Skip to main content


Log in

Low-Value Practices for Pelvic Floor Dysfunction—Choosing Wisely Recommendations from the Brazilian Association of Physiotherapy in Women’s Health: Observational Study

  • Original Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript


Introduction and Hypothesis

The Choosing Wisely campaign is an international initiative that is aimed at promoting a dialog between professionals, helping the population to choose an evidence-based, truly necessary and risk-free care. The aim of the study was to develop the Choosing Wisely Brazil list on Women's Health Physiotherapy in the area of the pelvic floor.


A observational study was carried out between January 2022 and July 2023, proposed by the Brazilian Association of Physiotherapy in Women's Health, and developed by researchers working in the area of the pelvic floor. The development of the list consisted of six stages: a panel of experts, consensus building, national research, a review by the Choosing Wisely Brazil team, preparation of the list, and publication of the recommendations. Descriptive and content analyses were carried out in order to include evidence-based recommendations with over 80% agreement by physiotherapists in Brazil.


The expert panel was made up of 25 physiotherapists who submitted 63 recommendations. Seven physiotherapists/researchers carried out a critical analysis of the literature and refined the recommendations, resulting in 11 recommendations that were put to a national vote, in which 222 physiotherapists took part. After a review by the Choosing Wisely Brazil team, five recommendations with an average agreement of 88.2% agreement were chosen for publication.


The Choosing Wisely Brazil team in Physiotherapy in Women's Health/Pelvic Floor proposed a list of five recommendations that showed a high agreement among Brazilian physiotherapists working in the area.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data Availability

We declare that the data will be available to all those who request the corresponding author.



Brazilian Association of Physiotherapy in Women's Health


American Urological Association


American Urogynecologic Society


Federal Council of Physiotherapy and Occupational Therapy


Fecal incontinence


International Continence Society


Federal Institute of Rio de Janeiro


International Urogynecological Association


Pelvic floor dysfunction


Pelvic floor muscles


Pelvic floor muscle training


Pelvic organ prolapse


Society of Gynecologic Oncology


Federal University of São Carlos


Urinary incontinence


University of Campinas


Federal University of Alfenas


University of São Paulo—Ribeirão Preto


  1. Zadro JR, Farey J, Harris IA, Maher CG. Do choosing wisely recommendations about low-value care target income-generating treatments provided by members? A content analysis of 1293 recommendations. BMC Health Serv Res. 2019;19(1):707.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Jung N, Lehmann C, Fätkenheuer G. The “Choosing Wisely”: initiative in infectious diseases. Infection. 2016;44(3):283–90.

    Article  PubMed  Google Scholar 

  3. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801–2.

    Article  CAS  PubMed  Google Scholar 

  4. Scott IA, Duckett SJ. In search of professional consensus in defining and reducing low-value care. Med J Aust. 2015;203(4):179–81.

    Article  PubMed  Google Scholar 

  5. White NT, Delitto A, Manal TJ, Miller S. The American Physical Therapy Association’s top five choosing wisely recommendations. Phys Ther. 2015;95(1):9–24.

    Article  PubMed  Google Scholar 

  6. Levinson W, Kallewaard M, Bhatia RS, et al. ‘Choosing Wisely’: a growing international campaign. BMJ Qual Saf. 2015;24(2):167–74.

    Article  PubMed  Google Scholar 

  7. Reis FJJ, Meziat-Filho N, Soares RJ, Correia LCL. Choosing Wisely Brazil: top 5 low-value practices that should be avoided in musculoskeletal physical therapy. Physiotherapy. 2021Sep;112:9–15.

    Article  CAS  PubMed  Google Scholar 

  8. International Continence Society. The 2024 compilation of the International Continence Society standardisations, consensus statements, educational modules, terminology and fundamentals documents, with the International Consultation on Incontinence algorithms. Toronto: International Continence Society; 2024.

    Google Scholar 

  9. Frawley H, Shelly B, Morin M, et al. An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment. Neurourol Urodyn. 2021;40(5):1217–60.

    Article  PubMed  Google Scholar 

  10. Sharma A, Minh NTD, Luu Lam Thang T, et al. A consensus-based Checklist for Reporting of Survey Studies (CROSS). J Gen Intern Med. 2021;36(10):3179–87.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–9.

    Article  Google Scholar 

  12. Bø K, Kvarstein B, Hagen RR, Larsen S. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence. II. Validity of vaginal pressure measurements of pelvic floor muscle strength and the necessity of supplementary methods for control of correct contraction. Neurourol Urodyn.1990;9(5):479–87.

    Article  Google Scholar 

  13. Torelli L, de Jarmy Di Bella ZI, Rodrigues CA, et al. Effectiveness of adding voluntary pelvic floor muscle contraction to a Pilates exercise program: an assessor-masked randomized controlled trial. Int Urogynecol J. 2016;27(11):1743–52.

    Article  PubMed  Google Scholar 

  14. Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;10(10):CD005654.

    Article  PubMed  Google Scholar 

  15. Martín-Rodríguez S, Bø K. Is abdominal hypopressive technique effective in the prevention and treatment of pelvic floor dysfunction? Marketing or evidence from high-quality clinical trials? Br J Sports Med. 2019;53(2):135–6.

