Demographic and geographical variability in physiotherapy provision following hip and knee replacement. An analysis from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

Published:November 20, 2019DOI:



      Total hip (THR) and knee replacement (TKR) are two of the most common elective orthopaedic procedures worldwide. Physiotherapy is core to the recovery of people following joint replacement. However, there remains uncertainty as to physiotherapy provision at a national level.


      To examine the relationship between patient impairment and geographical variation on the provision of physiotherapy among patients who undergo primary total hip or knee replacement (THR/TKR).


      Population-based observational cohort study.


      Patients undergoing THR (n = 17,338) or TKR (n = 20,260) recorded in the National Joint Registry for England (NJR) between 2009 and 2010 and completed Patient Reported Outcome Measures (PROMs) questionnaires at Baseline and 12 months postoperatively. Data were analysed on the frequency of physiotherapy over the first postoperative year across England’s Strategic Health Authorities (SHAs). Logistic regression analyses examined the relationship between a range of patient and geographical characteristics and physiotherapy provision.


      Following THR, patients were less likely to receive physiotherapy than following TKR patients (‘some’ treatment by a physiotherapist within 1st post operative year: 53% vs 79%). People with worse functional outcomes 12 months postoperatively, received more physiotherapy after THR and TKR. There was substantial variation in provision of physiotherapy according to age (younger people received more physiotherapy), gender (females received more physiotherapy) ethnicity (non-whites received more physiotherapy) and geographical location (40% of patients from South West received some physiotherapy compared to 40 73% in London after THR).


      There is substantial variation in the provision of physiotherapy nationally. This variation is not explained by differences in the patient’s clinical presentation.


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        • Ackerman I.N.
        • Bohensky M.A.
        • de Steiger R.
        • Brand C.A.
        • Eskelinen A.
        • Fenstad A.M.
        • et al.
        Substantial rise in the lifetime risk of primary total knee replacement surgery for osteoarthritis from 2003 to 2013: an international, population-level analysis.
        Osteoarthr Cartil. 2017; 25: 455-461
        • Ackerman I.N.
        • Bohensky M.A.
        • de Steiger R.
        • Brand C.A.
        • Eskelinen A.
        • Fenstad A.M.
        • et al.
        Lifetime risk of primary total hip replacement surgery for osteoarthritis from 2003-2013: a multi-national analysis using national registry data.
        Arthritis Care Res. 2017; 69: 1659-1667
      1. National Joint Registry (NJR). Stats Online. (Date last accessed 18 December 2018).

        • National Institute for Health and Care Excellence
        Osteoarthritis: care and management. Clinical Guideline CG177.
        2017 (. (Date last accessed 11 July 2018))
        • Krummenauer F.
        • Wolf C.
        • Gunther K.P.
        • Kirschner S.
        Clinical benefit and cost effectiveness of total knee arthroplasty in the older patient.
        Eur J Med Res. 2009; 14: 76-84
        • Hershkovitz A.
        • Vesilkov M.
        • Beloosesky Y.
        • Brill S.
        Characteristics of patients with satisfactory functional gain following total joint arthroplasty in a postacute rehabilitation setting.
        J Geriatr Phys Ther. 2017; (in press)
        • Peter W.F.
        • Nelissen R.G.
        • Vlieland T.P.
        Guideline recommendations for post-acute postoperative physiotherapy in total hip and knee arthroplasty: are they used in daily clinical practice?.
        Musculoskeletal Care. 2014; 12: 125-131
        • Westby M.D.
        • Brittain A.
        • Backman C.L.
        Expert consensus on best practices for post-acute rehabilitation after total hip and knee arthroplasty: a Canada and United States Delphi study.
        Arthritis Care Res. 2014; 66: 411-423
        • Artz N.
        • Elvers K.T.
        • Lowe C.M.
        • Sackley C.
        • Jepson P.
        • Beswick A.D.
        Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis.
        BMC Musculoskelet Disord. 2015; 16: 15
        • Coulter C.L.
        • Scarvell J.M.
        • Neeman T.M.
        • Smith P.N.
        Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review.
        J Physiother. 2013; 59: 219-226
        • Khan F.
        • Ng L.
        • Gonzalez S.
        • Hale T.
        • Turner-Stokes L.
        Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthroplasty.
        Cochrane Database Syst Rev. 2008; 2CD004957
        • Westby M.D.
        • Marshall D.A.
        • Jones C.A.
        Development of quality indicators for hip and knee arthroplasty rehabilitation.
        Osteoarthr Cartil. 2018; 26: 370-382
        • Hamilton D.F.
        • Loth F.C.
        • MacDonald D.J.
        • MacFarlane G.J.
        • Beard D.J.
        • Simpson A.H.R.
        • et al.
        Exploring variation in patient access of postdischarge physiotherapy following total hip and knee arthroplasty under a choice based system in the UK: an observational cohort study.
        BMJ Open. 2019; 9e021614
        • Department of Health
        Liberating the NHS: greater choice and control – government response.
        Extending patient choice of provider (Any qualified provider). Department of Health, 2011
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • Pocock S.J.
        • Gøtzsche P.C.
        • Vandenbroucke J.P.
        • et al.
        The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.
        J Clin Epidemiol. 2008; 61: 344-349
      2. NJR 2010 Annual Report. Available at: (Date last accessed 17 October 2017).

        • Smith T.
        • Noble M.
        • Noble S.
        • Wright G.
        • McLennan D.
        • Plunkett E.
        The English indices of deprivation 2015.
        Department for Communities and Local Government, 2015
        • Health Authorities Order
        The Health Authorities (Establishment and Abolition) (England) Order 2002.
        2002 (. (Date last accessed 18 July 2018))
        • Dawson J.
        • Fitzpatrick R.
        • Carr A.
        • Murray D.
        Questionnaire on the perceptions of patients about total hip replacement.
        J Bone Joint Surg Br. 1996; 78: 185-190
        • Dawson J.
        • Fitzpatrick R.
        • Murray D.
        • Carr A.
        Questionnaire on the perceptions of patients about total knee replacement.
        J Bone Joint Surg Br. 1998; 80: 63-69
        • Murray D.W.
        • Fitzpatrick R.
        • Rogers K.
        • Pandit H.
        • Beard D.J.
        • Carr A.J.
        • et al.
        The use of the oxford hip and knee scores.
        J Bone Joint Surg Br. 2007; 89: 1010-1014
        • Department for Environment, Food and Rural Affairs
        Local Authority District (LAD) Rural Urban Classification.
        2010 (. (Date last accessed 03 January 2019))
        • Dryden R.
        • Williams B.
        • McCowan C.
        • Themessl-Huber M.
        What do we know about who does and does not attend general health checks? Findings from a narrative scoping review.
        BMC Public Health. 2012; 12: 723
        • Artz N.
        • Dixon S.
        • Wylde V.
        • Beswick A.
        • Blom A.
        • Gooberman-Hill R.
        Physiotherapy provision following discharge after total hip and total knee replacement: a survey of current practice at high-volume NHS hospitals in England and Wales.
        Musculoskeletal Care. 2013; 11: 31-38
        • Jones C.A.
        • Martin R.S.
        • Westby M.D.
        • Beaupre L.A.
        Total joint arthroplasty: practice variation of physiotherapy across the continuum of care in Alberta.
        BMC Health Serv Res. 2016; 16: 627
      3. National Institute for Health and Care Excellence. Joint replacement (primary): hip, knee and shoulder. Clinical Guideline GID-NG10084. (Date last accessed 03 January 2019).