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Article

Development of a Clinical Guideline for Managing Knee Osteoarthritis in Portugal: A Physiotherapist-Centered Approach

by
Ricardo Maia Ferreira
1,2,3,* and
Rui Soles Gonçalves
2,4
1
Social Sciences, Education and Sport Department, Polytechnic Institute of Maia, N2i, 4475-690 Maia, Portugal
2
Physiotherapy Department, Coimbra Health School, Polytechnic University of Coimbra, Rua da Misericórdia, Lagar dos Cortiços, S. Martinho do Bispo, 3045-093 Coimbra, Portugal
3
Sport Physical Activity and Health Research & Innovation Center (SPRINT), Rua Escola Industrial e Comercial Nun’Álvares, 4900-347 Viana do Castelo, Portugal
4
Health & Technology Research Center (H&TRC), Coimbra Health School, Polytechnic University of Coimbra, Rua 5 de Outubro, 3045-043 Coimbra, Portugal
*
Author to whom correspondence should be addressed.
Osteology 2025, 5(3), 23; https://doi.org/10.3390/osteology5030023
Submission received: 24 March 2025 / Revised: 13 May 2025 / Accepted: 16 July 2025 / Published: 22 July 2025
(This article belongs to the Special Issue Advances in Bone and Cartilage Diseases)
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Abstract

Background/Objectives: Knee osteoarthritis is one of the most significant diseases globally and in Portugal. Despite the availability of international guidelines, there is a lack of tailored, evidence-based recommendations specifically for Portuguese physiotherapists to manage their knee osteoarthritis patients with non-pharmacological and non-surgical interventions. This study aimed to develop a clinical practice guideline that integrates the latest international evidence with local clinical practice data to enhance patient outcomes. Methods: To achieve the objective, a comprehensive search was conducted in November 2024 across major health-related databases, to identify robust and recent evidence regarding the efficacy of non-pharmacological and non-surgical interventions, as well as their usage in the national context. Two key sources were identified: An umbrella and a mixed-methods study. Data from both sources were independently reviewed and integrated through a comparative analysis to identify interventions with robust scientific support and high local acceptability. Recommendations were then formulated and categorized into gold (strong), silver (moderate), and bronze (weak) levels based on evidence quality and clinical relevance. A decision-making flowchart was developed to support guideline implementation and clinical usage. Results: The integrated analysis identified three gold-level interventions, namely Nutrition/Weight Loss, Resistance Exercise, and Self-care/Education. Five silver-level recommendations were Aerobic Exercise, Balneology/Spa, Extracorporeal Shockwave Therapy, Electrical Stimulation, and Manual Therapy. Similarly, five bronze-level recommendations comprised Kinesio Taping, Stretching, Ultrasound Therapy, Thermal Agents, and Walking Aids. Conclusions: This clinical practice guideline provides a context-specific, evidence-based framework for Portuguese physiotherapists managing knee osteoarthritis. By bridging international evidence with local clinical practice, the guideline aims to facilitate optimal patient care and inform future research and guideline updates.

