Received:23July2023 Accepted:13September2023
DOI:10.1111/jebm.12555
GUIDELINE
Chineseguidelinesfortherehabilitationtreatmentofknee
osteoarthritis:AnCSPMRevidence-basedpracticeguideline
SiyiZhu
1,2
ZhuoWang
1,2
QiuLiang
1
YutingZhang
1
SheyuLi
3
LinYang
1,2
ChengqiHe
1,2
ChineseSocietyofPhysicalMedicineandRehabilitation
WestChinaHospital
1
DepartmentofRehabilitationMedicine,West
ChinaSchoolofMedicine/WestChina
Hospital,SichuanUniversity,Chengdu,China
2
RehabilitationKeyLaboratoryofSichuan
Province,WestChinaHospital,Sichuan
University,Chengdu,China
3
DepartmentofEndocrinologyand
MetabolismandDepartmentofGuidelineand
RapidRecommendation,CochraneChina
Center,MAGICChinaCenter,Chinese
Evidence-BasedMedicineCenter,WestChina
Hospital,SichuanUniversity,Chengdu,China
Correspondence
LinYangandChengqiHe,Departmentof
RehabilitationMedicine,WestChinaHospital,
SichuanUniversity,Chengdu,Sichuan,China.
Email:green.yanglin@scu.edu.cn;
hxkfhcq2015@126.com
Fundinginformation
NationalNaturalScienceFoundationofChina,
Grant/AwardNumbers:81972146,82002393,
82272599;SichuanUniversityPostgraduate
EducationReformProject,Grant/Award
Numbers:GSSCU2021038,GSSCU2021130;
NaturalScienceFoundationofSichuan
Province,Grant/AwardNumber:
2022NSFSC1512;The135ProjectofWest
ChinaHospital,Grant/AwardNumber:
ZYGD18018
Abstract
Background: Knee osteoarthritis (KOA) is the most common degenerative joint dis-
ease in China, causing a huge economic burden on patients, families, and society.
Standardized KOA rehabilitation treatment is an important means to prevent and
treatthediseaseandpromotethedevelopmentofhigh-qualitymedicalservices.This
guidelineisupdatedonthebasisofthe2016and2019editions.
Methods:Clinicalquestionsregardingrehabilitationassessmentandtreatmentwere
selectedthroughclinicalquestionsscreeninganddeconstruction,andmultiplerounds
of Delphi questionnaire consultation. The InternationalClassification of Functioning,
Disability and Health (ICF) was used as the theoretical framework, and the Grading
ofRecommendationsAssessment,DevelopmentandEvaluation(GRADE)methodwas
usedtogradethequalityofevidenceandrecommendations.
Results: The reporting of this guideline followed the standard of Reporting Items
for Practice Guidelines in Healthcare (RIGHT). Taking into account patients’ prefer-
ences and values and the needs of Chinese clinical practice, a total of 11 clinical
questions and 28 recommendations were established. The clinical questions were
grouped into two categories: KOA assessment (body function, body structure, activ-
ity and participation, quality of life, and environmental factors and clinical outcomes
assessment, resulting in 9 recommendations) and KOA treatment (health education,
therapeutic exercise, therapeutic modalities, occupational therapy, assistive devices,
andregenerativerehabilitationapproaches,resultingin19recommendations).
Conclusion:Thisisthefirstevidence-basedguidelineforKOArehabilitationinChina
utilizingtheICFframework.Thisguidelineprovideskeyguidancefordevelopingsys-
tematic, standardized, and precise rehabilitation protocols for KOA across various
healthcaresettings.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium,providedtheoriginalworkisproperlycited,theuseisnon-commercialandnomodificationsoradaptationsaremade.
? 2023 The Authors. Journal of Evidence-Based Medicine published by Chinese Cochrane Center, West China Hospital of Sichuan University and John Wiley & Sons
Australia,Ltd.
JEvidBasedMed.2023;1–18. wileyonlinelibrary.com/journal/jebm 1
2 ZHUET AL.
KEYWORDS
evidence-based medicine, knee osteoarthritis, practice guidelines, rehabilitation assessment,
rehabilitationtreatment
1 INTRODUCTION
Knee osteoarthritis (KOA), with the primary symptom of joint pain,
is a degenerative disease caused by various factors leading to fibro-
sis, cracking, ulceration, and loss of articular cartilage.
1,2
From 1990
to 2019, the global prevalence of KOA increased by 48%.
3
Nearly
100 million people worldwide are disabled due to KOA, resulting in
18.9millionyearslivedwithdisability(YLD),whichaccountsfor2.2%
of the global disease burden and ranks as the fourth most disabling
condition.
4
InChina,theprevalenceofsymptomaticKOAis8.1%,with
1.97millionyearslivedwithdisability(YLD).KOAismorecommonin
femalesthanmalesandisbecomingoneofthemostcommondisabling
diseases.
5,6
Withahigh-incidenceanddisabilityrate,KOAhascaused
a significant economic burden on patients, families, and society. The
2021editionoftheChineseOrthopedicAssociationguideline,Amer-
ican Academy of Orthopedic Surgeons guideline, and other earlier
evidence-basedguidelinesallrecommendthatmedicationandsurgical
treatments shouldbeconsideredwhentreatment options arelimited
due to indications, comorbidities, and adverse events.
2,7
Instead, the
first-linetreatmentforKOAisnonpharmacologicalinterventions,such
aspatienteducation,self-management,andphysicaltherapy.
8–10
Although the Royal Dutch Society for Physical Therapy (KNGF)
developed clinical guidelines for the physical therapy of hip and knee
osteoarthritis in 2010 and 2020, respectively,
11,12
the methods of
guidelinedevelopmentandthecomprehensivecoverageofrehabilita-
tion clinical issues related to knee osteoarthritis are insufficient, and
therecommendationshavecertainregionallimitations.Astudyexam-
iningtheapplicabilityofguidelinesshowedthatthemeanandmedian
domain scores for applicability were 43.6% and 42.0%.
13
Specifically
for KOA guidelines, with an awareness rate of 41.2%, a survey fur-
ther demonstrated the low applicability and implementation of KOA
clinicalpracticeguideline.
14
InChina,WestChinaHospitalofSichuan
University developed the “Rehabilitation Guideline for Osteoarthri-
tis” in 2016.
15
In 2019, the Chinese Society of Physical Medicine and
Rehabilitation led the development of the “Guideline and Consensus
of Physical Medicine and Rehabilitation: Rehabilitation Guideline for
Knee Osteoarthritis.”
16
These guidelines have been widely applied in
clinicalpractice;however,theyalsohavesomepracticalissues,suchas
inadequaterecommendationsandevidence,andcannotfullymeetthe
needsofclinicalpractice.Theseguidelinesweremainlybasedonexpert
consensusandneededtomeettherigorousevidencesynthesisprocess
criteria.
Thus, developing a high-quality guideline is needed to address the
limitationsmentionedabove.Itisnotonlyameaningfulwaytoimprove
theoveralllevelofmedicalservicesbutcanalsoreducemedicalcosts
and patient burdens, thereby promoting the rational use of medical
resources. The guideline will provide evidence-based recommenda-
tions to standardize knee osteoarthritis’s rehabilitation treatment
systematically.
Therefore, after 1 year of work, we have developed the “Chinese
guidelinesfortherehabilitationtreatmentofkneeosteoarthritis(2023
edition)” (hereinafter referred to as “this guideline”). Based on the
coreclinicalquestionsofkneeosteoarthritisrehabilitationtreatment,
this guideline was developed under the theoretical framework of the
InternationalClassificationofFunctioning,DisabilityandHealth(ICF).
Using the best available evidence, this guideline clearly defined the
qualityofevidenceandthestrengthofrecommendations,takinginto
accountpatients’preferencesandvaluesandclinicalpracticeevidence
inChina.
2 METHODS
The formulation of this guidelinestrictly followed the “World Health
OrganizationHandbookforGuidelineDevelopment”publishedbythe
WorldHealthOrganization(WHO),
17
the“BasicMethodsandProce-
dures for the Development/Revision of Clinical Practice Guidelines”
publishedbytheChineseMedicalAssociation,
18
andthe“GuidingPrin-
ciplesfortheDevelopment/RevisionofClinicalPracticeGuidelinesin
China (2022 edition).”
19
Based on the core classifications and corre-
sponding codes in the ICF,
20
a systematic review and evidence syn-
thesis of clinical questions related to knee osteoarthritis assessment
and rehabilitation intervention were conducted. The Grading of Rec-
ommendationsAssessment,DevelopmentandEvaluation-Evidenceto
Decision(GRADE-EtD)frameworkwasusedtoguidetheformulation
ofthequestions,assessmentoftheevidence,andsummarizationofthe
conclusion.
21
TheGradingofRecommendationsAssessment,Develop-
ment and Evaluation (GRADE) method was used to grade the quality
ofevidenceandrecommendations.Thereportingofthisguidelinefol-
lowedthestandardsoftheReportingItemsforPracticeGuidelinesin
Healthcare(RIGHT).