    Article  PubMed  Google Scholar 

  16. Resende APM, Bernardes BT, Stüpp L, et al. Pelvic floor muscle training is better than hypopressive exercises in pelvic organ prolapse treatment: an assessor-blinded randomized controlled trial. Neurourol Urodyn. 2019;38(1):171–9.

    Article  PubMed  Google Scholar 

  17. Jacomo RH, Nascimento TR, Lucena da Siva M, et al. Exercise regimens other than pelvic floor muscle training cannot increase pelvic muscle strength-a systematic review. J Bodyw Mov Ther. 2020;24(4):568–74.

    Article  PubMed  Google Scholar 

  18. Bø K, Herbert RD. There is not yet strong evidence that exercise regimens other than pelvic floor muscle training can reduce stress urinary incontinence in women: a systematic review. J Physiother. 2013;59(3):159–68.

    Article  PubMed  Google Scholar 

  19. Hung HC, Hsiao SM, Chih SY, et al. An alternative intervention for urinary incontinence: retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. Man Ther. 2010;15(3):273–9.

    Article  PubMed  Google Scholar 

  20. Hernández RRV. Eficacia de la gimnasia abdominal hipopresiva en la rehabilitación del suelo pélvico de las mujeres: revisión sistemática. Actas Urol Esp. 2018;42(9):557–66.

    Article  Google Scholar 

  21. Lemos AQ, Brasil CA, Valverde D, Ferreira JDS, Lordêlo P, Sá KN. The Pilates method in the function of pelvic floor muscles: systematic review and meta-analysis. J Bodyw Mov Ther. 2019;23(2):270–7.

    Article  PubMed  Google Scholar 

  22. Wieland LS, Shrestha N, Lassi ZS, Panda S, Chiaramonte D, Skoetz N. Yoga for treating urinary incontinence in women. Cochrane Database Syst Rev. 2019;2(2):CD012668.

    Article  PubMed  Google Scholar 

  23. Dumoulin C, Hay-Smith J, Frawley H, et al. 2014 consensus statement on improving pelvic floor muscle training adherence: International Continence Society 2011 state-of-the-science seminar. Neurourol Urodyn. 2015;34(7):600–5.

    Article  PubMed  Google Scholar 

  24. Hay-Smith EJ, Herderschee R, Dumoulin C, Herbison GP. Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev. 2011;(12):CD009508.

  25. Abrams P, Andersson KE, Apostolidis A, et al. 6th International Consultation on Incontinence. Recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence. Neurourol Urodyn. 2018;37(7):2271–2.

    Article  PubMed  Google Scholar 

  26. Bø K, Sherburn M. Evaluation of female pelvic-floor muscle function and strength. Phys Ther. 2005;85(3):269–82.

    Article  PubMed  Google Scholar 

  27. Matsumura ESDS, Sousa AS, Guedes JA, Teixeira RC, Kietzer KS, Castro LSDF. Distribuição territorial dos profissionais fisioterapeutas no Brasil. Fisioterapia e Pesquisa. 2018;25:309–14.

    Article  Google Scholar 

  28. Brasil Conselho Nacional de Educação. Câmara de Educação Superior (2002) Resolução CNE/CES 4, de 19 de fevereiro de 2002. Diretrizes Curriculares Nacionais do Curso de Graduação em Fisioterapia. Publishing PhysicsWeb. Accessed 29 April 2024

  29. Brasil. Cadastro Nacional de Cursos e Instituições de Educação Superior e-MEC Accessed 29 April 2024

Download references


This work was supported by the Coordination for the Improvement of Higher Education Personnel—Brazil (CAPES)—Finance Code 001 and the Fundação de Amparo à Pesquisa do Estado de Minas Gerais—FAPEMIG (PPM-00471-18), in partnership with ABRAFISM and the University Research Laboratories UNICAMP, UNIFAL-MG, UFSCar, USP-RP, and IFRJ.

Author information

Authors and Affiliations



L.P.: project development, data analysis, and manuscript writing; P.D.: project development and data analysis; F.J.J.R.: project development and data analysis; J.C.R.: project development and data collection; C.C.C.: project development and data collection; C.R.: project development and manuscript writing; C.H.J.: project development and data analysis; S.B.: project development, data analysis, and manuscript writing.

Corresponding author

Correspondence to Simone Botelho.

Ethics declarations

Ethical/Institutional Review Board Approval

Research Ethics Committee of Federal University of São Carlos (UFSCar) under CAAE number 51932321.0.0000.5504 and opinion number 5.165.999 in accordance with Resolution 466/12 of the National Health Council.

Conflicts of Interest


Additional information

Handling Editor: Tony Bazi

Editor in Chief: Maria A. Bortolini

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Pasqualotto, L., Driusso, P., dos Reis, F.J.J. et al. Low-Value Practices for Pelvic Floor Dysfunction—Choosing Wisely Recommendations from the Brazilian Association of Physiotherapy in Women’s Health: Observational Study. Int Urogynecol J (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: