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Earlier Physiotherapy Improves Outcomes in Nontraumatic Knee Pain

Abstract: A recent study finds that physiotherapy within two weeks of a medical consult for nontraumatic knee pain correlates with reduced healthcare utilisation compared to no physiotherapy. Early physiotherapy reduces the chance of narcotic-taking by 33% and reduces the chance of surgery by 42%. Earlier referrals reduced the risks better than later referrals. The current study adds to a body of evidence demonstrating that earlier referrals to physiotherapy achieve better outcomes.

The prevalence of knee pain in Australia has been measured as high as 48% among older adults.1 Popular treatments include narcotics, injections, arthroscopic surgery, and total knee arthroplasty. Physiotherapy for the management of knee pain may be less utilised, but several evidence-based guidelines recommend physiotherapy as a first-line treatment.2-5  Strengthening, coordination, and aerobic improvement may decrease joint loading rate and stresses on articular cartilage, thereby playing an important role in improving knee function and in ameliorating the progression of osteoarthritis.  

Dr Joel Stevans noticed that many patients receive referrals to rehabilitation relatively late in the course of their treatment and that many patients receive recommendations for narcotics, injections, and even surgery before rehabilitation. Dr. Stevens and colleagues wondered if there would be a difference in healthcare utilisation for patients receiving guideline-adherent treatments (i.e. first-line physiotherapy). They studied the insurance claims of 52,504 Medicare beneficiaries who received evaluation or management services for a primary complaint of nontraumatic knee pain (a category encompassing multiple diagnoses including osteoarthritis of the knee).6 Researchers divided patients into four groups: (1) no rehabilitation, (2) early rehabilitation (1-15 days), (3) intermediate rehabilitation (16-120 days), and (4) late rehabilitation (>120 days). 


In terms of reducing other healthcare utilisation for knee pain, the early rehabilitation group experienced the best results. In risk-adjusted outcomes compared to no rehabilitation, the data associated early rehabilitation with a 33% lower chance of taking narcotics, a 50% lower chance of nonsurgical invasive procedures, and a 42% lower chance of surgery. 

The current study adds to a growing body of evidence demonstrating that patients achieve better outcomes when physiotherapy is prescribed earlier. Campian and colleagues found that back pain cases immediately referred to physiotherapy realised more than double the improvement in physical function, had less than half the radiographs, had 0 MRIs compared to 16.9% in the usual care group, and had 90% fewer injections.7 A back pain study published in Spine in 2012 shows that patients who begin physiotherapy within 14 days of their primary care consult cost $3,058 less than those who begin physiotherapy later and are 55% less likely to need surgery.8  Similarly, an ambitious meta-analysis published in the Journal of Occupational Rehabilitation finds that delayed rehabilitation for back pain predicts longer time off work.9 Rosenfeld’s work with whiplash shows that patients receiving physiotherapy within 96 hours of the injury realize better outcomes than patients with later referrals.10-12 At three-year follow-up, only the earlyreferral group had neck range of motion approaching the flexibility of the uninjured control group.


The data suggests that withholding physiotherapy in a waitand-see approach may be counterproductive in terms of both healthcare spending and patient outcomes. The earlier patients receive physiotherapy, the better.



1. Zhai G, Blizzard L, Srikanth V, et al. Correlates of knee pain in older adults: Tasmanian Older Adult Cohort Study. Arthritis Rheum. 2006; 55: 264–71.  

2. McAlindon T, Bannuru R, Sullivan M, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22(3):363–388. 

3. Hochberg M, Altman R, April K, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64(4):465–474. 

4. Fernandes L, Hagen K, Bijlsma J, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013;72(7): 1125–1135. 

5. American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline. 2nd ed., 2013. 

6. Stevans J, Fitzgerald K, Piva S, Schneider M. Association of early outpatient rehabilitation with health service utilization in managing Medicare beneficiaries with nontraumatic knee pain: retrospective cohort study. Physical Therapy. 2017; 97 (6): 614-624.

7. Campian M, Hedin T, Hansen P, et al. Rapid access to physical therapy for low back pain: a continuous quality improvement project. Presented at: Annual Meeting of the Association of Academic Physiatrists. 2017; Sacramento, CA, USA.

8. Fritz J, Childs J, Wainner R, Flynn T. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs.  Spine. 2012; 37 (25): 2114-21.

9. Steenstra I, Munhall C, irvin E, et al. Systematic review of prognostic factors in return to work in workers with sub acute and chronic low back pain. J Occup Rehabil. 2016; DOI 10.1007/ s10926-016-9666-x.

10. Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders. Spine. 2000; 25 (14): 1782-87.

11. Rosenfeld M, Seferiadis A, Carlsson UJ, et al. Active intervention in patients with whiplash associated disorders improves long term prognosis. A randomised controlled clinical trial. Spine. 2003; 28, 2491-2498.

12. Rosenfeld M, Seferiadis, Gunnarsson. Active involvement and intervention in patients exposed to whiplash trauma in automobile pressures reduces costs. A randomised controlled clinical trial and health economic evaluation. Spine. 2006; 31, 1799-1804.

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