22
PleaserefertoFigure1fortheflowchart.
2.1 The initiating and supporting organizations
This guideline was initiated by Chinese Society of Physical Medicine
and Rehabilitation and the West China Hospital of Sichuan Univer-
sity. Methodological support for the development of this guideline
was provided by the Chinese Evidence-based Medicine Center, the
WorldHealthOrganizationCollaboratingCenterforGuidelineImple-
mentation and Knowledge Translation, the Guideline and Standard
Research Center of the Chinese Medical Journal Publishing House,
the GRADE Center of Lanzhou University, and the Guideline and
Standard Research Center of the Institute of Health Data Science
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ZHUET AL. 3
FIGURE1 Flowchartofguidelinedevelopment.
at Lanzhou University. This guideline has been registered on the
International Practice Guideline Registry Platform (Registration No:
IPGRP-2022CN008). The guideline plan has been written and can be
obtainedbycontactingthecorrespondingauthorortheplatform.
2.2 Guideline development committee
The committee consisted of guideline experts, methodology experts,
andexternalreviewexperts(SupplementaryMaterial1).
Theguidelineexpertcommitteewascomposedofmultidisciplinary
experts from rehabilitation medicine, orthopedics, rheumatology and
immunology, pain management, radiology, epidemiology, etc. They
were responsible for developing the outline of the guideline, deter-
mining the core clinical questions and scope, evaluating the evidence
for their respective chapters, drafting initial recommendations and
key points, formulating preliminary key points and recommenda-
tions through consensus voting, modifying the initial draft based on
feedback from other groups, and approving the final version of the
guideline.
The methodology expert committee was composed of guideline
methodologists and evidence-based medicine experts. They were
responsible for literature review, evidence synthesis and quality
assessment, as well as determining the standard of evidence evalua-
tionandwritingforeachchapter,providingmethodologicaltrainingto
eachexpertgroup,assistinginsummarizingthekeypointsandrecom-
mendationsoftheguideline,assistingtheexternalreviewoftheinitial
draft,andapprovingthefinalversionoftheguideline.
The external review expert committee comprised relevant multi-
disciplinary experts, guideline users (including relevant medical pro-
fessionals and therapists), and patient representatives. The external
review expert group did not participate in developing the guidelines.
They were responsible for reviewing the initial draft of the guideline
andprovidingkeyfeedbackfortheapprovalofthefinalversion.Patient
representatives served as the reference group and were responsible
forconfirmingthereadabilityoftheguidelineandapprovingthefinal
versionoftheguideline.
2.3 Conflict of interest declaration
DevelopingtheguidelinestrictlyfollowedtheWHOguidelinesoncon-
flict of interest regulations and ethical standards for guideline devel-
opment.Membersoftheguidelinedevelopingcommittee,experts,and
consultants invited to participate in guideline development meetings
all filled out a declaration of interest form, declaring any financial or
academic conflicts of interest within the past three years. After eval-
uating their declarations of interest, it was determined that there
was no direct financial conflict of interest with this guideline, and all
committeemembersagreedtopublishitintheguideline.
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4 ZHUET AL.
TABLE 1 GRADElevelofevidenceandgradeofrecommendations.
Levelofevidence Description
High(A) Theauthorsareveryconfidentthatthetrueeffectliesclosetothatoftheestimateofeffect.
Moderate(B) Theauthorsaremoderatelyconfidentintheeffectestimate:thetrueeffectislikelytobeclosetotheestimateofthe
effect,butthereisapossibilitythatitissubstantiallydifferent.
Low(C) Theauthors’confidenceintheeffectestimateislimited:thetrueeffectmaybesubstantiallydifferentfromthe
estimateoftheeffect.
Verylow(D) Theauthorshavelittleconfidenceintheeffectestimate:thetrueeffectislikelytobesubstantiallydifferentfromthe
estimateoftheeffect.
Gradeof
recommendation Description
Strong(1) Benefitsclearlyoutweighriskandburdens,orviceversa.
Weak(2) Uncertainlyintheestimatesofbenefits,risks,andburden;benefit,risk,andburdenmaybecloselybalanced.
2.4 Users and target population
Thisguidelineisintendedforusebyclinicalprofessionalsinrehabilita-
tionmedicine,orthopedicsurgery,sportsmedicine,rheumatologyand
immunology,andpainmanagementwhoareinvolvedinthediagnosis,
treatment,andrehabilitationmanagementofkneeosteoarthritis.The
targeted population for the recommended advice in the guideline is
adultkneeosteoarthritispatients.
2.5 Scope and core clinical questions
The scope of the guidelines was determined jointly by the initiat-
ing institution and the guideline expert committee. By systematically
reviewing published guidelines, original articles, systematic reviews,
and other evidence in the field of KOA rehabilitation, with reference
to the core classification combinations and corresponding codes for
knee osteoarthritis in the ICF, core clinical questions were selected.
The guideline expert committee members were invited to complete
a Delphi questionnaire: a total of 23 questionnaires were sent out,
with a response rate of 100%. The average coefficient of variation
for the importance scores of rehabilitation assessment clinical ques-
tionswas14.68%,withacoefficientofagreementof0.434(p<0.05).
Theaveragecoefficientofvariationfortheimportancescoresofreha-
bilitation treatment clinical questions was 16.17%, with a coefficient
of agreement of 0.407 (p < 0.05). Finally, based on the ranking of
importance and experts’ supplementary suggestions, 11 core clinical
questionsintwocategories(rehabilitationassessmentandtreatment)
wereselectedforthisguideline(SupplementaryMaterial2).
2.6 Evidence synthesis and quality appraisal
For the core clinical questions included, the search strategy was
formulated according to the principles of population, intervention,
comparison, and outcome (PICO) (see Tables 2 and 3). English and
Chinese literature databases were systematically searched, including
PubMed, Embase, The Cochrane Library, Web of Science, CINAHL,
WanFang, China National Knowledge Infrastructure (CNKI), VIP, and
China Biology Medicine Database (CBM). Clinical guideline websites
were also systematically searched, including the National Guide-
line Clearinghouse (NGC), Scottish Intercollegiate Guidelines Net-
work(SIGN),WHO,GuidelinesInternationalNetwork(GIN),National
Institute for Health and Care Excellence (NICE), and Physiother-
apy Evidence Database (PEDro). English and Chinese search terms
included knee osteoarthritis, rehabilitation, and physical therapy. The
search time was set from the establishment of the databases to
the present. The inclusion criteria were as follows: (1) study popu-
lation (P): patients diagnosed with knee osteoarthritis (see footnote
in Table 2); (2) intervention and comparison measures (I, C): reha-
bilitation assessment and treatment; (3) outcome measures (O): not
limited;(4)studytypes:clinicalguidelines,expertconsensus,reviews,
systematic reviews/meta-analyses, and original studies (randomized
controlled trials, observational studies). The exclusion criteria were
as follows: excluding patients with inflammatory arthritis such as
rheumatoid arthritis and lupus arthritis; excluding interventions and
comparisonmeasuressuchastraditionalChinesemedicineorpsycho-
logicaltherapy(acupuncture,electroacupuncture,cognitivebehavioral
therapy, etc.); excluding duplicate publications and project proposals
(SupplementaryMaterial3).
The systematic reviews/meta-analyses included in this study were
evaluatedforriskofbiasusingtheAMeasurementTooltoAssessSys-
tematicReviews(AMSTAR).TheRiskofBias(RoB)toolfromCochrane
(used for randomized controlled trials), the Quality Assessment of
Diagnostic Accuracy Studies (QUADAS-2) tool (used for studies on
diagnosticaccuracy),andtheNewcastle-OttawaScale(NOS)(usedfor
observationalstudies)wereusedtoassessthemethodologicalquality
of the corresponding types of primary studies.
23–26
An evidence syn-
thesistableandsummaryexplanationswerethencreated,providingan
importantbasisforformingrecommendations.
2.7 Formation of guideline items and
recommendations
Basedonevidencesynthesistablesandevidencesummary,keypoints
and recommendations for each clinical question were written as rec-
ommendations, explanation of recommendations, and summary of
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ZHUET AL. 5
TABLE 2 SummaryofKOArehabilitationassessmentclinicalquestionsandrecommendations.
Clinicalquestions
Isitrecommendedtoconductrehabilitationassessment
forpatientswithkneeosteoarthritis?
a
Whatarethe
suggestedmethodsandtools? Recommendations
1.Bodyfunctionassessment
1.1Sensoryandpainassessment(ICF:b280) ItisrecommendedtousetheNRS/VASscaleforaquickandeasyassessmentofpain
levels.Additionally,theWOMAC(Pain)andKOOS(Pain)scalesaresuggestedfor
supplementaryevaluationofpainseverity(2D).
1.2Rangeofmotionassessment(ICF:b710) Itisrecommendedtouseagoniometertomanuallymeasuretherangeofmotionofthe
joints(2D).