1. Introduction

Osteoarthritis (OA) is the most common form of arthritis, affecting the tissues of movable joints and leading to functional limitations, social impairment, disability, reduced independence, and a lower quality of life in older adults [1,2,3,4,5,6,7]. Although there is no widely accepted, single definitive definition of OA, OA can be defined as a condition characterized by focal areas of loss of articular cartilage within the synovial joints, associated with bone hypertrophy and capsular thickening [8]. Variability in signs, symptoms, biomarkers, pathological patterns, and diagnostic criteria across individuals and joint sites contributes to heterogeneity in OA definition, and prevalence and incidence estimates [8,9].
Owing to societal trends such as aging, obesity, and joint injuries [10,11], the global burden of OA has markedly increased in recent years, with approximately 400–500 million people worldwide suffering from OA, age-standardized incidence rates of around 490–535 per 100,000 population, and an estimated annual percentage change of 0.33% (1990–2021) [12,13]. OA ranks 14th in terms of years lived with disability, accounting for 2.3% of all causes, with a 36.9% increase over a decade (2010–2021) [14]. Regarding disability-adjusted life years, OA has increased by approximately 189.49 million (114.5%) over 30 years (1990–2019), with an age-standardized rate growth of 3.3% [13,15]. The sociodemographic trends indicate a higher burden in low–middle Socio-Demographic Index regions, among females, and in individuals aged 45 years and older [12,13,14,15].
Among the joints affected by OA, the knee is the most prevalent, accounting for 70% of all cases [12,13,16,17]. Globally, there are approximately 364.58 million (4.90%) prevalent cases, 29.51 million (0.07%) incident cases, and 11.53 million (0.45%) disability-adjusted life years attributable to knee OA [18]. Annually, the number of knee OA cases has increased, with prevalence rising by 54.17% per year, incidence by 49.14% per year, and disability-adjusted life years by 126.93% per year (1990–2019) [18]. In Portugal, knee OA is estimated to affect between 11% and 12.4% of the overall population [11,19,20,21].
Individuals with knee OA may exhibit radiographic findings (e.g., osteophytes, synovitis, cartilage and capsular degradation, cysts, alterations in joint space and alignment, sclerosis, and bone deformities), clinical signs and symptoms (e.g., crepitus, morning stiffness, joint instability, swelling, reduced proprioceptive acuity, pain, muscular weakness, deformity, tenderness, heightened temperature sensitivity, and range of motion [ROM] limitation), or both [22,23,24,25,26,27]. As OA is an irreversible non-communicable disease, current rehabilitation strategies employ a multimodal approach involving both surgical and non-surgical (pharmacological and non-pharmacological) interventions to address these radiological and clinical findings [3,28,29,30,31,32,33]. Because the majority of non-pharmacological and non-surgical interventions are safe, low cost, low-tech, promote self-management at home or in the community, and have a substantial public health impact, they are considered as the first step in knee OA management [3,20,28,33,34,35]. More invasive strategies, due to their risks, complications, and post-treatment outcomes, are considered only for patients who fail to respond to these initial measures [3,28,30,33].
Among the various non-pharmacological and non-surgical interventions available for managing knee OA [36,37], the majority are physiotherapy-related [38,39,40,41,42,43]. Despite their widespread use, physiotherapy practices have long faced criticism for being underpinned by a limited research base, often relying on anecdotal evidence and treatment techniques lacking robust scientific support [44,45]. Emphasizing the importance of research within the physiotherapy profession as specialized healthcare providers, one goal is to shift from traditional practice models (driven by therapist interests, values, beliefs, intuition, experiences, expectations, and tacit knowledge) toward a more evidence-based practice (EBP) over time [44,45]. This transition is crucial given that the combined direct (e.g., pharmacological treatment, surgery) and indirect (e.g., absenteeism, premature mortality) OA-related costs are estimated at USD 4.99 billion over a two-year period (approximately USD 2460 per person), potentially accounting for 1–2.5% of a country’s gross domestic product [6,46]. In Portugal, the estimated annual indirect OA costs amount to EUR 656 million (EUR 384 per capita; EUR 1294 per OA patient; and EUR 2095 per OA patient out-of-work), representing 0.4% of the 2013 Portuguese gross domestic product [47]. These costs are likely underestimated due to OA-related comorbidities (such as hypertension [29%], depression [20%], chronic obstructive pulmonary disease [19%], diabetes [10%], and congestive heart failure [6%]) [48], coupled with an expected 60–100% increase in OA prevalence (depending on the joint affected) by 2050, potentially affecting 1 billion people [49]. Therefore, implementing effective and efficient evidence-based interventions is imperative [16].
