On 'The American Physical Therapy Association's top five Choosing Wisely recommendations.' White NT, Delitto A, Manal TJ, Miller S. Phys Ther. doi: 10.2522/ptj.20140287

[ Editor's note: Both the letter to the editor by Bjordal and colleagues and the response by White and colleagues are commenting on the author manuscript version of the article that was published ahead of print September 15, 2014. ] We have read “The American Physical Therapy Association's Top Five Choosing Wisely Recommendations”1 (CWR) with interest. The article will probably have great impact as an official white paper originating from APTA, and it joins a national initiative aimed at reducing health care costs across professions. This is an important and timely initiative, and it is welcomed. The first of the 5 specific recommendations is to limit the use of “passive” physical agents (PAs) because: “A carefully designed active treatment plan has a greater impact on pain, mobility, function, and quality of life.” Within our profession, other interventions such as massage, manipulation, and mobilization also are “passive” modalities (cf, exercise), but they are very seldom labeled as such. Similarly, analgesic medications, injections, and surgery also are “passive” treatments. All of these non–physical therapy-related interventions come with higher risk than physical agents or even manual therapies. Physical agents can provide safe, low-cost management as an alternative to analgesic medications or more invasive procedures, such as injections or surgery. Some physical agents also can be provided to the patient for home use as part of a self-management plan. Additionally, this recommendation is not based on the best available evidence. It is important to remember that the framework for CWR demands identification of certain tests or treatments commonly used “in the absence of evidence demonstrating benefit.” The ABIM Foundation even strengthens the evidence criterion to say that: “there is strong evidence that demonstrates that the service offers no benefit to most patients.”1 The first CWR states, “Don't use passive physical agents except …