified, most of which related to musculoskeletal physical therapy. Brazil had the highest number of CWC recommendations, with 15 related to musculoskeletal physical therapy and five to women's health.

Our findings indicate that a significant number of physical therapy associations may not have adopted CWC. In fact, despite explaining the CWC in our contact message, many associations were still unaware of this initiative. It is crucial for physical therapy associations to recognize the potential of CWC in reducing low-value care, as well as the fact that physical therapists are more likely to follow CWC recommendations especially when they are detailed and positively framed.8 To maximize the impact of CWC, it is essential to communicate the campaign's message clearly, emphasizing the importance of improving quality, preventing harm, and engaging both practitioners and patients in discussions about appropriate care.9

Implementing CWC requires careful consideration of potential barriers, which include (i) clinicians' beliefs, experience, and knowledge, (ii) patients' clinical presentation, beliefs, and expectations, (iii) workplace demands and culture, and (iv) vague recommendations, restrictive language, and lack of awareness.10 To address these challenges, proposed solutions include (i) conducting educational meetings about CWC, (ii) understanding the reasons behind patient requests and engaging in shared decision-making, (iii) prioritizing time spent with patients over performing unnecessary interventions, and (iv) discussing the evidence for each recommendation with transparency.

The main strength of this study was its ability to provide a comprehensive overview of CWCs in physical therapy by examining all associations that are members of World Physiotherapy. To the best of our knowledge, such an overview has not been conducted. The main limitation of this study is the low response rate, despite our efforts to address this by sending three emails at different times and reaching out to World Physiotherapy. Another potential limitation is that some CWC were not available in English. To address this, we requested that the associations provide translations of their recommendations.

CWCs represent an important strategy for enhancing communication between patients and clinicians by helping patients understand the benefits and risks of treatment options, clarifying uncertainties, and ensuring decisions align with individual values and preferences. During the development of recommendations, physical therapy associations should rely on the best available evidence and clearly communicate when strong evidence indicates that a service provides no benefit to most patients.11 Given this, CWC lists should be regularly reviewed and updated as new evidence emerges. We recommend that physical therapy associations adopt CWC in their countries and that World Physiotherapy compile global recommendations. Further discussion is needed to assess the impact on clinical practice and identify effective strategies for implementation and dissemination.

The identified Choosing Wisely recommendations highlight key areas of low-value care in physical therapy, especially in musculoskeletal practice. The adoption of Choosing Wisely campaigns among physical therapy associations seems to be limited. These findings underscore the opportunity for broader engagement with Choosing Wisely campaigns to reduce low-value care in physical therapy worldwide.