EBP is now well established in healthcare and is defined as the “conscientious, explicit and judicious use of the best evidence in making decisions about the care of the individual patient” [50,51]. Although EBP integrates clinical experience, patient preferences, and scientific evidence, it is the scientific evidence that forms the foundation for informed decision-making [50,51,52,53]. Healthcare professionals are therefore expected to search, read, and critically appraise scientific studies [47], relying on high-level evidence such as clinical practice guidelines (CPGs) [54,55,56]. CPGs are statements containing recommendations intended to optimize patient care, informed by systematic reviews of evidence and assessments of the benefits and harms of alternative treatment options [57]. Consequently, CPGs have become increasingly important in clinical practice, as they rigorously synthesize and interpret evidence into actionable recommendations, providing an overview of how to manage a condition or to employ an intervention [57,58,59,60,61]. They serve as guidance rather than prescriptive instructions and are intended to complement, not substitute, clinical judgment [61]. There are several advantages when healthcare practitioners follow available CPG recommendations, as their appropriate use will contribute to raising the standard of clinical practice and outcomes (for example, by reducing costs through cost-effective interventions, and by achieving better short-, medium-, and especially long-term results) [57,61].
Despite the existence of numerous recommendations, studies, and knee OA CPGs [62,63,64,65,66,67,68], along with the guidance of clinicians, researchers, and professional organizations that healthcare practitioners (such as physiotherapists [PTs]) have an ethical obligation to base their practice on research findings, many still do not utilize CPGs [57,69,70,71,72,73] or engage in EBP [74,75,76]. Various cultural, financial, educational, historical, social, organizational, demographic, political, personal, and environmental factors have been implicated in this issue [44,45,56,57,61,70,72,73,76,77,78,79,80]. While numerous barriers and facilitators may influence the adoption of CPGs, contextualization is paramount [57,69,70,76,77,81,82]. Contextualization shapes CPG dissemination and implementation, but it exerts an even stronger influence on their long-term sustainability [58,59,62]. The closer the recommendations align with the specific clinical, professional, and national context, the greater the likelihood of adherence by professionals and healthcare organizations. Therefore, during both development and post-development phases, it is crucial to engage local health authorities, clinicians, and trainees to ensure enduring sustainability [61,69,76,77,81,82,83]. To date, no evidence-based CPG has been developed specifically for Portuguese PTs managing knee OA.
Therefore, this study aims to develop an evidence-based CPG for the management of knee OA patients tailored to the Portuguese PTs context.

2. Materials and Methods

To achieve the aim of this study, established methodological frameworks were followed [57,72,84,85]. The current CPG was developed in three main steps: Data Sources and Literature Search, Evidence Synthesis and Integration, and Development of Recommendations and Support Tools.

2.1. Data Sources and Literature Search

A comprehensive search was conducted in November 2024 across major health-related databases (PubMed, PEDro, Scopus, EBSCO, Cochrane Library, and Web of Science) to identify up-to-date complete data on non-pharmacological and non-surgical interventions (via reviews) and on the local context of Portuguese PTs in managing knee OA patients (via an empirical study).
To identify the most current and comprehensive data on non-pharmacological, non-surgical interventions, the electronic databases were searched using the search string “knee*” AND “osteoarthr*” AND “review*” with the appropriate MeSH terms and filters (example of PubMed search strategy: ((“Osteoarthritis, Knee”[Mesh]) OR (“knee* osteoarthr*”[All fields]) OR (“gonarthr*”[All fields])) AND (review*[Title/Abstract])). Eligible studies had to meet the following criteria: they focused specifically on knee OA patients; evaluated non-pharmacological and non-surgical interventions; were available in full text; were published in peer-reviewed journals; reported detailed data on primary knee OA outcomes; and were narrative reviews, systematic reviews, overviews of reviews, scoping reviews, or rapid reviews.
A similar methodological process was applied to investigate the Portuguese PTs’ clinical context. A comprehensive search was conducted across major health-related databases using the search string “knee*” AND “osteoarthr*” AND “portug*” AND “physi*” with the appropriate MeSH terms and filters (example of PubMed search strategy: ((“Osteoarthritis, Knee”[Mesh]) OR (“knee*osteoarthr*”[All fields]) OR (“gonarthr*”[All fields])) AND ((“Portugal”[Mesh]) OR (“portug*”[All fields])) AND ((“Physical Therapists”[Mesh]) OR (“Physical Therapy Modalities”[Mesh]) OR (“Physical Therapy Specialty”[Mesh]) OR (“physi*”[All fields]))). Eligible studies had to meet the following criteria: they addressed Portuguese PTs’ clinical practice in managing knee OA patients; were available in full text; were published in peer-reviewed journals; and employed qualitative, quantitative, or mixed-methods designs.

