Physiotherapy 112 (2021) 9–15

Choosing Wisely Brazil: top 5 low-value practices that

should be avoided in musculoskeletal physical therapy
F.J.J. Reis a,b,c,∗ , N. Meziat-Filho d , R.J. Soares e , L.C.L. Correia f
a Physical Therapy Department, Instituto Federal do Rio de Janeiro (IFRJ)
b Postgraduate Progam – Clinical Medicine Department, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
c Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education
& Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
d Postgraduate Program in Rehabilitation Sciences, Centro Universitário Augusto Motta, Rio de Janeiro, Brazil
e Universidade de Taubaté, Taubaté, São Paulo, Brazil
f Escola Bahiana de Medicina, Bahia, Brazil

Abstract
Background The Choosing Wisely initiative aims to promote discussions among healthcare professionals and patients about low-value, or
potentially harmful, health practices.
Objectives To describe the process of development of the Brazilian Choosing Wisely list for musculoskeletal physical therapy.
Methods The Brazilian Choosing Wisely list was developed in accordance with the recommendations of the American Board of Internal
Medicine. A three-step procedure was used. First, an expert panel was selected, and a modified Delphi approach was used to obtain a list
of evidence-based statements. Second, members of the research team performed content analysis. Third, a national survey was conducted to
present selected statements to a sample of physical therapists. Participants were invited to vote considering the level of importance of selected
statements for physical therapists and patients.
Results The expert panel comprised 17 physical therapists. The median age of the expert panel was 33 [interquartile range (IQR) 29 to 37;
range 26 to 60] years and the median length of professional experience was 12 (IQR 10 to 18) years. A list of eight recommendations was
presented to a national sample composed of 1127 physical therapists. The median length of professional experience of the national sample
was 10 (IQR 5 to 15) years. Based on the number of votes, the five most important recommendations were included in the Brazilian Choosing
Wisely list for musculoskeletal physical therapy. Descriptive and frequency analysis were used to report the results.
Conclusion The Brazilian Choosing Wisely list for musculoskeletal physical therapy provides an opportunity for physical therapists, patients,
society and policy makers to collaboratively discuss tests and treatments that are unnecessary or potentially harmful.
© 2021 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Physical therapy modalities; Musculoskeletal diseases; Clinical decision-making; Patient education

Introduction Choosing Wisely initiative (http://www.choosingwisely.org).

Low-value care can be defined as services (tests, proce-
dures and treatments) that provide no benefit to patients or
can even cause harm [1]. Several initiatives have been devel-
oped with the aim of reducing low-value care, including the
∗ Corresponding author at: Instituto Federal do Rio de Janeiro, Campus
Realengo – Rua Carlos Wenceslau, 343, Realengo, CEP 21715-000 Rio de
Janeiro, RJ, Brazil.
E-mail address: felipe.reis@ifrj.edu.br (F.J.J. Reis).
This initiative was developed in the USA in 2012 by the
American Board of Internal Medicine (ABIM) Foundation
with the aim of promoting discussions among healthcare pro-
fessionals and patients about tests and treatments that are
commonly used and the need for which should be ques-
tioned [2–4]. Discussions between healthcare professionals
and patients, or even healthcare associations and society,
should consider procedures that may be unnecessary and, in
some instances, harmful. This promising approach focuses

https://doi.org/10.1016/j.physio.2021.03.003
0031-9406/© 2021 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
10 F.J.J. Reis et al. / Physiotherapy 112 (2021) 9–15

on value of care and potential risks to patients, rather than

using cost as the motivating factor [5]. Currently, Choos-
ing Wisely is a major public awareness campaign with 1293
recommendations (48% tests and 49% treatments) [6].
Given that wasteful clinical practices are a problem for
all health systems, the Choosing Wisely initiative has gained
attention worldwide and has been adopted by more than 20
countries [7]. Surprisingly, with the exception of Brazil and
India, most Choosing Wisely initiatives have been adopted
by developed countries. In physical therapy, the Choosing
Wisely initiatives are fairly recent, such as those promoted
by the American Physical Therapy Association [8], the
Australian Physiotherapy Association [9] and the Italian
Association of Physiotherapists [6]. Initiatives to reduce
low-value care in physical therapy, including overtesting,
overdetection, overdefinition and overtreatment, are relevant
and necessary [10]. As such, the aim of this study was to
describe the process of development of the Brazilian Choos-
ing Wisely list for musculoskeletal physical therapy.