1.3Musclestrengthassessment(ICF:b730) Itisrecommendedtousemanualorinstrumentedstrengthassessmentmethodsto
assessthemusclestrengthofthekneeflexorandextensorgroup(1B).
1.4Gait,balance,andneuromuscularfunction
assessment(ICF:b770;b755;b780)
Itisrecommendedtousemethodssuchasthetimedup-and-gotest,dynamic-static
balancetest,andthree-dimensionalgaitanalysistoobtaininformationonpatients’
walkingspeed,steplength,stridelength,walkingduration,plantarpressure,balance,
andneuromuscularcontrol(2C).
2.Bodystructureassessment(knee) ItisrecommendedtouseX-rayforaquickandeasyassessmentofjointstructures,and
supplementaryevaluationsofthekneejointandaccessorystructurescanbe
conductedusingmethodssuchasweight-bearingfull-lengthX-rayofthelowerlimbs,
MRI,CT,andultrasound(1B).
3.Activityandparticipationassessment
3.1Activityofdailylivingassessment ItisrecommendedtousetheBarthelIndextoassessthedaily-lifeactivitiesofthe
patients.TheWOMAC(PhysicalFunction)scale,KOOS(Activitiesofdailyliving)scale,
andthe6-minwalkingtestcanbeusedaseffectivesupplements(2D).
3.2Participationassessment ItisrecommendedtousethePSKeventreportandtheKOOS(Sportandrecreation
function)scaletoassesspatients’participationability(2D).
4.Qualityoflifeassessment ItisrecommendedtousetheSF-36questionnairetoevaluatethepatient’s
health-relatedqualityoflife.TheKOOS(Knee-relatedqualityoflife)andAQoL-6D
scalescanalsobeusedaseffectivesupplements(2D).
5.Environmentalfactorsandclinicaloutcomes(fall,
surgery,anddeath)
Itisrecommendedtoanalyzetheimpactofpatients’diseasepreventionandtreatment
ontheoccurrenceofeventssuchastimetosurgery(ICF:e580)anddeath(2C).
a
Patientswithkneeosteoarthritis(ICD-11code:FA01)shouldmeetcriterion1+(any2criteriaoutof2–5criteria)ofthefollowing:(1)recurrentkneejoint
paininthepastmonth;(2)radiographicevidenceofjointspacenarrowing,subchondralbonesclerosis,and/orcystformation,andosteophyteformationat
thejointmarginsonweight-bearingorstandingX-rays;(3)age≥50years;(4)morningstiffnesslasting≤30min;and(5)presenceofcrepitusduringjoint
movement.
evidence appraisal. The GRADE methodology was used to grade the
level of evidence and the grade of recommendations for each clini-
calquestion(Table1).ConsideringthepreferencesandvaluesofKOA
patientsinChinaandthecostsandbenefitsofinterventionmeasures,
preliminarykeypointsandrecommendationswereformulated.ADel-
phiquestionnairesurveywasconductedfortherecommendations:18
questionnaires were received, with a response rate of 78.3% (>75%).
Consensus was reached for all recommendations in the first round,
withaconsensusrateof100%andanaveragecoefficientofvariation
of<35%. After revision based on the feedback, 11 key points and 28
recommendationswereestablishedinthisguideline.
2.8 Writing and external review
The guideline expert committee wrote the initial draft of each chap-
ter based on the final key points and recommendation items. With
theassistanceofthemethodologyexpertcommittee,theinitialdrafts
wereintegratedandthensubmittedtotheexternalreviewexpertcom-
mitteeforevaluation.Thequalityoftheguidelinewasassessedusing
the Appraisal of Guidelines for Research and Evaluation II (AGREE II)
tool
27
and the Appraisal of Guidelines for Research & Evaluation in
China(AGREE-China)
28
evaluationsystem.Basedonthefeedbackand
ratings from the external review expert committee, the responsible
expertsforeachchapterandthemethodologyexpertsfurtherrevised
andfinalizedthedraft,ensuringthatthewritingandreportingwerein
accordancewiththeRIGHTcriteria.
22
2.9 Publication, dissemination, and updates
The guideline expert committee approved the final version of the
guideline and authorized its publication. After publication, the guide-
line will be interpreted at relevant academic conferences and will be
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6 ZHUET AL.
TABLE 3 SummaryofKOAtreatmentclinicalquestionsandrecommendations.
Clinicalquestions
Isitrecommendedtodeliverrehabilitationtreatment
forpatientswithkneeosteoarthritis?Whatarethe
suggestedinterventions? Recommendations
1.Healtheducation PatientswithKOAarerecommendedtoreceivevariousformsofhealtheducation,suchas
face-to-faceeducation,brochures,electronicmultimedia,onlineinteraction,andremote
video(1B).
2.Therapeuticexercises
2.1Walking AccordingtotheWHOguidelinesfordailyactivity,itisrecommendedthatpatientswith
kneeosteoarthritisshouldengageinwalkingatanintensitythatisbeneficialfortheir
healthondailybasis(2D).
2.2Aquaticexercise Aquaticexerciseisrecommendedasatreatmentmodalityformanagingsymptomsin
patientswithkneeosteoarthritis.Considerpatients’preferenceandaccessibilitywhen
prescribingaerobicexercise(1B).
2.3Stationarycycling Stationarycyclingexerciseisrecommendedasasuitableoptionforaerobicexercisein
patientswithkneeosteoarthritis.Whenprescribingexercise,itisimportanttoconsider
factorssuchaspatients’preferenceandaccessibility(1B)
2.4Strengthtraining Strengthandresistancetrainingarerecommendedforpatientswithkneeosteoarthritis,
specificallytargetingthekneeextensors(quadricepsfemoris).Toachievesymptomatic
andfunctionalimprovement,thetrainingshouldaimformusclestrengthgainsabove30%
(1B).
2.5Neuromusculartraining Whendevelopinganindividualizedandstructuredexerciseprogramforpatientswithknee
osteoarthritis,itisrecommendedtoincorporateneuromusculartrainingintotheprogram
(1B)
2.6Balance/proprioceptivetraining Balancetrainingorproprioceptivetrainingisrecommendedforpatientswithknee
osteoarthritiswhodemonstratebalanceorproprioceptivedysfunction(2C).
2.7Mind–bodyexercise Mind–bodyexercise,suchasTaiChioryoga,isrecommendedformanagingsymptomsof
kneeosteoarthritis.Thechoicebetweenthesemethodsshouldbebasedonpatients’
preferenceandaccessibility(1B).
2.8Jointmobilitytraining Jointmobilitytrainingisnotrecommendedasastandaloneinterventionforknee
osteoarthritis.Instead,itisrecommendedasanadjunctinterventiontobeusedin
conjunctionwithexercisetherapy(2D).
3.Therapeuticmodalities
3.1Ultrasound Ultrasoundtherapy(2B),pulsedelectromagneticfields(2B),low-energylasertherapy(2B),
andextracorporealshockwavetherapy(2C)arerecommendedasadjunctiveinterventions
forsymptomcontrolandfunctionalimprovementofkneeosteoarthritis.
3.2Pulsedelectromagneticfields
3.3Low-energylasertherapy
3.4Extracorporealshockwave
3.5Transcutaneouselectricalstimulation Transcutaneouselectricalstimulationtherapyisrecommendedasanadjunctive
rehabilitationinterventionfollowingexercisetherapyforkneeosteoarthritis.However,it
isnotrecommendedforuseasanadjunctorcombinedinterventionwithothertreatment
modalities(2B)
3.6Whole-bodyvibration Whole-bodyvibrationtherapyisrecommendedasanadjunctiveinterventiontoquadriceps
femoristrainingforkneeosteoarthritis.Itcanbeincorporatedintoastructuredexercise
program,takingintoconsiderationpatients’preferenceandassessmentresults(2C).
3.7Kinesiologytape Kinesiologytapeisrecommendedasanadjunctiverehabilitationinterventiontoaddress
jointfunctionallimitationsinpatientswithkneeosteoarthritis,particularlyforthosewith
jointmobilityandwalkinglimitations(1C).
3.8Balneotherapy Basedonacomprehensiveassessmentofthequalityofevidence,patients’preferences,
accessibilityconsiderations,andcost-effectiveness,thisguidelinedoesnotcurrently
recommendtheutilizationofbalneotherapy(2C),neuromuscularelectricalstimulation
therapy(2D),short-wavediathermy(1C),andinfraredtherapy(2D)asroutineor
adjunctiverehabilitativeinterventionsforpatientswithkneeosteoarthritis.
3.9Neuromuscularelectricalstimulation
3.10Short-wavediathermy
3.11Infraredtherapy
(Continues)
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ZHUET AL. 7
TABLE 3 (Continued)
Clinicalquestions
Isitrecommendedtodeliverrehabilitationtreatment
forpatientswithkneeosteoarthritis?Whatarethe
suggestedinterventions? Recommendations
4.Occupationaltherapy Itisrecommendedtotreatpatientswithkneeosteoarthritiswithenergy-savingtechniques
andjoint-protectiontechniquesasneededaccordingtopatients’preferencesand
assessmentresults.Itisalsorecommendedtoprovidepatientswithcounseling,including
theapplicationofkneebraces,activitiesofdailyliving,environmentalmodifications,and
vocationaltrainingasappropriate,tohelppatientsovercomeactivityorsocial
participationbarriers(2D).
5.Assistivedevices
5.1Orthoticinsoles ItisrecommendedthatforKOApatientswithmedialcompartmentinstabilityorincreased
medialcompartmentpressure,customorthoticinsolesmaybeprescribedbasedon
patients’preferencesandassessmentfindings.Theseorthoticinsolesshouldbewornand
utilizedundertheguidanceofaphysicaltherapistoroccupationaltherapisttoensure
properuse.Theuseoforthoticshoesisnotrecommendedforpatientswithknee
osteoarthritis(2B).
5.2Kneeorthoses(braces) Itisrecommendedthatforkneeosteoarthritispatientswithinternalandexternalknee
deformities,patellofemoralortibiofemoralalignmentabnormalities,andstructural
disturbances,customkneeorthosesmaybeprescribedbasedonpatients’preferencesand
assessmentfindings.Thesekneeorthosesshouldbewornandutilizedundertheguidance
ofaphysicaltherapistoroccupationaltherapisttoimprovepainandfunctionallimitations
duetobiomechanicalfactors(1B).
5.3Walkingaids ItisrecommendedthatforKOApatientswithgaitdysfunction,jointstability,orhighlevels
ofpain,awalkingaidmaybeprescribedforuseundertheguidanceofaphysicaltherapist
oroccupationaltherapist.Unilateralwakingaidispredominantlyrecommended,andit
shouldbeplacedatacertaindistanceeitheripsilateralorcontralateraltotheaffectedside
(1C).
6.Regenerativerehabilitationapproaches
6.1Platelet-richplasmainjections
6.2Stemcellinjections
Platelet-richplasmainjectionsmaybeconsideredasanadjuncttootherrehabilitative
interventionsforkneeosteoarthritiswhenconventionalapproacheshavefailedorin
combinationwithothertreatments(2B).Stemcellinjectionsarenotcurrently
recommendedasroutinetherapyforkneeosteoarthritispatients(1B).However,stemcell
injectionscouldbeutilizedinregisteredclinicaltrialsenrollingkneeosteoarthritis
patientsifdeemedethicalandalignedwithpatientpreferences,guidedbyprinciplesof
soundclinicalresearchconduct.
publicly published in high-quality academic journals in both Chinese
andEnglish,aimingtopromotethestandardizeduseoftheguideline.
Itisplannedtoupdatetherecommendationsofthisguidelineevery3–
5years,followingtherequirementofinternationalguidelineupdating
regulations.
3 RESULTS
3.1 Rehabilitation assessment for KOA
After diagnosis of KOA, a rehabilitation assessment should be con-
ducted on KOA patients, aiming to determine the functional impair-
ments and provide a basis for setting rehabilitation goals and plans.
TheassessmentshouldfollowICFframeworkfromthelevelsofbody
functionsandstructures,activities,andparticipation.
3.1.1 Body function assessment
Clinical question 1: Is it recommended to conduct body function
assessments for patients with knee osteoarthritis? What are the
suggestedmethodsandtools?
a.Recommendation
Itisrecommendedtoconductbodyfunctionassessmentsforpatients
with knee osteoarthritis, primarily including sensory and pain assess-
ments (ICF: b280), range of motion (ROM) assessments (ICF: b710),
musclestrengthassessments(ICF:b730),gaitassessments(ICF:b770),
and balance and neuromuscular function assessments (ICF: b755;
b780).Thespecificrecommendationsareasfollows:
1. It is recommended to use the NRS/VAS scale for a quick and easy
assessment of pain levels. Additionally, the WOMAC (Pain) and
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8 ZHUET AL.
KOOS(Pain)scalesaresuggestedforsupplementaryevaluationof
painseverity(2D).
2. It is recommended to use a goniometer to manually measure the
rangeofmotionofthejoints(2D).
3. Itisrecommendedtousemanualorinstrumentedstrengthassess-
mentmethodstoassessthemusclestrengthofthekneeflexorand
extensorgroup(1B).
4. It is recommended to use methods such as the timed up-and-
go test, dynamic-static balance test, and three-dimensional gait
analysis to obtain information on patients’ walking speed, step
length, stride length, walking duration, plantar pressure, balance,
andneuromuscularcontrol(2C).
b.Evidencesummary
Sensory and pain. Joint pain and tenderness are the most common
clinical signs and symptoms of knee osteoarthritis, with an inci-
dencerangingfrom36.8%to60.7%.
29
Previousguidelinesandexpert
consensus
11,12,20,30,31
have all emphasized that pain assessment is a
crucialoutcomemeasure,withanexpertconsensusrateof97%–100%.
Theseverityofpainshouldbequantified,andtheevaluationmethods
based on the Likert scale, such as the Visual Analogue Scales (VAS)
and Numeric Rating Scale (NRS), are convenient, feasible, and easy
to use. The pain assessment tools used for evaluating the severity of
kneeosteoarthritis,suchasWesternOntarioandMcMasterUniversity
Osteoarthritis Index (WOMAC)- and Knee Injury and Osteoarthritis
OutcomeScore(KOOS)-painassessment,arecommonlyusedaswell.
Inadditiontoassessingpainseverity,itisalsoimportanttorecordthe
triggersofpain(suchaspainatrestorduringactivity)anditstempo-
ralcharacteristics(suchasfrequency,worstpaininthepastweek,and
persistentpain).Evidencesuggeststhatthetimingofpainassessment
iscrucial,anditshouldbedoneascloseaspossibletotheoccurrence
ofpain,preferablywithin48h.
32
Range of motion. Range of motion (ROM) consists of active ROM
and passive ROM. Previous expert consensus
20,30
and systematic
reviews
33
have all pointed out that ROM assessment is a crucial
objective outcome measure, with a consensus rate of 100%. Using
a goniometer for ROM measurement is the preferred method. Mea-
surement method: Place the subject in a certain position, fix the axis,
determine the fixed arm and the moving arm, ask the subject to per-
form joint movement, and measure the degree of motion. The active
ROM and passive ROM should be measured separately to determine
thepossiblecauseofROMrestriction.However,theaccuracyofgonio-
metric measurements is influenced by multiple factors, so it is crucial
toestablishastandardizedmeasurementprocedure.
Muscle strength. Previous systematic reviews/meta-analyses
34
and
expert consensus
20,30
have all indicated that muscle weakness is
an important risk factor for the progression of knee osteoarthri-
tis, with a consensus rate of 100%. Observational studies
35,36
have
found a strong correlation between decreased knee extensor mus-
cle strength (OR = 1.65) and knee osteoarthritis. Currently, muscle
strengthassessmentcanbedividedintomanualmuscletesting(MMT)
andinstrumentedstrengthassessmentbasedonwhetherinstruments
areused,orcanbedividedintoisometricmusclestrengthassessment,
isotonic muscle strength assessment, and isokinetic muscle strength
assessmentbasedonthetypeofmusclecontraction.MMTisthemost
widely used and convenient method for muscle strength assessment,
whichismainlymodifiedfromLovett6-gradescoringsystem.Itfurther
differentiates grades 2–5 based on the magnitude of external resis-
tanceand/orrangeofmotion,denotingthemas“+”or“?,”resultingin
amoredetailed13-gradescoringsystem.
Gait, balance, and neuromuscular function. Pain and changes in mus-
cle strength have important effects on the changes in step time, gait
pattern,plantarpressure,balance,andneuromuscularcontrolinKOA
patients.Therefore,assessingwalkingduration,gait,andbalancefunc-
tion in KOA patients is not only helpful in detecting the presence of
gait abnormalities and balance dysfunction but also provides strong
evidence for assessing the risk of falls and developing rehabilitation
plans. Previous expert consensus
20,30
has stated that gait, balance,
andneuromuscularcontrolfunctionassessmentshouldbeconducted
in patients with knee osteoarthritis, with a consensus rate of 98%–
100%. The main assessment methods include timed up-and-go test,
dynamic-staticbalancetest,andthree-dimensionalgaitsystemassess-
ment, which can comprehensively evaluate the impact of pain and
inflammation on joint control, balance function, and walking ability.
37
However,thedataforgait,balance,andneuromuscularcontrolinknee
osteoarthritislackhighvalidityandstillneedtobeimprovedtosupport
theiruseasobjectiveassessmentmethodsorobservedoutcomes.
3.1.2 Body structure assessment (Knee, ICF:
s75011)
Clinical question 2: Is it recommended to conduct body structure
assessments for patients with knee osteoarthritis? What are the
suggestedmethodsandtools?
a.Recommendation
It is recommended to use X-ray for a quick and easy assessment of
joint structures, and supplementary evaluations of the knee joint and
accessorystructurescanbeconductedusingmethodssuchasweight-
bearing full-length X-ray of the lower limbs, MRI, CT, and ultrasound
(1B).
b.Evidencesummary
X-ray examination is the preferred method for assessing joint struc-
tures. The three typical manifestations of knee osteoarthritis (KOA)
on standard weight-bearing X-rays are asymmetric narrowing of the
affectedjointspace,subchondralbonesclerosisand/orcysticchanges,
andosteophyteformationatthejointmargins.Somepatientsmayhave
varying degrees of joint swelling, the presence of loose bodies within
thejoint,andevenjointdeformities.BasedonX-rayfindings,theKell-
gren and Lawrence grading system should be applied to classify the
severityofkneejointchanges.
38
Thegradingcriteriaareasfollows:no
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ZHUET AL. 9
changes/normal(Grade0);slightosteophytes(Grade1);obviousosteo-
phyteswithoutjointspacenarrowing(Grade2);moderatejointspace
narrowing (Grade 3); marked joint space narrowing with subchondral
bonesclerosis(Grade4).
Weight-bearing full-length X-rays of lower limbs can provide an
overall understanding of the morphological and physiological charac-
teristics of the entire lower limb skeleton from the hip joint to the
anklejointinpatientswithKOA.Thisisbeneficialforcomprehensively
assessing coronal alignment changes in the lower limbs and guiding
rehabilitationassessmentandtreatment.
MRI significantly improves the reliability and validity of analyzing
cartilage injuries and has some value in the early diagnosis of KOA.
The main manifestations include thinning and defects in the carti-
lage of the affected joint, bone marrow edema, meniscus injuries and
degeneration,jointeffusion,andpoplitealcysts.
39
KOA typically shows joint space narrowing, subchondral bone
sclerosis,cysticchanges,andosteophyteformationonCTscans;ultra-
sound has high sensitivity in identifying osteophytes and synovitis.
The latter two methods are mainly used for differential diagnosis of
KOA and pretreatment evaluations and are not the first choices of
assessmentmethods.
3.1.3 Activity and participation assessment
Clinical question 3: Is it recommended to assess the activity and
participation of patients with knee osteoarthritis? What are the
recommendedmethodsandtools?
a.Recommendation
It is recommended to assess the activity and participation of patients
with knee osteoarthritis, focusing on daily-life activities (ICF: d410,
d430, d450, d455, d540) and participation assessment (ICF: d640,
d920).Thespecificrecommendationsareasfollows:
1. ItisrecommendedtousetheBarthelIndextoassessthedaily-life
activities of the patients. The WOMAC (Physical Function) scale,
KOOS (Activities of daily living) scale, and the 6-min walking test
canbeusedaseffectivesupplements(2D).
2. It is recommended to use the PSK event report and the KOOS
(Sport and recreation function) scale to assess patients’ participa-
tionability(2D).
b.Evidencesummary
Activity of daily living assessment. Patients with KOA may experience
activity limitations related to the affected joints. Previous guidelines
and expert consensus
11,12,20,30,31
have indicated that assessing activ-
ities of daily living is a key outcome measure, with agreement rates
reaching90%–100%.Appropriatetestsorscalescanbeselectedbased
ontheaffectedjointstoassesspatients’activityabilities.Basedonthe
ICFframework,thetoolsforassessingactivityabilitiesinKOAmainly
includetheBarthelIndex.OtherassessmenttoolsincludetheWOMAC
(PhysicalFunction)scale,theKOOS(Activitiesofdailyliving)scale,and
the6-minwalkingtest.
Participation assessment. KOA leads to joint structural abnormali-
ties, functional impairments, and activity restrictions, which can
affect patients’ work, social interactions, and leisure activities, lead-
ing to a decreased quality of life. Previous guidelines and expert
consensus
11,12,20,30,31
have all emphasized the assessment of partic-
ipation ability, specifically focusing on activities related to work and
sports. The consensus rate is 84%–95%. Therefore, it is essential to
evaluatethesocialparticipationabilityofpatientsbasedontheirspe-
cific circumstances, mainly using self-report tools such as the Patient
Specific Complaints (PSK) event report and the KOOS (Sport and
recreationfunction)scale.
3.1.4 Quality of life assessment (ICF: d230)
Clinical Question 4: Is it recommended to assess the quality of life
in patients with knee osteoarthritis? What are the recommended
methodsandtools?
a.Recommendation
It is recommended to use the SF-36 questionnaire to evaluate the
patient’shealth-relatedqualityoflife.TheKOOS(Knee-relatedquality
oflife)andAQoL-6Dscalescanalsobeusedaseffectivesupplements
(2D).
b.Evidencesummary
The Medical Outcomes Study 36-item Short Form Health Survey
(SF-36) is a widely used assessment method that evaluates patients’
physiologicalfunction,physicalrole,physicalpain,generalhealth,vital-
ity, social function, emotional role, and mental health across eight
dimensions. It has good reliability and validity.
40
Other assessment
tools includethe KOOS(Knee-relatedqualityof life)andAssessment
ofQualityofLife-6D(AQoL-6D)scales.
3.1.5 Environmental factors and clinical outcomes
(fall, surgery, and death)
Clinical question 5: Should the rehabilitation assessment of knee
osteoarthritis include important environmental factors and clinical
outcomes?Whatinformationisrecommendedtoberecorded?
a.Recommendation
It is recommended to analyze the impact of patients’ disease preven-
tionandtreatmentontheoccurrenceofeventssuchastimetosurgery
(ICF:e580)anddeath(2C).
b.Evidencesummary
Asalternativeorultimateoutcomeindicators,theoccurrenceofevents
is influenced by multiple factors such as disease and environment.
Recording and analyzing the relationship between time and events
and their related influencing factors provides important informa-
tion for developing disease prevention, treatment, and rehabilitation
programs.
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10 ZHUET AL.
3.2 Treatment for KOA
Healtheducationcanbeofferedtohigh-riskandhigh-incidencegroups
of KOA, including individuals over 50 years old, postmenopausal
women, and those with a history of trauma, to prevent the occur-
rence of osteoarthritis. The key principles of early diagnosis, early
treatment, and progressive rehabilitation guide the development of
comprehensive, standardized, and personalized rehabilitation inter-
ventions/programsforpatients.
3.2.1 Health Education
Clinical Question 6: Should KOA patients receive health education?
Whataretherecommendedapproachestodeliverpatienteducation
effectively?
a.Recommendations
Patients with KOA are recommended to receive various forms of
healtheducation,suchasface-to-faceeducation,brochures,electronic
multimedia,onlineinteraction,andremotevideo(1B).
b.Evidencesummary
A synthesis of data from relevant clinical trials
41–43
indicated that
health education did not show a significant effect on pain relief
(SMD =?0.07, 95% CI: ?0.28 to 0.13) and functional improve-
ment (SMD =?0.08, 95% CI: ?0.25 to 0.09) in patients with knee
osteoarthritis. However, previous guidelines
1,12,44
strongly recom-
mend health education for knee osteoarthritis, suggesting that the
traditional face-to-face approach should be routinely used as a clini-
calintervention.Additionally,paper-based,electronic,oronlineaccess
to educational content is an important complement to the tradi-
tional mode. This education should cover essential topics such as
diseaseetiologyandprogression,thesignificanceofahealthylifestyle
and exercise, and appropriate interventions or treatments tailored to
differentstagesofthecondition.
3.2.2 Therapeutic exercises
Clinical Question 7: Should therapeutic exercise be prescribed to
KOApatients?Whatkindsofexercisesarerecommended?
a.Recommendations
Forindividualswithkneeosteoarthritis,itisrecommendedtofollowan
individualizedandstructuredexerciseprogramsupervisedbyaphysi-
cian or therapist. This program should include exercise modalities to
enhance muscle strength, motor control, joint mobility, and aerobic
capacity.Theprogramshouldbetailoredtoeachindividual,consider-
ing the principlesof individualization. The selectionof exercise types,
frequencies, andintensities shouldbebasedonthe resultsof theICF
assessment,aswellasthepreferencesofthepatient.
1. According to the WHO guidelines for daily activity, it is recom-
mended that patients with knee osteoarthritis should engage in
walking at an intensity that is beneficial for their health on a daily
basis(2D).
2. Aquatic exercise is recommended as a treatment modality for
managingsymptomsinpatientswithkneeosteoarthritis.Consider
patients’ preference and accessibility when prescribing aerobic
exercise(1B).
3. Stationarycyclingexerciseisrecommendedasasuitableoptionfor
aerobic exercise in patients with knee osteoarthritis. When pre-
scribingexercise,itisimportanttoconsiderfactorssuchaspatients’
preferenceandaccessibility(1B).
4. Strength and resistance training are recommended for patients
with knee osteoarthritis, specifically targeting the knee exten-
sors (quadriceps femoris). To achieve symptomatic and functional
improvement, the training should aim for muscle strength gains
above30%(1B).
5. When developing an individualized and structured exercise
program for patients with knee osteoarthritis, it is rec-
ommended to incorporate neuromuscular training into the
program(1B).
6. Balance training or proprioceptive training is recommended for
patients with knee osteoarthritis who demonstrate balance or
proprioceptivedysfunction(2C).
7. Mind–body exercise, such as Tai Chi or yoga, is recommended for
managing symptoms of knee osteoarthritis. The choice between
thesemethodsshouldbebasedonpatients’preferenceandacces-
sibility(1B).
8. Joint mobility training is not recommended as a standalone inter-
vention for knee osteoarthritis. Instead, it is recommended as
an adjunct intervention to be used in conjunction with exercise
therapy(2D).
b.Evidencesummary
According to recent research, exercise therapy demonstrated similar
effects on pain and function as oral NSAIDs and paracetamol.
45
This
guidelinerecommendedspecificexercisesasfollows:
Walking. Accordingtoguidelinerecommendations,
46
itisadvisedthat
healthy adults engage in daily activity at an intensity that includes
thefollowing:(1)atleast150minofmoderate-intensityaerobicphys-
ical activity per week, (2) or at least 75 min of vigorous-intensity
aerobic physical activity per week, (3) or a combination of both mod-
erate and vigorous activity, (4) with each aerobic activity session
lasting at least 10 min, and (5) aiming for a daily step count of 7000.
However,asystematicreviewandmeta-analysis
47
revealedthatonly
41% of individuals with knee osteoarthritis were able to achieve 150
min of moderate-intensity aerobic physical activity per week, 13%
could sustain aerobic activity for 10 min or longer per session, and
48%couldcomplete7000dailywalkingsteps.Thesefindingsindicate
that less than 50% of individuals with knee osteoarthritis meet the
recommendeddailyactivitytargets.
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ZHUET AL. 11
Aquatic exercise. Aquatic exercise is considered a safe alternative for
patients who are not suitable for weight-bearing exercises due to
its ability to reduce joint weight-bearing and potential joint damage.
According to current evidence,
48–54
the guideline panel found that
aquaticexerciseprovidespainrelief(SMD=?0.52,95%CI:?0.74to
?0.3), improves functional capacity (SMD =?0.37, 95% CI: ?0.7 to
?0.04), and enhances the 6-min walking distance (SMD = 0.44, 95%
CI:0.08to0.8).However,thesustainedeffectofsymptomrelieffrom
water exercise is shorter, with effectiveness lasting up to 3 months
postintervention. The Osteoarthritis Research Society International
(OARSI)guidelineprovidesaconditionalrecommendation,
1
whilethe
American College of Rheumatology (ACR) guideline
44
gives a strong
recommendationforincludingaquaticexerciseaspartofexercisether-
apy. When considering regional differences in studies conducted, it
is important to consider patient preference and accessibility when
incorporatingaquaticexerciseintothetreatmentplan.
Stationarycycling. Stationarycyclingexerciseisaerobicexercise.Asys-
tematicreviewandmeta-analysis
55
demonstratedtheeffectivenessof
power cycling in various aspects for patients with knee osteoarthri-
tis.Ithasbeenfoundtobeeffectiveinrelievingpain(MD12.86,95%
CI:6.90to18.81),improvingexercisecapacity(MD8.06,95%CI:0.92
to15.20),andachievingminimalclinicallysignificantchange.Further-
more, it also demonstrated a reduction in joint stiffness (MD 11.47,
95%CI:4.69to18.25)andimprovementsinoverallfunction(MD8.28,
95% CI: 2.44 to 14.11) and quality of life (MD 0.99, 95% CI: ?4.27
to 6.25), while the efficacy did not reach minimal clinically significant
change.TheACRguideline
44
stronglyrecommendsstationarycycling
exerciseforpatientswithkneeosteoarthritis.
Strength training. Reduced muscle strength, particularly in the knee
extensor/quadriceps muscles, is a significant risk factor for devel-
oping and progressing knee osteoarthritis. According to current
evidence,
56–58
targeted strengthening training has been shown to
improve muscle strength (SMD = 0.448, 95% CI: 0.091 to 0.805)
and decrease intraarticular weight-bearing stress. It is recommended
that the improvement in strength should exceed 30%, resulting in
pain relief (SMD =?1.41, 95% CI: ?2.33 to ?0.49) and overall func-
tionalimprovement(SMD=?1.43,95%CI:?2.43to?0.49).Previous
guidelines
1,12,44,59
strongly recommend strengthening or resistance
training as an exercise treatment for knee osteoarthritis. However, it
isimportanttonotethattheintensityofstrengtheningtrainingshould
notbeexcessivelyhigh,andthedosageshouldbeindividualizedbased
on patient preferences and assessment results. The guideline panel
suggests the following strength training protocol: resistance setting
(10%-60%1-RM),8–12repetitionspermusclegroup,2–3sets,30–60
minpersession,atleast3timesperweek,andaminimumdurationof
8weeks.
Neuromuscular training. Patients with knee osteoarthritis commonly
experience reduced strength in the quadriceps and posterior femoral
muscle groups. As the disease progresses, individuals, particularly
women, may encounter difficulties in muscle strength control and
voluntary contraction without evident signs of muscle nerve activity,
conduction velocity, or central nerve damage. According to current
evidence,
60–64
the guideline panel found that neuromuscular training
effectivelyalleviatedpain(SMD=2.18,95%CI:1.73to2.64).However,
nosignificantimprovementwasobservedinfunctionallevelsoractiv-
itiesofdailyliving.Previousguidelines
1,12,44
stronglyrecommendthe
incorporation of neuromuscular training within a structured exercise
program.
Balance/proprioceptive training. Balance dysfunction in patients with
knee osteoarthritis is not solely attributed to reduced joint muscle
strength but also linked to impaired proprioceptive signal transmis-
sion, resulting in compromised postural control and coordination.
According to current evidence,
65–67
proprioceptive/balance training
could alleviate pain to some degree (SMD =?0.97, 95% CI: ?1.6
to ?0.34). However, due to heterogeneity in study designs, small
sample sizes, and low study quality, the definitive benefits of bal-
ance/proprioceptive training for knee osteoarthritis patients remain
uncertain. The ACR guideline
44
provides a conditional recommenda-
tion, while the OARSI and KNGF guidelines
1,12
strongly recommend
incorporatingbalance/proprioceptivetrainingasapartofastructured
exerciseprogram.
Mind–body exercise. The mind–body exercise, exemplified by Tai Chi
and yoga, is safe and exhibits notable effects on symptom improve-
ment. These exercises enhance muscle strength, proprioception, bal-
ance, and flexibility. Particularly, Tai Chi exhibits promising outcomes
inalleviatinganxietyanddepressionamongpatients.Accordingtocur-
rentevidence,
68–72
theguidelinepanelfoundthatmind–bodyexercise,
including yoga and Tai Chi, effectively alleviates pain (SMD =?0.63,
95% CI: ?0.95 to ?0.32) and improves overall functional status
(SMD =?0.65, 95% CI: ?0.93 to ?0.36). Additionally, an indepen-
dent evidence synthesis and evaluation conducted by the Ottawa
Expert Group
73
supports the benefits of mind–body exercise in knee
osteoarthritispatients,recommendingitsadoptionbasedonindividual
preferencesandaccessibility.TheOARSIguideline
1
supportstheinclu-
sionofmind–bodyexerciseasacoreinterventionforkneeosteoarthri-
tis, while the ACR guideline
44
provides a strong recommendation for
TaiChiandaconditionalrecommendationforyoga.
Joint mobility training. Exercise should aim to improve joint mobil-
ity as one of its objectives. Joint mobility improvement can be
achieved through both active and passive manual therapy. Previ-
ous guidelines
12,44
do not recommend joint mobility training as a
standalone intervention. Instead, it is recommended to incorporate
joint mobility training as a part of a comprehensive exercise therapy
program,complementingotherformsofexercisesandinterventions.
3.2.3 Therapeutic modalities
Clinical Question 8: Should therapeutic modalities be utilized for
KOA patients? What are the recommended therapeutic modality
interventions?
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12 ZHUET AL.
a.Recommendations
Therapeuticmodalitiesarerecommendedasvaluableadjunctiveinter-
ventions in rehabilitation programs for KOA patients. When imple-
menting these modalities, it is important to consider factors such as
patientpreference,accessibility,indications,andappropriatedosageof
use.
1. Ultrasound therapy (2B), pulsed electromagnetic fields (2B), low-
energy laser therapy (2B), and extracorporeal shockwave therapy
(2C) are recommended as adjunctive interventions for symptom
controlandfunctionalimprovementofkneeosteoarthritis.
2. Transcutaneous electrical stimulation therapy is recommended as
an adjunctive rehabilitation intervention following exercise ther-
apy for knee osteoarthritis. However, it is not recommended for
use as an adjunct or combined intervention with other treatment
modalities(2B).
3. Whole-body vibration therapy is recommended as an adjunctive
interventiontoquadricepsfemoristrainingforkneeosteoarthritis.