2.2. Evidence Synthesis and Integration

Data from the umbrella review and the local Portuguese study were independently reviewed by two Portuguese researchers with expertise in knee OA and physiotherapy. The umbrella review provided a robust synthesis of the current evidence on the effectiveness and safety of various interventions, while the local study offered essential contextual insights into clinical preferences and practical constraints. A comparative analysis was undertaken to map evidence-based intervention efficacy against the reported non-pharmacological and non-surgical practices of Portuguese PTs. Interventions demonstrating both high levels of evidence and strong local acceptance were prioritized, ensuring that the resulting recommendations were scientifically sound and tailored to the practical realities of the Portuguese healthcare context.

2.3. Development of Recommendations and Support Tools

Following the recommendations outlined by Conley et al. [65], Ferreira de Meneses et al. [70], and Meneses et al. [86], the integrated data were used to formulate clear, actionable guideline recommendations and to develop a flowchart for clinical decision-making. Each author drafted recommendations independently, and these drafts were then merged. The combined recommendations were discussed, reviewed, and refined until no further improvements were suggested. Each recommendation was articulated with specific clinical parameters and orientations, and categorized by strength (Strong, Moderate, or Weak) based on the quality of supporting evidence and clinical benefits, thereby ensuring clarity and facilitating implementation. The accompanying flowchart was designed as a visual algorithm to guide PTs through the assessment, intervention selection, and knee OA management. The arrangement of the recommendations and the flowchart were strategically developed to enhance clinical interpretation and decision-making, and the rationale for recommendations across different levels was provided, specifying core interventions, adjunctive options, and referral criteria.

3. Results

Among the identified studies, the most current and suitable evidence was provided by an umbrella review [36]. This umbrella review, published in 2024, aimed to summarize (and update) the effectiveness of non-pharmacological and non-surgical interventions for patients with knee OA. Designed in accordance with the PRISMA statement and guided by a pre-established PICOS (knee osteoarthritis; non-pharmacological and non-surgical treatments; pharmacological, surgical, placebo, no intervention, or other non-pharmacological/non-surgical conservative treatments; pain, function, quality of life, and other knee-specific measures; systematic reviews), it synthesized the effectiveness of various interventions. Quality of evidence was assessed using the R-AMSTAR checklist and GRADE principles. The review included 57 systematic reviews (published between 2018 and 2022), which together encompassed 714 trials (a mean of 13 per systematic review) and involved 59,343 participants (a mean of 1041 participants per review, and 82 per primary study). For the purposes of this CPG, the evidence levels and overall assessments (including efficiency, costs, adverse effects, etc.) of the 24 non-pharmacological and non-surgical interventions were extracted.
Regarding the latest available information on the Portuguese PTs’ context for managing knee OA patients, a study [87] was published in 2023. This study aimed to identify the most common non-pharmacological and non-surgical interventions used by Portuguese PTs to manage knee OA patients and to explore the factors influencing their treatment decisions. This study employed a mixed-methods design, collecting quantitative data through a nationwide e-survey (completed by 120 PTs) and qualitative insights from semi-structured, one-to-one interviews (with 10 purposefully selected PTs representing diverse sociodemographic, educational, professional, and clinical backgrounds). This local context analysis provided critical information regarding the feasibility, accessibility, and real-world implementation of non-pharmacological and non-surgical interventions in Portugal.
From the umbrella review [36], the most promising interventions for managing knee OA were Nutrition/Weight Loss, Self-care/Education, and Resistance Training. Moderate support was observed for Aquatic Therapy, Balance Training, Balneology, Extracorporeal Shockwave Therapy, and Tai chi. In contrast, the evidence quality for Kinesio Tape, Blood Flow Restriction Therapy, Circuit-based Exercises, Whole-body Vibration, Baduanjin, Wu Qin Xi, Yoga, Manual Therapy, Acupuncture, Dry Needling, Interferential Current, Laser Therapy, Magnetic Field Therapy, Ultrasound Therapy, and Cryotherapy was low, with mixed or inconclusive results or insufficient efficacy to support their use. According to the study exploring the context of Portuguese PTs [87], the most commonly used interventions to manage knee OA were Electrical Stimulation (including Interferential Current, Neuromuscular Electrical Stimulation, and Transcutaneous Electrical Nerve Stimulation), Exercise (Aerobic, Aquatic, Balance, and Resistance), Kinesio Taping, Manual Therapy, Nutrition/Weight Loss, Self-care/Education, Stretching, Thermal Agents, Ultrasound Therapy, and Walking Aids. Table 1 presents a side-by-side comparison of the evidence and Portuguese PTs’ reporting.
The majority of interventions identified in both studies were consistent between the evidence and real-world usage among Portuguese PTs. Exceptions include Manual Therapy, Tai chi, Extracorporeal Shockwave Therapy, and Balneology. Although some Portuguese PTs may employ Tai chi, its selection was extremely low (only 1 PT [0.2%] chose it) [87]. Consequently, no studies have been conducted on this intervention within the Portuguese PT population. Similarly, Extracorporeal Shockwave Therapy and Balneology/Spa were infrequently chosen in the Ferreira et al. [87] study (2 [0.3%] and 0 [0.0%], respectively), despite being more context-specific, as evidenced by the number of Portuguese physiotherapy clinics offering these services and the corresponding national scientific studies. On the other hand, despite evidence classifying Manual Therapy as a moderate- to low-quality intervention, Portuguese PTs chose it as one of their top three most important interventions for managing patients (in fact, 30.8% ranked it first) [87].
After analyzing the studies, the recommendations were derived by balancing the information from both studies, ensuring that they align with the Portuguese context without compromising evidence levels. The recommendation levels were determined based on evidence quality, the frequency of use, and PTs’ preferences, as well as the positive or negative responses that OA patients exhibit to these interventions. For the Portuguese PT context, the gold (should do/strong recommendation) non-pharmacological and non-surgical interventions are Nutrition/Weight Loss, Resistance Exercises, and Self-care/Education. In certain cases, Resistance Exercises may be substituted with Aquatic Exercises (for fragile patients or those with comorbidities) or Balance Exercises (for patients with poor proprioceptive acuity). The silver (could do/moderate recommendation) interventions include Aerobic Exercises, Balneology/Spa, Extracorporeal Shockwave Therapy, Electrical Stimulation, and Manual Therapy. The bronze (uncertain/weak recommendation) interventions consist of Kinesio Taping, Stretching, Ultrasound Therapy, Thermal Agents, and Walking Aids.
Additionally, it is highly recommended that CPGs include patient-relevant outcomes and evaluations to guide practitioners [57]. This aspect was emphasized by Portuguese PTs, as the decision to implement, modify, or supplement interventions is largely dependent on patient preferences and clinical status/symptoms [87]. Although the most frequently used scales/tests in the Portuguese PTs’ context could not be identified, this CPG provides criteria for a comprehensive OA evaluation to enhance clarity for the general reader. According to the evidence [22,66,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102], an optimal evaluation should include: personal characteristics and clinical history (e.g., BMI, past traumas, age, sex, race, age, and comorbidities); knee OA clinical inspection and classification (e.g., American College of Rheumatology criteria); knee-specific OA self-reported questionnaires (e.g., ICOAP, KOOS, and WOMAC); health status self-reported questionnaires (e.g., Medical Outcomes Study—36-item Short Form or Health Assessment Questionnaire); and physical examination tests (e.g., VAS, goniometry, dynamometry, 40-m fast-paced walk test, timed up and go test, 6-min walk test, 11-step stair climb test, and 30-s chair-stand test). These measures may be used concurrently to obtain a comprehensive (biopsychosocial) assessment of the patient, both at initial evaluation and throughout the intervention plan, to tailor treatments to the patient’s specific condition. Table 2 and Figure 1 present the detailed recommendations and the corresponding flowchart.

4. Discussion

Several key findings emerged from the analysis of the identified studies. The types of studies and the information gathered were intended to be integrated to achieve the primary goal: developing foundations for a CPG for managing knee OA patients treated by Portuguese PTs.
Among the 16 international CPGs found [103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120], our findings showed the highest concordance with the Turkish League Against Rheumatism [115], European Alliance of Associations for Rheumatology [106], and the Royal Dutch Society for Physiotherapy [109] CPGs (agreement levels ranging between 95% and 75%). Moderate agreement was observed with the guidelines from the Italian Society for Rheumatology [108], National Institute for Health and Care Excellence [118], Pan-American League of Associations for Rheumatology [114], European Society for Clinical and Economic Aspects of Osteoporosis [105], United States Department of Veterans Affairs and Defense [116], and Malaysian Health Technology Assessment Section [119] (agreement levels between 74% and 50%). Lower levels of agreement were identified with the French Society of Rheumatology, Physical Medicine and Rehabilitation [107], Royal Australian College of General Practitioners [120], Osteoarthritis Research Society International [110], Chinese Rheumatology and Immunology Expert Committee of the Cross-Strait Medical and Health Exchange Association [104], and American Academy of Orthopaedic Surgeons [117] (agreement levels between 46% and 25%). Very low agreement (below 25%) was found with the guidelines from the American College of Rheumatology [103] and Ottawa [111,112,113]. For further details, see Table 3.
These deviations or approximations from the levels recommended by international CPGs can be attributed to factors such as the year of publication (reflecting the available evidence and its evaluation), the context (proximity to or divergence from Europe), or the composition of the professional societies/expert panels (e.g., PT versus medical professionals) [55,63,67].
A notable example is observed with Mind-body Therapies (such as Tai chi and Yoga) and Acupuncture. Although some evidence supports their use [36,121,122] and several CPGs recommend these interventions [103,104,105,107,108,110,111,112,113,120], they are not well adapted to the local context. In fact, their use among Portuguese PTs remains very low (only 1.2% combined) as many did not considered interventions related to the PT profession in Portugal [87]. Similarly, while Braces and Walking Aids are among the most recommended interventions in international CPGs [103,105,106,107,108,114,116,117,118,119,120], they are not considered primary interventions by Portuguese PTs (only 2.4% combined [87]). Although these interventions may improve certain outcomes (e.g., pain reduction), PTs preferred taking more active approaches or those involving direct patient interaction (such as Manual Therapy or Exercise-related interventions) [87].
Conversely, only one international CPG has provided a low-level recommendation for Extracorporeal Shockwave Therapy [117]. However, given that the evidence presented in this CPG [34] and other similar studies [122] demonstrates its efficacy, it may begin to receive higher recommendations in future updates. Similarly, Stretching is only recommended by one international CPG [114], likely because it is frequently combined with Exercises and/or Manual Therapy. Nevertheless, since maintaining a range of motion with knee OA is a key objective, it remains prudent to recommend Stretching.
Finally, upon analyzing all the gathered information, it appears that in the future some interventions should be re-evaluated, with a reduction in both their usage among the Portuguese PTs community and their associated recommendation levels. The two most significant examples are Manual Therapy and Ultrasound Therapy. Manual Therapy continues to be excessively used by Portuguese PTs [87] (with 14.3% of treatment plans reporting its use), although the evidence still yields mixed results and recommendations regarding its efficacy [36]. Regarding Ultrasound Therapy, almost no international CPG currently recommends its use, and the supporting evidence is progressively diminishing [64,65]. Therefore, it is expected that this intervention may lose its recommendation in future CPG updates.
The development of this context-specific CPG marks a pivotal advancement in managing knee OA in Portugal, combining global evidence with local practitioner expertise to maximize relevance and uptake. By using a dual evidence–practice approach, the CPG’s recommendations are scientifically robust, culturally tailored, feasible in routine Portuguese practice, and aligned with PTs’ skills and preferences. By providing precise recommendations, the CPG empowers PTs to deliver consistent, evidence-based interventions with confidence [123]. Beyond offering (cost-)effective solutions, these interventions may also act as early preventive measures, potentially delaying disease progression and reducing reliance on pharmacological or surgical treatments [124]. This is particularly relevant in the Portuguese healthcare context, where optimal care for patients with knee OA is still not consistently delivered [125]. The biophysical, psychosocial, and functional assessment framework embedded within the CPG further enhances its clinical utility by standardizing outcome measurement [126]. This comprehensive approach supports data-driven decision-making, enables benchmarking across practices, and creates opportunities for continuous quality improvement [127]. Simultaneously, clear guidance on cost-effective interventions provides a roadmap to reduce healthcare expenditures, ensuring that local resources are allocated to treatments with the greatest value [128]. As such, it can serve as the foundation for training programs (by defining core competencies and intervention protocols for physiotherapy education), clinical audits (by supplying measurable indicators and standards for evaluating practitioner adherence and patient outcomes), and policy decisions (by offering policymakers locally tailored evidence on interventions that balance effectiveness, feasibility, and cost-efficiency) [129,130]. Finally, this study should serve as groundwork for developing a more robust nationwide CPG through additional processes (e.g., multidisciplinary consensus, pilot implementation, and health economic evaluations). Rather than a static document, this CPG acts as a strategic catalyst to elevate the standards of knee OA care, improve patient outcomes, and guide resource-efficient service delivery across Portugal. Critically, although this context-sensitive adaptation process was designed for Portugal, it serves as a replicable model that contributes to the broader literature on guideline adaptation and knowledge translation, offering a useful template for other countries aiming to enhance OA care through context-aware CPG development [131].

5. Limitations

Some limitations are associated with this study. This study was developed solely based on available evidence and PT-reported intervention usage that individually can have related bias. No formal consensus process (e.g., Delphi methodology) involving other healthcare professions or patients was conducted, which may limit the depth and breadth of the recommendations. Consequently, this study should be considered as a basis for the creation of a CPG specific to Portuguese PTs, rather than a national CPG to all healthcare professions.

6. Conclusions

Analysis of the data indicates that, within the Portuguese context, the core non-pharmacological and non-surgical interventions for knee OA management are Nutrition/Weight Loss, Self-care/Education, and Resistance Exercise. In certain patient-related conditions, Resistance Exercises may be substituted with either Aquatic or Balance Exercises. If these core interventions do not adequately address the patient’s problems, secondary interventions—such as Aerobic Exercises, Balneology/Spa, Extracorporeal Shockwave Therapy, Electrical Stimulation, and Manual Therapy—may be applied. When these interventions also fail to meet patient needs, tertiary interventions including Kinesio Taping, Stretching, Ultrasound Therapy, Thermal Agents, and Walking Aids could be considered. If none of these interventions yield the desired response, referral to an orthopedist or rheumatologist is recommended for further assessment and management. Additionally, to establish a comprehensive clinical treatment plan, PTs are advised to perform a thorough patient assessment incorporating biopsychosocial measures, including personal characteristics and clinical history, knee OA clinical inspection and classification, knee-specific OA and health status self-reported questionnaires, and relevant physical examination tests. As this study provides the foundation for a broader, nationwide CPG, it is recommended to include additional healthcare professionals, organizations, and patients in a Delphi study. Furthermore, the CPG should be pilot tested in diverse clinical settings. Both steps will strengthen its development, implementation, and long-term sustainability.

Author Contributions

Conceptualization, R.M.F. and R.S.G.; methodology, R.M.F. and R.S.G.; formal analysis, R.M.F. and R.S.G.; investigation, R.M.F. and R.S.G.; writing—original draft preparation, R.M.F.; writing—review and editing, R.S.G. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author(s).