Methods

Design and ethical aspects of the study

According to the ABIM Foundation, specialty societies
can develop their lists independently using their own meth-
ods. However, the process for developing the list should be
transparent, available to the public upon request, and should
consider items that meet specific Choosing Wisely selection
criteria, including: (1) the intervention is commonly per-
formed; (2) there is no evidence of benefit to most patients;
(3) the intervention may be harmful; (4) the intervention may
be expensive; and (5) the use of the intervention is within
the specialty’s competence and control. For development of
the Brazilian Choosing Wisely list for musculoskeletal phys-
ical therapy, a three-step process was adopted. First, a sample
of Brazilian physical therapists was selected to compose an
expert panel, and a modified Delphi approach was used to
obtain a list of evidence-based statements [11]. Second, mem-
bers of the research team analyzed all statements provided by
the expert panel. Third, a national survey was conducted to
present selected statements to a sample of physical thera-
pists. The five statements that received the most votes in the
national survey were submitted to Choosing Wisely Brazil,
and a final list of recommendations was published (Fig. 1).
Data from the expert panel and the national survey were
collected online using Google Forms. All ethical principles
were followed and the study was approved by the Ethics and
Research Committee of the Universidade de Taubaté (CAAE
68817517.0.0000.5501).
Expert panel
The expert panel was composed of physical therapists
experienced in the musculoskeletal field. Convenience sam-
Fig. 1. Flow chart of research methodology.
pling was used, considering the following criteria: (1)
registered physical therapist; (2) Brazilian nationality; (3)
experience in evidence-based practice; and (4) > 5 years of
experience in teaching musculoskeletal physical therapy, and
have made a significant contribution to musculoskeletal phys-
ical therapy (i.e. have published an article in a peer-reviewed
scientific journal related to the topic in the preceding 3 years).
The exclusion criteria were: (1) non-response within 30 days;
and (2) incomplete form. The curriculum vitae of each health-
care professional with the potential for inclusion in the expert
panel was analyzed independently by two members of the
research team (physical therapists with >15 years of expe-
rience in the field). Snowball sampling was used to identify
other physical therapists with the potential for inclusion in
the expert panel, with participants asked to indicate one or
more professionals.
The invitation to participate in the study was sent by e-
mail every 15 days (i.e. days 1, 15 and 30). All details of the
study, including the design, aims, procedures and a link to an
online form, were sent by e-mail. In the online form, experts
were asked to provide personal and professional information,
and to submit three to five recommendations considering this
guidance sentence: ‘Do not use (intervention or exam)
for (condition/patient) when ’. Supporting references
for all recommendations were required [8]. The aim was to
recruit a sample of 15 to 30 experts to compose the expert
panel [12].
 F.J.J. Reis et al. / Physiotherapy 112 (2021) 9–15 11

