In recent years, a number of Australian and global clinical recommendations and guidelines for best practice have been developed and promoted for a variety of musculoskeletal conditions including low back pain, knee osteoarthritis and whiplash. 

However, it is unclear how well these recommendations and guidelines are implemented by physiotherapists working in either private practice or the hospital and community sector. 

Public health researcher Dr Priti Kharel has been working with physiotherapists at the Institute for Musculoskeletal Health, University of Sydney, on a project investigating one set of recommendations— the Choosing Wisely Australia program—in particular, whether it has changed the way that physiotherapists might treat conditions like low back pain. 

Choosing Wisely Australia was launched in 2015 by NPS MedicineWise, based on an initiative of the American Board of Internal Medicine Foundation, and was developed with the input of the APA. 

The program aims to end unnecessary tests, treatments and procedures, supporting people to choose healthcare that is evidence-based and truly necessary for a wide range of conditions. 

It was acquired by the Australian Commission for Safety and Quality in Health Care in 2023 and has been folded into the Better Care Everywhere initiative. 

The APA’s contribution comprised six recommendations, including two for low back pain recommending that clinicians (a) do not request imaging for non-specific low back pain with no indicators of a serious cause and (b) avoid using electrotherapy modalities for management of low back pain. 

Recently, Priti has published the results of a randomised controlled study looking at how effective the recommendations from Choosing Wisely Australia are in reducing the intentions of physiotherapists to refer for imaging and use electrotherapy for low back pain. 

The study, which was published in BMJ Open, provided 473 participants with either the two original Choosing Wisely recommendations, optimised versions of the recommendations that used more positive language and included alternative options, or no recommendations. 

Participants then read three clinical vignettes of a person with low back pain and were asked to respond to questions about the tests and treatments they would provide based on the information given. 

The study was conducted completely online and included physiotherapists from a range of countries, with the majority from Australia, the USA and the UK. 

The results were surprising, Priti says. 

There were no significant differences between the three groups. 

This was despite more than 60 per cent of the participants feeling at least ‘a fair amount’ influenced by the recommendations when making decisions based on the information provided in the vignettes. 

‘When asked whether the imaging guidelines and evidence on using electrotherapy influenced their clinical practice, many of them did say, “Yes, that influences me”, but when we did the analysis, we found there were no differences.’ 

About 93 per cent reported that imaging guidelines somewhat or greatly influenced their practice, while 89 per cent indicated that evidence on electrotherapy had a similar impact on their practice. 

She notes that almost 50 per cent of the participants were working in private practice, with another 36 per cent working in public hospital settings, and they had a wide range of experience. 

All of them had seen at least one patient with low back pain in the previous 12 months, while 43 per cent had treated between six and 50 patients and 52 per cent had seen more than 50. 

One factor that Priti highlighted was the need for practitioners, particularly those working in private practice, to provide the care that patients and clinic owners expected—which may have included imaging and electrotherapy—over and above current best practice care. 

While most participants said they had at least some knowledge of the guidelines and were influenced by the evidence for both the imaging guidelines and the effectiveness of electrotherapy for low back pain, this clearly didn’t translate into their intentions as measured in the study. 

‘Obviously, what people preach is different from what people do,’ Priti says. 

‘But this was a hypothetical study; participants had to make a decision but didn’t have to do it hands-on. 

‘They could have done what was right but they didn’t.’ 

Ultimately, the study points to the difficulty in implementing clinical guidelines and recommendations. 

‘The main takeaway for healthcare providers in this study is that simply presenting guidelines or recommendations, even if they are clearly worded and evidence-based, is not enough to make a shift in practice and behaviours. 

The underlying drivers of clinical decision-making are not that simple—it’s a bit more complicated than just choosing to follow the recommendations.’ 

Reference: Kharel et al (2025). Effectiveness of Choosing Wisely recommendations in reducing physiotherapists’ intentions to refer for imaging and use electrotherapy for low back pain: a randomised controlled experiment. BMJ Open. 2025 (15:e097202). doi:10.1136/bmjopen-2024-097202