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
BMIBody Mass Index
CPGClinical practical guideline
EBPEvidence-based practice
ICOAPIntermittent and Constant Osteoarthritis Pain
KOOSKnee injury and Osteoarthritis Outcome Score
OAOsteoarthritis
PTPhysiotherapy
ROMRange of motion
VASVisual Analog Scale
WOMACWestern Ontario and McMaster Universities Arthritis Index

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Osteology 05 00023 g001
Figure 1. Portuguese knee OA clinical practice guideline flow diagram. Abbreviations: ADLs—Activities of Daily Living; BMI—Body Mass Index; ICOAP—Intermittent and Constant Osteoarthritis Pain; KOOS—Knee injury and Osteoarthritis Outcome Score; m—meters; min—minutes; PT—Physiotherapy; ROM—Range of Motion; sec—seconds; SF-36—36 item Short Form or Health Assessment Questionnaire; VAS—Visual Analogue Scale.
Figure 1. Portuguese knee OA clinical practice guideline flow diagram. Abbreviations: ADLs—Activities of Daily Living; BMI—Body Mass Index; ICOAP—Intermittent and Constant Osteoarthritis Pain; KOOS—Knee injury and Osteoarthritis Outcome Score; m—meters; min—minutes; PT—Physiotherapy; ROM—Range of Motion; sec—seconds; SF-36—36 item Short Form or Health Assessment Questionnaire; VAS—Visual Analogue Scale.
Osteology 05 00023 g001
Table 1. Comparison between evidence and local practice regarding non-pharmacological and non-surgical interventions for managing knee OA patients.
Table 1. Comparison between evidence and local practice regarding non-pharmacological and non-surgical interventions for managing knee OA patients.
InterventionsEvidence LevelClinical Importance
Umbrella Review
[36]		Local Practice
[87]
AcupunctureWeakWeak
Aerobic Exercise-Moderate
Aquatic TherapyModerateStrong
BaduanjinWeak-
Balance ExerciseModerateModerate
Balneology/SpaModerateWeak
Blood Flow Restriction TherapyWeak-
Braces-Weak
Circuit-based ExerciseWeak-
Dry NeedlingWeak-
Electrical Stimulation TherapiesWeakModerate
Electroacupuncture-Weak
Extracorporeal Shockwave TherapyModerateWeak
Insoles-Weak
Kinesio TapeWeakModerate
Laser TherapyWeakWeak
Magnetic Field TherapyWeakWeak
Manual TherapyWeakStrong
Moxibustion-Weak
Non-elastic Tape-Weak
Nutrition/Weight LossStrongStrong
Resistance TrainingStrongStrong
Self-care/EducationStrongStrong
Stretching-Strong
Tai ChiModerateWeak
Thermal AgentsWeakModerate
Ultrasonic TherapyWeakModerate
Walking Aids-Moderate
Whole-body VibrationWeakWeak
Wu Qin XiWeak-
YogaWeakWeak
Table 2. Portuguese Knee OA Clinical Practice Guideline Recommendations.
Table 2. Portuguese Knee OA Clinical Practice Guideline Recommendations.
NumberRecommendationLevel
1.The primary objectives in managing patients with knee OA are to alleviate pain, enhance and maintain muscular strength, improve or preserve ROM, support functional independence, and optimize QoL. To achieve these outcomes, a comprehensive treatment strategy should prioritize non-pharmacologic interventions, followed by pharmacologic therapies, and surgical options when indicated. Moreover, the therapeutic approach must be individualized to address each patient’s specific needs.Strong recommendation
2.In individuals with knee OA, assessments should follow a biopsychosocial framework, including:
  • Knee OA classification and inspection;
  • Clinical and physical examination tests;
  • Health status questionnaires;
  • Clinical history and personal characteristics;
  • Knee-specific OA questionnaires.
Strong recommendation
3.Knee OA management should be tailored to the individual according to:
  • Environmental factors;
  • QoL impairments and ADL restrictions;
  • Patient characteristics (such as BMI, sex, and age);
  • Patient preferences;
  • Level of pain, knee ROM, function, strength loss, and imbalances;
  • OA severity;
  • Societal participation;
  • Anatomical/Biomechanical/Structural changes;
  • Comorbidities, risk factors, and red-flags.
Strong recommendation
4.Patients with knee OA should receive a personalized management plan that incorporates core non-pharmacological and non-surgical interventions. The intervention plan should be multicomponent and individualized, based on shared decision-making taking into account the individual’s needs, preferences, and capabilities. The core interventions should include:
  • Nutrition/Weight Loss
    • Adopt a long-term dietary plan to maintain weight in individuals with a normal BMI;
    • Implement a sustained weight-reduction diet for those who are overweight or obese;
    • Promote and progressively increase physical activity levels;
    • Record regularly (e.g., weekly or monthly) nutritional intake and body weight;
    • Provide education on nutrition and healthy eating behaviors;
    • Consider advising an increase in protein consumption.
  • Resistance Exercises
    • Low-intensity isokinetic muscle strengthening (start with isometric strength, if the patient is more fragile);
    • Emphasize strengthening the knee extensors and hip musculature;
    • Exercise protocols should consist of 2–3 sets, 8–12 repetitions, 50–60% 1 RM, three times per week;
    • Progressively increase exercise complexity (e.g., from monoarticular to multiarticular movements) as the patient’s physical capacity improves;
    • The exercises chosen should always be patient-appropriate, personalized (e.g., preferences, needs, self-motivation, comorbidities, ability, and clinical condition), and pain free, and must pay attention to the specific kinesiophobia.
  • Self-care/Education
    • Always adapt the information to the patient’s level of health literacy;
    • Conduct 1:1 meetings, supported by written, verbal, and/or digital materials;
    • Provide comprehensive information covering knee anatomophysiology, OA pathophysiology, OA progression, prognosis, lifestyle modifications, joint protection strategies, home-based exercises, and self-management techniques;
    • Beyond informing the patient of his/her condition to improve their educational capability, the objective is to promote hope, optimism, and positive expectations;