Procedures and consensus building Table 1

Demographic and professional characteristics of the expert panel.
The research team was composed of three physical ther- Characteristics (n = 17) Values
apists with doctoral degrees and >15 years of experience in Age, median (IQR) 33.0 (29 to 37)
the field, including research, teaching and clinical practice. Gender, n (%)
The research team analyzed all statements and supporting Female 3 (18)
Male 14 (82)
references independently. In a consensus meeting, recom- Brazilian region, n (%)
mendations were discussed by two members of the research South 2 (12)
team (NM and RJS) considering the following criteria: (1) South-east 8 (47)
the item must be a test or intervention commonly used by Mid-west 2 (12)
physical therapists; (2) the use of the identified test or inter- North-east 4 (24)
North 1 (6)
vention must be within the purview of physical therapists; Academic degree, n (%)
and (3) the use of the identified test or intervention should be Graduate specialization 1 (6)
questioned based on current evidence. The ABIM Foundation Masters (MSc) 6 (35)
recommends that tests or interventions that should be avoided Doctoral (PhD) 10 (59)
should be included in the list, and that statements on the list Physical therapy field, n (%)
Orthopaedics 14 (82)
should be written in the negative (i.e. ‘do not do’, ‘don’t do’ or Neurology 1 (6)
‘avoid’). Each member of the research team was instructed to Sports 2 (12)
indicate the items to retain for consideration. Disagreements IQR, interquartile range.
were resolved by consensus or by arbitration by a third author
(FJJR). This consensus meeting resulted in the selection of
eight recommendations. tical Package for the Social Sciences Version 22 for Windows
(IBM Corp., Armonk, NY, USA). Descriptive and frequency
National survey of physical therapists analysis were used to report all quantitative data. Data nor-
mality was tested by visual inspection of histograms and the
An electronic survey containing the eight recommenda- Shapiro–Wilk test.
tions was sent to a sample of Brazilian physical therapists.
According to the Brazilian Physical Therapy National
Council (COFFITO; https://coffito.gov.br), there are approx- Results
imately 240 000 registered physical therapists in Brazil.
COFFITO includes all physical therapists registered in each Twenty physical therapists were sent an invitation to join
physical therapy regional council. Currently, there are 18 the expert panel. The final sample was composed of 17 phys-
physical therapy regional councils covering the Brazilian ter- ical therapists [14 (82%) male and three (18%) female]. The
ritory. In addition to regional councils, physical therapists median age of the expert panel was 33 [interquartile range
can enrol in specialty associations. At the present time, there (IQR) 29 to 37; range 26 to 60] years, and the median length
is one national association (Physiotherapists’ Association of of professional experience was 12 (IQR 10 to 18; range 7 to
Brazil) and 13 specialty associations. In order to reach a 41) years. Table 1 shows the characteristics of members of
large number of physical therapists, invitations were sent by the expert panel.
e-mail using the e-mail database and social media commu- The expert panel provided 50 statements that were ana-
nications (Facebook and Instagram) of all regional councils lyzed by the research team (Supplementary File 1, see online
and specialty associations. Participants were invited to vote supplementary material). Grouping the statements indicated
on the eight recommendations in terms of their inclusion in that the most common interventions/services were elec-
or omission from the Choose Wisely list based on the level of trotherapy (n = 12), imaging tests (n = 12), taping (n = 8),
importance for physical therapists and patients. Participants physical examination (n = 7), passive interventions (n = 6),
were asked to provide their professional registration num- cryotherapy (n = 1) and others (n = 3). The recommenda-
ber, age, professional experience, workplace and Brazilian tions included low back (n = 21), knee (n = 3), ankle (n = 3),
region. Reminders to participate in the survey were sent via wrist/hand (n = 2), sacroiliac joint (n = 1), neck (n = 1) and
e-mail and social media from January 2018 to July 2018. elbow (n = 1).
The research team selected eight recommendations con-
Data collection and data analysis sidering current evidence and clarity of the statements for
presentation to a national sample of physical therapists. In
Data were imported from Google Forms to Excel for total, 1127 physical therapists participated in the national
MacOS (Microsoft Corp., Redmond, WA, USA). In the first survey. Ten responses were excluded due to duplication, so
step, all recommendations provided by the experts were ana- the final sample consisted of 1117 responses. The sample was
lyzed according to their content. In the third step, data from composed of 702 (63%) female and 415 (37%) male physi-
the sample of physical therapists were analyzed using Statis- cal therapists. The median length of professional experience
12 F.J.J. Reis et al. / Physiotherapy 112 (2021) 9–15

