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Kia āta kōwhiri Choosing Wisely

The Choosing Wisely campaign seeks to reduce harm from unnecessary and low-value tests and treatment.

Australasian Faculty of Rehabilitation Medicine

The Australasian Faculty of Rehabilitation Medicine (AFRM) is a Faculty of the Royal Australasian College of Physicians (RACP). AFRM provides training and continuing education for Rehabilitation Medicine Fellows and trainees throughout all stages of

Recommendations and resources

1) Do not discharge patients with osteoporotic fractures without an assessment and/or treatment for osteoporosis.

Studies of patients with osteoporotic fractures have found that they are at significantly greater risk of suffering a new fracture compared to the general population. This risk is particularly marked in but not restricted to elderly patients, particularly given that recent clinical guidelines recommend that all individuals over the age of 50 who sustain a fracture following minimal trauma (such as a fall from standing height or less) should be considered to have a presumptive diagnosis of osteoporosis. Despite this, there have been reports of insufficient provision for the management of these patients before discharge.

Osteoporosis assessments and/or treatments before discharge are clinically very important and moreover may be highly cost effective even after taking account of the additional resources associated with providing these services.

2) Do not prescribe spinal orthotics or bed rest for patients with non-specific low back pain.

There is insufficient and conflicting evidence on the effectiveness of spinal orthotics and other forms of lumbar support for treating or preventing low back pain, either as an intervention in its own right or as a supplement to other interventions.

While there is no evidence that short term bed rest is harmful, long periods of bed rest can lead to complications such as muscular atrophy. The only randomised control trial to assess optimal periods of bed rest suggests two days is as effective as any longer period but the evidence is of low quality. There is evidence to support other approaches, such as advice to stay active and exercise which help with pain relief and improved function.

3) Do not use Mini Mental State Examination as the only tool to assess cognitive deficit in acquired brain injury.

Numerous studies suggest that the Montreal Cognitive Assessment (MoCA) is one of the most effective means of assessing cognitive deficits in acquired brain injury (for instance after transient ischemic attack and stroke) and is to be preferred to the Mini Mental State Evaluation (MMSE). MMSE may under-detect cognitive impairment in acquired brain injury; it is more appropriate for assessing dementia.

4) Do not routinely use splinting for prevention and/or management of contractures after stroke.

Reviews of the evidence and individual case studies on the use of hand splinting for stroke patients have been unable to find conclusive evidence that it leads to improvements in managing spasticity and preventing contractures or more generally improving upper limb function.  Moreover, there is high quality evidence that stretch, whether administered from splints or other means, does not have clinically important effects on joint mobility in people with or without neurological conditions, at least for the periods it is typically prescribed of less than seven months.

5) Do not use imaging for diagnosing non-specific acute low back pain in the absence of red flags.

The majority of acute low back pain episodes are benign, self-limited cases that do not warrant the use of imaging (e.g. X-rays, CTI or MRI). There is evidence that early imaging for low back pain in the absence of red flags does not facilitate improvements in primary outcomes such as pain and function, even for older patients. If anything such imaging may be harmful insofar as it may reveal incidental findings that divert attention and increase the risk of having unnecessary interventions and invasive treatments including unnecessary surgery.

Supporting evidence

How this list was developed

A working group within AFRM initially identified 10 recommendations on low value practices in the field of rehabilitation medicine that may be widespread in Australia and New Zealand. Following a review of the evidence these were reduced to seven. An online survey based on these seven recommendations was distributed to all AFRM members asking them to rate these recommendations based on whether they thought they were evidence based, whether the low-value practices targeted were still being undertaken in significant numbers, and whether the recommendation was important in terms of reducing harm and unnecessary costs to patients.  The working group reviewed the feedback and finalised the ‘top 5’ recommendations which were approved by AFRM Executive in mid-2017.


Published: 10 Dec 2021 Modified: 10 Dec 2021