It can be incorporated into a structured exercise program, tak-
ingintoconsiderationpatients’preferenceandassessmentresults
(2C).
4. Kinesiology tape is recommended as an adjunctive rehabilita-
tion intervention to address joint functional limitations in knee
osteoarthritis patients, particularly those with joint mobility and
walkinglimitations(1C).
5. Based on a comprehensive assessment of the quality of evi-
dence,patients’preferences,accessibilityconsiderations,andcost-
effectiveness, this guideline does not currently recommend the
utilization of balneotherapy (2C), neuromuscular electrical stim-
ulation therapy (2D), short-wave diathermy (1C), and infrared
therapy (2D) as routine or adjunctive rehabilitative interventions
forpatientswithkneeosteoarthritis.
b.Evidencesummary
Ultrasound therapy. Ultrasound therapy is widely acknowledged for
its therapeutic role, primarily attributable to the mechanical vibra-
tion waves and thermal effects it generates. This modality has shown
effectiveness in alleviating pain in individuals with knee osteoarthri-
tis (KOA), consequently contributing to enhanced joint function
and activity with specific parameter settings. According to current
evidence,
74–77
theguidelinepanelfoundthatultrasoundtherapyeffec-
tively reduces pain (SMD =?0.44, 95% CI: ?0.75 to ?0.12) and
enhances functional activity levels (SMD =?0.4, 95% CI: ?0.82 to
0.02) in patients with KOA. However, it is important to note that the
findings related to ultrasound therapy’s impact on joint mobility and
musclestrengthexhibitcertainlimitations,includinglargeconfidence
intervals for effect sizes, study heterogeneity, and relatively lower
qualityoftheoriginalstudies.Asaresult,previousguidelines,suchas
theACRguideline
44
(conditionalrecommendation)andtheOARSIand
KNGF guidelines
1,12
(tentative nonrecommendation), present some-
whatcontroversialrecommendationsregardingtheuseofultrasound
therapyasatreatmentmodalityforKOA.
Pulsed electromagnetic fields. Pulsed electromagnetic fields have
demonstratedanalgesiceffectsonpatientswithKOAandcanfurther
improve joint function and mobility. Experimental research has con-
firmed the biological effects of pulsed electromagnetic fields, such
as cartilage repair, remodeling of subchondral bone, and inhibition of
synovial inflammation. According to current evidence,
78,79
the guide-
line panel found that pulsed electromagnetic fields were effective in
relievingpain(SMD=?0.53,95%CI:?0.84to?0.21)andimproving
functionalactivity(SMD=?0.39,95%CI:?0.58to?0.21)inpatients
withkneeosteoarthritis.Thetherapeuticeffectoccurswithinaspecific
parameterrange(0-300Hz,0–10mT,4–24weektreatmentduration),
as identified through meta-analyses. However, the long-term efficacy
remainsunclear.Previousguideline
1,12,44
recommendationsforpulsed
electromagneticfieldshavebeeninconsistent.
Low-energy laser therapy. Low-energylasertherapycanprovideshort-
term pain relief (SMD =?0.7, 95% CI: ?1.37 to ?0.03) and improve
overall function (SMD =?0.71, 95% CI: ?1.23 to ?0.18) in patients
with knee osteoarthritis, according to meta-analyses.
80,81
Although
clinical application remains controversial, accumulated evidence sup-
port its potential as an important treatment. The OARSI guideline
1
recommendslow-energylasertherapyasanadjunctiverehabilitation
interventionforkneeosteoarthritispatients.Carefulselectionoftreat-
mentparametersiscrucial,witheffectiverangesfoundtobe4–8Jat
785–860nmand1–3Jat904nm.Whilemoreresearchisstillneeded,
low-energylasertherapyshowspromiseforsymptomaticreliefinknee
osteoarthritiswhenappliedwithappropriateparameters.
Extracorporeal shockwave therapy. Extracorporeal shockwave therapy
has been shown to relieve pain (SMD =?0.54, 95% CI: ?1.03 to
?0.05) and improve functional activity levels (SMD=?0.48, 95% CI:
?1.12to0.15)inpatientswithkneeosteoarthritis,accordingtometa-
analyses.
82,83
Ithasalsodemonstratedsomebenefitsforjointmobility
and walking performance. However, there is limited original research
data to support optimal treatment parameters. The choice of thera-
peuticdoseremainscontroversial,althoughmoderateenergyintensity
is generally preferred. Treatment should be individualized based on
patient preferences, accessibility, and indications. More high-quality
studiesareneededtodeterminetheefficacyandoptimalprotocolfor
extracorporealshockwavetherapyinkneeosteoarthritis.
Transcutaneous electrical stimulation. Transcutaneous electrical stimu-
lationhasasignificantshort-termeffectonpainreliefinpatientswith
KOA and may improve walking ability to some extent. According to
current evidence,
84,85
the guideline panel found that transcutaneous
electrical stimulation relieved pain (SMD =?0.76, 95% CI: ?1.13 to
?0.39)andimprovedwalkingdistanceaftertreatment(SMD=?0.72,
95% CI: ?1.29 to ?0.14). However, the current evidence was of
low quality, with limitations such as small sample sizes, inconsistent
controls, heterogeneity of effect sizes, and inaccurate calculation of
combined effect sizes. The KNGF guideline
12
recommends that it be
usedasanadjunctiveinterventiontoexercisetherapy.
17565391, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jebm.12555 by CochraneChina, Wiley Online Library on [25/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ZHUET AL. 13
Whole-body vibration therapy. Whole-body vibration therapy relieves
pain and improves self-reported functional activity (WOMAC score:
MD=?27.2,95%CI:?32.71to?21.69),andthemostrecentevidence
onlysuggeststhatwhole-bodyvibrationtherapyshouldbeusedasan
effectivecomplementtoexercisetherapy(especiallystrengthtraining),
and studies have found that combined interventions are more effec-
tivethanindividualinterventionsinimprovingquadricepsstrengthand
activityfunction.
86–88
Thefrequencyanddurationofvibrationshould
besetaccordingtothepatients’preferenceandassessmentresultsto
match the training needs better, and the duration of the intervention
shouldbenolessthan8–12weeks.
Kinesiology tape. Kinesiology tape may help patients perform better
(increaseinwalkingdistance,SMD=?1.19,95%CI:?1.87to?0.5)
89
byenhancingjointmobility.TheACRguideline
44
conditionallyrecom-
mendstheuseofkinesiologytape.Indicationsandassessmentresults
should be fully considered prior to implementing this intervention to
improvethepatient’sfunctionallimitationofthejoint.
Balneotherapy. Balneotherapy relieves pain (SMD =?0.61, 95% CI:
?1.06 to ?0.16) and enhances the level of functional activity of
patients (SMD =?0.97, 95% CI: ?1.43 to ?0.5), and the thera-
peutic effect can be maintained for a certain period of time (10-
12weeks).
90–92
However,itsclinicalapplicationneedstobeimproved
consideringthehighcostofusingthismethod,thelowpatientprefer-
ence,andthelargeconsumptionofpublicresources.
Other modalities. Theshort-wavediathermyhashighenergyandther-
maleffects,butitisnotsignificantforpainreliefandfunctionalactivity
improvementinKOApatients.Itisdifficulttocalculateitstherapeutic
effectsbasedoncurrentavailableevidence,andinsufficientsupporting
evidenceexistsforitsclinicalapplication.
93
Neuromuscularelectricalstimulationtherapyandinfraredtherapy
areineffectiveinrelievingpainandimprovingfunction,andtheireffi-
cacy in knee osteoarthritis cannot be determined due to the lack of
originalresearch.
94
3.2.4 Occupational therapy
ClinicalQuestion9:Shouldoccupationaltherapybeusedforpatients
with knee osteoarthritis? What are the recommended occupational
therapyinterventions?
a.Recommendations
It is recommended to treat patients with knee osteoarthritis with
energy-saving techniques and joint-protection techniques as needed
according to patients’ preferences and assessment results. It is also
recommendedtoprovidepatientswithcounseling,includingtheappli-
cationofkneebraces,activitiesofdailyliving,environmentalmodifica-
tions,andvocationaltrainingasappropriate,tohelppatientsovercome
activityorsocialparticipationbarriers(2D).
b.Evidencesummary
Though there is no evidence-based support for occupational ther-
apy as a rehabilitation intervention for knee osteoarthritis, based on
the ICF principles and the consensus reached by the expert panel
of this guideline, occupational therapy is still an important interven-
tion strategy and modality for patients with knee osteoarthritis who
encounter activity or social participation barriers. It can assist in the
functional rehabilitation and improvement of the quality of life of
patientsthroughguidance,training,andcounseling.