Table 2 Discussion
Demographic and professional characteristics of the physical therapists
included in the national survey.
To the best of the authors’ knowledge, this study is the
Characteristics (n = 1117) Values first to develop a Choosing Wisely list for physical therapy
Gender, n (%) in Latin America. The methods used during the development
Male 702 (63%) process were rigorous, transparent and reproducible in accor-
Female 415 (37%)
Professional experience in years, median (IQR) 10 (5 to 15)
dance with the recommendations of the ABIM Foundation.
Brazilian region Although some recommendations in the Choosing Wisely
South 68 (6%) list have been made in other campaigns, the authors sought
South-east 742 (66%) to identify specific practices that are common in the Brazilian
Mid-west 41 (4%) context by recruiting experts and physical therapists from all
North-east 260 (23%)
North 6 (1%)
regions.
Workplace, n (%) In this study, the majority of recommendations made by
Private services/clinics 704 (63%) the expert panel referred to electrotherapy, imaging tests,
Public services 298 (27%) taping, physical examination and the use of passive inter-
University 115 (10%) ventions in patients with chronic pain conditions. Although
IQR, interquartile range. electrotherapy was often cited, the research team judged that
some recommendations were incomplete or imprecise (e.g.
was 10 (IQR 5 to 15; range 1 to 41) years. The characteris- ‘Do not use electrotherapy for the treatment of chronic low
tics of the physical therapists included in the national sample back pain’), the electrophysical agent is not widely available
are presented in Table 2. Table 3 shows the list of eight in most physical therapy services (e.g. ‘Do not use shock
recommendations and the results of the national survey. wave therapy in patients with lower limb tendinopathies
before 6 months of treatment with exercises’), or the evidence
Final list development to support the recommendation is inconclusive (e.g. ‘Do not
use TENS for acute, subacute and chronic low back pain).
The five statements that received the most votes in Only one recommendation was included in the national sur-
the national survey were included in the Brazilian Choos- vey (‘Do not use ultrasound in patients with ankle sprains’).
ing Wisely list for musculoskeletal physical therapy. The Surprisingly, this recommendation received the most votes
final list was submitted to Choosing Wisely Brazil and (59%) for omission from the final list. Although the precise
some statements were rephrased in accordance with their reason for this finding is unknown, it may be that this rec-
recommendations. The final list was published on the ommendation was not sufficiently clear (e.g. acute or chronic
Brazilian Orthopaedic Physical Therapy Association web- ankle sprain?; for which outcome?), or therapeutic ultrasound
site (http://www.abrafitobr.com.br/) (Supplementary File 2, is widely used in ankle sprains and professionals considered
see online supplementary material). their clinical practice to judge the recommendation. In the

Table 3
The eight recommendations and results of the national survey.
Statement Results n (%)