    • Although initial instruction is required, the aim is that knee OA patients learn to undertake on their own in their own environment/context.
Strong recommendation
5.In addition to the core interventions and to respond to a specific condition, the following could be incorporated:
  • Aquatic Exercises
    • Indicated for patients who are overweight, fragile, exhibit a major muscular weakness, serious instability, and other comorbidities;
    • Conducting sessions of 40–60 min, 2–3 times per week, in water depths ranging 1.15–1.5 m, and temperatures between 33.5–35.5 °C (the session volume and water depth have to be patient tailored);
    • Gradually increasing the difficulty of the exercises, to facilitate progression toward land-based exercises.
  • Balance Exercises
    • Recommended for patients exhibiting static and/or dynamic instability, and proprioceptive deficits;
    • These exercises should ideally be integrated into the Resistance Exercise program;
    • Begin with a stable base using both lower limbs. Then progress to more challenge exercises, such as standing on one lower limb, incorporating dynamic movements, utilizing unstable surfaces, reducing visual input, and introducing dual-task. All exercises should be individualized and adjusted to the patient’s ADLs;
    • The primary objectives are to enhance lower limb stability, joint position sense, and proprioception.
Strong recommendation
6.If core and adjunctive interventions do not adequately address the patient’s signs, symptoms, and clinical needs, the following could be performed:
  • Aerobic Exercises
    • Advised for patients who are overweight, present with significant muscular weakness, have restricted knee ROM, and are initially unable to engage in Resistance Exercises;
    • Include low-load, soft cyclic movements that are simple to learn and execute;
    • Gradually increase exercise complexity and difficulty to facilitate eventual integration into a structured Resistance Exercises intervention plan;
    • Could be included in a Resistance Exercises intervention plan, as a type of warm-up and/or cool-down;
    • The primary goals are to enhance joint lubrication and improve knee ROM.
  • Manual Therapy
    • Adapt the technique, amplitude, force, rate, repetition, and duration to the type and severity of the patient’s signs, symptoms, clinical findings, and comorbidities;
    • The technique(s) selected should consider clinician-related factors (e.g., experience and objectives), patient-specific variables (e.g., preferences, characteristics, and clinical status) and external factors (e.g., session time and resources);
    • Manual therapy should not be employed as a standalone intervention.
  • Electrical Therapy
    • NMES may be considered for patients with significant muscular deficits who are unable to engage in active exercises;
    • TENS or IFC may be used in cases of severe, crippling pain that limits participation in active exercises;
    • These interventions should not be used as standalone treatment plan. Whenever possible, they should be combined with active interventions (such as, exercise). Consider these interventions only for short-term results in severely symptomatic and fragile patients (TENS/IFC for pain, and NMES for severe loss of muscle mass and strength).
  • Extracorporeal Shockwave Therapy
    • Administer 3–5 sessions, 15-20 min/session, 1000–2500 pulses per session at a frequency of 4-12 Hz, using a of medium-energy density dosage (0.08–0.25 mJ/mm2 or 1.5–2.5 bar);
    • Monitor for potential adverse effects (e.g., pain, minor bruising, soft tissue swelling, redness, burning sensation, or effusion);
    • Use it to mitigate pain, and improve physical function and ROM.
  • Balneology/Spa
    • Implement balneology/spa interventions that promote relaxation and well-being;
    • Encourage participation in interventions that facilitate high levels of social interaction.
  • Once the patient responds positively to these interventions, the intervention plan should progress to incorporate the core interventions.
Moderate recommendation
7.If the patient remains symptomatic, the following could be considered:
  • Ultrasound Therapy
    • Administer continuously, 1 MHz, 1.5 W/cm2, 20 min/session;
    • Use it to mitigate pain, and improve physical function and ROM.
  • Kinesio Taping
    • Employ a Y-shape, with a 120–140% stretching length, over a period of 3–4 weeks for optimal results;
    • Use it to ameliorate pain, and/or improve joint function and ROM.
  • Thermal Agents
    • May be considered when aligned with the patient’s preferences and clinically justified by the signs and symptoms (such as reduced pain or improved circulation);
  • Walking Aids
    • Assistive technologies and environmental adaptations at home and/or work may be considered to alleviate pain, enhance QoL, and promote social participation.
  • Stretching
    • May be indicated to relieve muscular tension and to maintain knee ROM and function.
  • Avoid excessive use of these interventions, due to the potential of dependence. As soon as possible, incorporate more active interventions.
Weak recommendation
8.If non-pharmacological and non-surgical interventions fail to adequately address the patient’s needs, referral to an orthopedic or rheumatology specialist should be considered to:
  • Further re-evaluate the patient’s clinical findings;
  • Consider integrating pharmacological therapies to complement existing interventions;
  • Reflect on the appropriateness of surgical intervention as a potential option.
Strong recommendation
