2025 Recommendations of the Brazilian society of Rheumatology for the non-pharmacological treatment of knee osteoarthritis

Abstract Aim Knee osteoarthritis (OA) remains a major cause of years lived with disability. There are neither disease-modifying drugs nor safe and effective long-term pain killers to treat these patients. Thus, non-pharmacological treatments remain essential to manage this condition, aiming to reduce pain and improve function. The Brazilian Society of Rheumatology (SBR) published recommendations to treat knee OA in 2002. We now update these recommendations, focusing initially on non-pharmacological strategies. Methods A task force of 21 researchers, including 19 rheumatologists, a general practitioner, and a pharmacist was established. After agreement on 12 research questions to support a systematic literature research (SLR) based on predefined PICO criteria, including articles published between May 2009 and October 2024, the data retrieved were subjected to a meta-analysis. After discussion by the task force panel and a voting process, recommendations were formulated using a Delphi process, where a ≥ 70% agreement in favor or against a proposal had to be achieved for a final decision. Results Four updated general recommendations were made, summarized as follows: (1) Treatment of knee OA aims to provide pain relief and improvement in function; (2) management should be individualized and involve health care professionals, the patient, family members, and caregivers; (3) periodic reevaluation should be implemented; (4) non-pharmacological therapies are essential at all stages of disease management. The summarized specific recommendations are as follows: (1) strong recommendation in favour of land-based and aquatic exercises; (2) conditional recommendation in favor of valgus orthoses in patients with a varus deformity; (3) strong recommendation against therapeutic ultrasound; (4) conditional recommendation in favor of medial insoles and conditional recommendation against lateral insoles; (5) conditional recommendation in favor of the use of adapted footwear. Conclusions Although based on an SLR, the updated SBR recommendations for the non-pharmacological treatment of knee OA also considered expert opinion in the decision-making process. The task force emphasized the need for better designed studies to further improve knowledge in this field.