Rethinking Physiotherapy: Are We Overtreating Patients?
"A critical look at the 'Choose Wisely' campaign and its implications for UK physiotherapy practices in an era of increasing healthcare costs."
In an era where healthcare budgets are increasingly stretched, the 'Choose Wisely' campaign has emerged as a significant movement, urging healthcare professionals to carefully evaluate the clinical and cost-effectiveness of their interventions. Originating in the United States, this initiative has since spread to numerous countries, including Canada, Australia, Japan, Germany, and France, sparking crucial conversations about the value of medical treatments.
This article delves into the 'Choose Wisely' campaign, examining the core concepts that drive its mission. We'll explore the ethical dimensions of this campaign within the UK's healthcare landscape, aiming to stimulate a vital discussion: Should UK-based physiotherapists embrace the 'Choose Wisely' approach?
The 'Choose Wisely' campaign can be traced back to 2009, when the National Physicians Alliance in the US supported volunteers across primary care specialties to identify commonly used interventions and tests that offered little to no benefit to patients. In 2012, the 'Choose Wisely' campaign was officially launched, leading professional organizations worldwide to develop lists of treatments that may not provide significant medical value or have similar outcomes to less expensive alternatives. 'Low-value care' has become the common term for these procedures.
Choosing Wisely in Physiotherapy
Choosing Wisely (CW) is a campaign designed to reduce healthcare overuse by developing and spreading recommendations about tests and treatments. Launched by the American Board of Internal Medicine in 2012, it has become an international, inter-professional campaign. Its adoption in physiotherapy is being examined as a way to standardize decisions, while implementation in physical therapy remains emerging. The American Physical Therapy Association created “5 Things Physical Therapists and Patients Should Question” to encourage discussion about whether frequently used tests and interventions are necessary.
Understanding the Core Concerns: Medicalization, Overdiagnosis, and Consumerism
The 'Choose Wisely' campaign is rooted in three primary concerns: medicalization, overdiagnosis, and medical consumerism. These issues have gained prominence through numerous publications over the past decade, prompting healthcare professionals to reconsider their practices.
- Medicalization: The process by which non-medical problems become defined and treated as medical issues.
- Overdiagnosis: Diagnosing a biomedical condition that, without testing, would not cause symptoms or death.
- Medical Consumerism: The over consumption of healthcare, driven by pharmaceutical companies and society's focus on health as a form of social capital.
Shared Decisions and Recommendation Design
Research on community health physiotherapy in rural Maharashtra collected therapist-patient communication experiences using the Observer OPTION measure, which assesses aspects of shared decision-making. A 2018 article asked whether UK-based physiotherapists should “Choose Wisely,” reflecting continuing debate about appropriate practice. A best-worst scaling study modified the six original Australian Physiotherapy Association Choosing Wisely recommendations across level of detail, strength, framing, and alternatives to low-value care, producing 60 recommendations for comparison.
Implementation Challenges
Choosing Wisely is described as promising for increasing awareness of low-value care in physiotherapy, but physiotherapists’ views of its recommendations have not always been clear. A study of the Australian Physiotherapy Association evaluated therapists’ feedback and agreement with the recommendations. A 2025 mapping study found that Choosing Wisely recommendations in physical therapy were organized across musculoskeletal, neurology, cardiorespiratory, women’s health, and mixed themes, indicating that implementation spans diverse clinical areas.
Recommended Access Levels
A study of NICE “Optimised” decisions evaluated recommendations published between 2015 and 2019. Of those recommendations, 40 contained sufficient information to estimate the recommended level of patient access. The study therefore provides a basis for comparing how recommendations define or imply access, although the supplied source material does not report the specific access levels.
The Path Forward: Choosing Wisely in the UK
The 'Choose Wisely' campaign presents both opportunities and challenges for UK-based physiotherapists. While governance mechanisms like NICE already offer guidance on effective interventions, 'Choose Wisely' provides a focused approach to identifying and reducing low-value care. Ultimately, the decision to embrace this campaign requires careful consideration of ethical implications, potential political issues, and the unique context of the UK healthcare system. By engaging in open dialogue and critical self-reflection, physiotherapists can ensure they are providing the most valuable and effective care to their patients.
From Recommendations to Practice
A three-arm parallel-group online randomised controlled trial examined the effect of Choosing Wisely recommendations on physiotherapists’ intentions to refer people with low back pain for imaging and to use electrotherapy. Participants were physiotherapists who treat people with low back pain and were randomised to receive different recommendation materials, including two original Australian Physiotherapy Association recommendations. Related research evaluated physiotherapists’ feedback and agreement with Australian recommendations, while another content-analysis study noted that its design and timing did not allow in-depth analysis of views, attitudes, and beliefs toward existing recommendations.