Include Omit
1. Do not recommend the use of insoles as prevention, as 633 (56) 484 (44)
well as treatment, of patients with low back pain
2. Do not recommend lumbar belts or braces to prevent 776 (69) 341 (31)
as well as to treat chronic low back pain
3. It is not recommended to use imaging exams to base 662 (59) 445 (41)
your treatment of patients with chronic low back pain
4. Do not use therapeutic ultrasound for ankle sprain 461 (41) 656 (59)
5. Do not use passive therapeutic interventions in a 820 (73) 297 (27)
prolonged and isolated way for patients with low back
pain
6. Do not use traction for low back pain 525 (47) 592 (53)
7. Imaging for low back pain is not recommended unless 698 (62) 419 (38)
serious illnesses such as trauma, cancer, infection,
cauda equina syndrome and inflammatory conditions
such as rheumatoid arthritis and ankylosing
spondylitis are suspected
8. Do not use elastic taping on the lower back to treat low 597 (53) 520 (47)
back pain
Statements in bold represent the five statements used in the Choosing Wisely list.
 F.J.J. Reis et al. / Physiotherapy 112 (2021) 9–15
Brazilian Choosing Wisely list for musculoskeletal physi-
cal therapy, most recommendations were related to low back
pain. This may have occurred as low back pain is a common
complaint in clinical practice [13].
The provision of low-value care is a global problem and
can be worse in countries with low resources [14,15]. It
is thought that reducing low-value care will contribute to
cost containment and more efficiency in health care, without
harming patient outcomes [16,17]. Although several efforts
have been made to measure the impact of low-value prac-
tices on healthcare costs and utilization [16,18–20], studies
looking at changes in costs after implementation of a Choos-
ing Wisely campaign remain lacking [21,22]. In addition,
the role of the Choosing Wisely campaign to reduce direct
or indirect costs remains the subject of debate [18,23,24]. It
is important to consider Choosing Wisely as a major pub-
lic awareness campaign that aims to reduce low-value care
by increasing discussions between patients and clinicians
[25]. In other words, although Choosing Wisely may help
to reduce costs, recommendations should be viewed as an
initiative to increase a collaborative relationship and shared
decision-making between patients and healthcare profession-
als.
It is recognized that the development of Choosing Wisely
recommendations is the first step in a long and challenging
journey. Recently, Zadro et al. [9] investigated physical ther-
apists’ feedback on Choosing Wisely recommendations and
agreement with each recommendation in a sample composed
of 543 professionals. Most participants (64%) agreed that the
negative wording (‘don’t’ style) of Choosing Wisely recom-
mendations is an acceptable method to engage the profession
in discussions about their clinical practice. However, some
physical therapists consider that clinical expertise is more
important, and the recommendations threaten physical thera-
pists’ autonomy and the profession [9]. In a qualitative study
including physicians, participants considered that the Choos-
ing Wisely campaign needed to be a guide rather than strict
rules. Although some clinicians recognize that the overuse of
health services is a problem, they justify their choices based
on patient expectations, fear of malpractice and lack of time
to explain why a patient does not need the test or treatment
[26].
The development and publication of Choosing Wisely rec-
ommendations alone can be insufficient to increase dialogue
between patients and healthcare professionals [27,28]. Sev-
eral inter-related reasons, including clinician factors (e.g.
confirmation bias, training, fear of malpractice, fear of
lawsuit, time pressures, intolerance of uncertainty), patient
factors (e.g. lack of knowledge, health literacy, financial con-
sequences) and healthcare system factors (e.g. institutional
culture, pricing, fee-for-service payment models), can make
it more difficult to stop a practice than the implementation
of new practices [29,30]. Indeed, some authors suggested the
term ‘de-implementation’ as a more appropriate term for the
Choosing Wisely initiative, as it describes a move away from
13
ineffective or harmful practices that are present in clinical
practice [31].
This study has some strong points that should be high-
lighted. Although some recommendations were identified
that are present in other Choosing Wisely lists or guide-
lines published previously in English, the development of
a Brazilian list for physical therapy can overcome barri-
ers of language and access to information. Moreover, this
Choosing Wisely list was the first initiative in Brazilian phys-
ical therapy, and has become a landmark example for other
physical therapy specialties. In fact, following publication
of the Brazilian Choosing Wisely list for musculoskeletal
physical therapy, the Brazilian Physical Therapy Associ-
ation in Cardiorespiratory and Intensive Care started the
development of a specific list. The methods described in
this study provide opportunities for other Brazilian phys-
ical therapy specialties and other developing countries to
develop their own Choosing Wisely lists. The research
team sought to include physical therapists from all regions
of Brazil during the development process. However, the
disparity in geographical distribution of physical thera-
pists is a problem in Brazil, with a high density of
professionals and physical therapy schools in the south-
east and a large area lacking professionals in the north
[32,33].
This study also had a few limitations. First, the expert
panel could be considered biased as the experts were selected
based on convenience. Second, the sample can be consid-
ered small in comparison with the total number of registered
physical therapists in Brazil. Third, the expert panel and the
national sample were composed mainly of male physical ther-
apists. Fourth, there was regional disparity in the national
survey, with a large number of participants from the south-
east region. The authors tried to overcome these limitations
using the database and social media of all regional councils
and associations. It is also possible that the national sam-
ple was composed of participants who were aware of the
Choosing Wisely initiative and were more interested in partic-
ipating. Fifth, it was not possible to infer if the answers to this
survey reflected professional decisions in clinical practice.
Finally, this study should be considered exploratory, focus-
ing on the description of a method. In the future, the spread
of Choosing Wisely campaigns will raise several questions
related to awareness, challenges and barriers for implemen-
tation, and impact on patient knowledge about wasteful and
harmful healthcare practices. These questions could shed
light on the value of developing and disseminating such lists,
whether these efforts are sufficient to make progress in tack-
ling overuse, and what else can be done.
Conclusion
The Brazilian Choosing Wisely list for musculoskeletal
physical therapy provides an opportunity for physical thera-
pists, patients, society and policy makers to collaboratively
14 F.J.J. Reis et al. / Physiotherapy 112 (2021) 9–15
discuss tests and treatments that are unnecessary or poten-
tially harmful.
Ethical approval
Ethics and Research Committee of the Universidade de
Taubaté (CAAE 68817517.0.0000.5501).
Conflict of interest
None declared.
Acknowledgements
The authors wish to thank the Brazilian Physical Ther-
apy National and Regional Councils and the Brazilian
Orthopaedic Physical Therapy Association for providing sup-
port to contact physical therapists.
Appendix A. Supplementary data
Supplementary material related to this article can be
found, in the online version, at https://doi.org/10.1016/j.
physio.2021.03.003.
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