3.2.5 Assistive devices
ClinicalQuestion10:Shouldassistivedevicesbeutilizedforpatients
withkneeosteoarthritis?Whatkindsofassistivedevicesarerecom-
mended?
a.Recommendations
1. It is recommended that for KOA patients with medial compart-
mentinstabilityorincreasedmedialcompartmentpressure,custom
orthotic insoles maybeprescribedbasedon patients’preferences
andassessmentfindings.Theseorthoticinsolesshouldbewornand
utilizedundertheguidanceofaphysicaltherapistoroccupational
therapist to ensure proper use. The use of orthotic shoes is not
recommendedforpatientswithkneeosteoarthritis(2B).
2. Itisrecommendedthatforkneeosteoarthritispatientswithinter-
nal and external knee deformities, patellofemoral or tibiofemoral
alignmentabnormalities,andstructuraldisturbances,customknee
orthoses may be prescribed based on patients’ preferences and
assessment findings. These knee orthoses should be worn and
utilized under the guidance of a physical therapist or occupa-
tional therapist to improve pain and functional limitations due to
biomechanicalfactors(1B).
3. ItisrecommendedthatforKOApatientswithgaitdysfunction,joint
stability, or high levels of pain, a walking aid may be prescribed
for use under the guidance of a physical therapist or occupational
therapist. Unilateral waking aid is predominantly recommended,
and it should be placed at a certain distance either ipsilateral or
contralateraltotheaffectedside(1C).
b.Evidencesummary
Orthotic insole. Orthoticinsoles,especiallywedge-shapedinsoles,can
decrease the adduction angle and moment of the affected knee, pro-
viding a correcting effect on the valgus foot. This can relieve pain by
reducing medial compartment knee loading (SMD =?0.74, 95% CI:
?1.42to?0.06).Theinstabilityofthemedialcompartmentforceline
orincreasedpressureisanimportantindicationfororthoticinsoleuse
in patients with knee osteoarthritis.
95,96
The OARSI guideline
1
pro-
vides a conditional recommendation supporting the use of orthotic
insoles in knee osteoarthritis patients. However, the vague defini-
tion of orthotic shoes and lack of high-quality evidence precludes a
recommendationfortheiruseinkneeosteoarthritis.
17565391, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jebm.12555 by CochraneChina, Wiley Online Library on [25/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
14 ZHUET AL.
Kneeorthoses(braces). Theuseofkneeorthoseshasbeenshowntopro-
vide pain relief (SMD =?0.63, 95% CI: ?0.9 to ?0.35) and improve
overall function (SMD =?0.71, 95% CI: ?1.14 to ?0.28) in knee
osteoarthritispatientsbybiomechanicallymodifyingriskfactors.
97–99
The ACR guideline
44
provides a strong recommendation supporting
the use of knee orthoses in knee osteoarthritis. Each knee orthosis
targetsdifferentbiomechanicalalignmentsanddeformities;therefore,
knee orthoses should be customized based on individual preference
and assessment findings. The main types used for knee osteoarthri-
tis are valgus braces, patellofemoral braces, tibiofemoral braces, and
universalkneebraces.
Walking aids. The use of walking aids has been demonstrated to pro-
videpainrelief(SMD=?1.72,95%CI:?2.3to?1.14),improveoverall
function (SMD =?1.03, 95% CI: ?1.55 to ?0.51), and significantly
increase6-minwalkdistance(SMD=2.09,95%CI:1.47to2.7)inknee
osteoarthritis patients.
100–102
Previous guidelines
1,44
have provided
strong recommendations supporting using walking aids. It is recom-
mended that walking aids need to be utilized under the guidance of
a physical therapist or occupational therapist. Unilateral waking aid
is predominantly recommended, and it should be placed at a certain
distanceeitheripsilateralorcontralateraltotheaffectedside.
3.2.6 Regenerative rehabilitation approaches
ClinicalQuestion11:Whatistheevidencefortheefficacyofregener-
ativerehabilitationapproachesinkneeosteoarthritispatients?What
regenerativerehabilitationapproachesarerecommended?
a.Recommendations
Platelet-rich plasma injections may be considered as an adjunct to
other rehabilitative interventions for knee osteoarthritis when con-
ventional approaches have failed or as an important supplement in
combination with other treatments (2B). Stem cell injections are
not currently recommended as routine therapy for knee osteoarthri-
tis patients (1B). However, stem cell injections could be utilized in
registered clinical trials if deemed ethical and aligned with patient
preferences.
b.Evidencesummary
Intraarticular platelet-rich plasma (IA-PRP) injections have demon-
strated efficacy in reducing pain (SMD =?1.75, 95% CI: ?2.61 to
?0.89)andimprovingfunction(SMD=?2.28,95%CI:?3.23to?1.34)
inkneeosteoarthritis.EvidenceindicatesPRPsustainsimprovedanal-
gesiaandfunctionat6-monthand1-yearfollow-upcomparedtoother
injections.
103–105
While the exact component and mechanism under-
lyingPRP’seffectsarestillunknown,leukocyte-depletedPRPappears
clinically superior. Patients’ preferences and accessibility should also
beconsideredwhenutilizingPRPinclinicalpractice.
Intraarticular stem cellinjections have demonstrated the abilityto
reduce pain (SMD =?3.41, 95% CI: ?4.31 to ?2.52), increase car-
tilage thickness (SMD = 4.69, 95% CI: 3.78 to 5.61), and improve
function (SMD =?5.05, 95% CI: ?7.01 to ?3.1) in knee osteoarthri-
tispatients.
106,107
However,conclusiveevidencesupportingthesafety
andefficacyofthisregenerativerehabilitationapproachisstilllacking.
Giventhecurrentlackofstandardizationinstemcellsourcing,mecha-
nism of action, and preparation, high-quality clinicaltrialsare needed
to further validate the safety and reliability of stem cell therapy for
clinical use in knee osteoarthritis. Standardization of stem cell ther-
apy protocols is also required to promote safe and effective clinical
application.
4 SUMMARY
This is the first evidence-based Guideline for Knee Osteoarthritis
RehabilitationinChinautilizingtheICFframeworkandrehabilitation
theory model. It strictly follows the requirements of WHO guide-
line development and international standards. A total of 11 core
clinical questions regarding assessment and treatment were system-
atically reviewed. Evidence was evaluated and synthesized based on
the best available data, forming the basis for 11 key points and 28
recommendations.
Thisguidelinehascertainlimitations.First,someoftheavailableevi-
dence was graded as low quality, resulting in weak strength for some
recommendationsincludingassessmentmethods,physicalmodalities,
andregenerativetechniques.Furtherhigh-qualitystudiesareneeded
to clarify the roles of interventions with weak recommendations or
insufficientevidence.Second,thisguidelinedidnotincludetraditional
Chinesemedicineconsideringthesophisticatedanddifferentnatureof
traditionalChinesemedicine.Aseparateguidelinediscussingtheuseof
traditionalChinesemedicinemaybeneededtounderstandtheimpor-
tance and recommendation of traditional Chinese medicine for KOA
patients. For example, a clinical practice guideline about acupuncture
for KOA has already been published, and similar guidelines could be
initiatedandappliedtoKOApatients.
108
When implementing this guideline, users should receive relevant
trainingandfollowethicalclinicalpractice,consideringpatientprefer-
encesandfunctionalbenefitstoimprovequalityoflife.Thisguideline
provides key guidance for developing systematic, standardized, and
precise rehabilitation protocols for knee osteoarthritis across vari-
ous healthcare settings. It will promote continuous optimization of
knee osteoarthritis rehabilitation approaches through standardized
evidence-basedcare.
ACKNOWLEDGMENTS
Development of this guideline was initiated by Chinese Society of
Physical Medicine and Rehabilitation and the West China Hospital of
SichuanUniversity.WegreatlyappreciateProf.YaolongChenandstaff
members from the World Health Organization Collaborating Center
for Guideline Implementation and Knowledge Translation, the Guide-
line and Standard Research Center of the Chinese Medical Journal
Publishing House, the GRADE Center of Lanzhou University, and the
Guideline and Standard Research Center of the Institute of Health
DataScienceatLanzhouUniversityfortheircontributionsinguideline
17565391, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jebm.12555 by CochraneChina, Wiley Online Library on [25/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ZHUET AL. 15
design,evidenceanalysis,andguidelinewriting.Furthermore,wethank
allmembersoftheGuidelinePanelfortheircontribution.
FUNDING
This guideline was funded by National Natural Science Foundation
of China (81972146; 82002393; 82272599), The 135 Project of
West China Hospital (ZYGD18018), Sichuan University Postgradu-
ateEducationReformProject(GSSCU2021038;GSSCU2021130),and
Natural Science Foundation of Sichuan Province (2022NSFSC1512).
The funders played no role in the development and reporting of this
guideline.
CONFLICT OF INTEREST STATEMENT
Theauthorsdeclarethatthereisnoconflictofinterestregardingthe
publicationofthisarticleorthedevelopmentoftheguideline.
ORCID
SiyiZhu https://orcid.org/0000-0001-8213-7622
ChengqiHe https://orcid.org/0000-0002-5349-0571
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Howtocitethisarticle: ZhuS,WangZ,LiangQ,etal.Chinese
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https://doi.org/10.1111/jebm.12555
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