A Strong recommendation (gold) means that the quality of the supporting evidence and the benefits is high. A Moderate recommendation (silver) means that the benefits exceed the potential harm, but the quality/applicability of the supporting evidence is not as strong. A Weak recommendation (bronze) means the quality of the supporting evidence is low or the benefits were trivial, but the studies did not cause patients harm or exert important secondary effects after the intervention application. Abbreviations: ADL—Activities of Daily Living; BMI—Body Mass Index; cm—centimeter; IFC—Interferential Current; MHz—Mega Hertz; min—Minutes; mJ—millijoule; mm—millimeter; NMES—Neuromuscular Electrical Stimulation; OA—Osteoarthritis; QoL—Quality of Life; RM—Maximum Repetition; ROM—Range of Motion; TENS—Transcutaneous Electrical Neuromuscular Stimulation; W—watts.
Table 3. Knee OA guidelines intervention recommendations.
Table 3. Knee OA guidelines intervention recommendations.
InterventionCurrent
(2025)		SFR/SOFMER [107]
(2024)		NICE [118]
(2023)		EULAR [106]
(2023)		AAOS [117]
(2021)		MAHTAS [119]
(2021)		CRIECCSMHEA [104]
(2020)		VA/DOD [116]
(2020)		KNGF [109]
(2020)		ACR [103]
(2019)		ESCEO [105]
(2019)		ISR [108]
(2019)		OARSI [110]
(2019)		RACGP [120]
(2018)		TLAR [115]
(2017)		Ottawa
[111,112,113]
(2017)		PANLAR [114]
(2016)
ExerciseOsteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001
Self-care/EducationOsteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i003Osteology 05 00023 i001 Osteology 05 00023 i001
Nutrition/Weight lossOsteology 05 00023 i001Osteology 05 00023 i003Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i003Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001 Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001Osteology 05 00023 i001
Balance exercisesOsteology 05 00023 i001 Osteology 05 00023 i001Osteology 05 00023 i003 Osteology 05 00023 i003 Osteology 05 00023 i003 Osteology 05 00023 i003
Manual therapyOsteology 05 00023 i003Osteology 05 00023 i002Osteology 05 00023 i003 Osteology 05 00023 i002 Osteology 05 00023 i003Osteology 05 00023 i002 Osteology 05 00023 i002Osteology 05 00023 i002 Osteology 05 00023 i003
BalneologyOsteology 05 00023 i003Osteology 05 00023 i002 Osteology 05 00023 i002Osteology 05 00023 i003 Osteology 05 00023 i003Osteology 05 00023 i003 Osteology 05 00023 i003
Electrical StimulationOsteology 05 00023 i003 Osteology 05 00023 i002 Osteology 05 00023 i002 Osteology 05 00023 i003 Osteology 05 00023 i003Osteology 05 00023 i002
ESWTOsteology 05 00023 i003 Osteology 05 00023 i002
Walking aidsOsteology 05 00023 i002Osteology 05 00023 i002Osteology 05 00023 i003Osteology 05 00023 i003Osteology 05 00023 i003 Osteology 05 00023 i001Osteology 05 00023 i002Osteology 05 00023 i001 Osteology 05 00023 i003 Osteology 05 00023 i002
TapingOsteology 05 00023 i002 Osteology 05 00023 i002 Osteology 05 00023 i003Osteology 05 00023 i002Osteology 05 00023 i002 Osteology 05 00023 i002 Osteology 05 00023 i002
Thermal agentsOsteology 05 00023 i002 Osteology 05 00023 i003Osteology 05 00023 i002 Osteology 05 00023 i003Osteology 05 00023 i002 Osteology 05 00023 i003
Ultrasound Osteology 05 00023 i002 Osteology 05 00023 i002
StretchingOsteology 05 00023 i002 Osteology 05 00023 i002
Braces Osteology 05 00023 i003Osteology 05 00023 i002 Osteology 05 00023 i003Osteology 05 00023 i001 Osteology 05 00023 i001 Osteology 05 00023 i001Osteology 05 00023 i003 Osteology 05 00023 i002 Osteology 05 00023 i003
Tai chi Osteology 05 00023 i001 Osteology 05 00023 i001Osteology 05 00023 i002 Osteology 05 00023 i003Osteology 05 00023 i001 Osteology 05 00023 i003
Acupuncture Osteology 05 00023 i003 Osteology 05 00023 i002 Osteology 05 00023 i003 Osteology 05 00023 i003 Osteology 05 00023 i002
Insoles Osteology 05 00023 i002 Osteology 05 00023 i001 Osteology 05 00023 i003 Osteology 05 00023 i002 Osteology 05 00023 i003
Yoga Osteology 05 00023 i003 Osteology 05 00023 i003Osteology 05 00023 i003 Osteology 05 00023 i003
Laser Osteology 05 00023 i002
Osteology 05 00023 i001—“Gold”: should do/strong recommendation; Osteology 05 00023 i003—“Silver”: could do/moderate recommendation; Osteology 05 00023 i002—“Bronze”: uncertain/weak recommendation; Abbreviations: AAOS—American Academy of Orthopaedic Surgeons; ACR—American College of Rheumatology; CRIECCSMHEA—Chinese Rheumatology and Immunology Expert Committee of the Cross-Strait Medical and Health Exchange Association; ESCEO—European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases; ESWT—Extracorporeal Shockwave Therapy; EULAR—European Alliance of Associations for Rheumatology; ISR—Italian Society for Rheumatology; KNGF—Royal Dutch Society for Physiotherapy; MAHTAS—Malaysian Health Technology Assessment Section; NICE—National Institute for Health and Care Excellence; OARSI—Osteoarthritis Research Society International; PANLAR—Pan-American League of Associations for Rheumatology; RACGP—Royal Australian College of General Practitioners; SFR/SOFMER—French Society of Rheumatology and the French Society of Physical Medicine and Rehabilitation; TLAR—Turkish League Against Rheumatism; VA/DOD—United States Department of Veterans Affairs and Defense; Note: Only the most recent guideline from each society are exposed. Only the recommended interventions are shown. The guidelines’ recommendations against an intervention are not displayed.
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Ferreira, R.M.; Gonçalves, R.S. Development of a Clinical Guideline for Managing Knee Osteoarthritis in Portugal: A Physiotherapist-Centered Approach. Osteology 2025, 5, 23. https://doi.org/10.3390/osteology5030023

AMA Style

Ferreira RM, Gonçalves RS. Development of a Clinical Guideline for Managing Knee Osteoarthritis in Portugal: A Physiotherapist-Centered Approach. Osteology. 2025; 5(3):23. https://doi.org/10.3390/osteology5030023

Chicago/Turabian Style

Ferreira, Ricardo Maia, and Rui Soles Gonçalves. 2025. "Development of a Clinical Guideline for Managing Knee Osteoarthritis in Portugal: A Physiotherapist-Centered Approach" Osteology 5, no. 3: 23. https://doi.org/10.3390/osteology5030023

APA Style

Ferreira, R. M., & Gonçalves, R. S. (2025). Development of a Clinical Guideline for Managing Knee Osteoarthritis in Portugal: A Physiotherapist-Centered Approach. Osteology, 5(3), 23. https://doi.org/10.3390/osteology5030023

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