Brazilian Rheumatology Society Updates Non-Drug Treatment Guidance for Knee Osteoarthritis

The Brazilian Society of Rheumatology has issued updated 2025 recommendations for the non-pharmacological treatment of knee osteoarthritis, revising guidance originally published in 2002. The guideline, published open access in Advances in Rheumatology, focuses on strategies to reduce pain and improve function in a condition that remains a major cause of years lived with disability. The society notes that no disease-modifying drugs and no safe and effective long-term painkillers are available for these patients, which is why non-drug approaches remain essential at every stage of disease management.

The update was produced by a task force of 21 researchers, including 19 rheumatologists, a general practitioner, and a pharmacist. The panel agreed on 12 research questions to support a systematic literature review based on predefined PICO criteria, covering articles published between May 2009 and October 2024. Data retrieved from that search were subjected to a meta-analysis. After discussion by the task force panel and a voting process, recommendations were formulated through a Delphi process in which at least 70 percent agreement in favor of or against a proposal was required for a final decision.

Four updated general recommendations were issued. Treatment of knee osteoarthritis should aim to provide pain relief and improvement in function. Management should be individualized and involve health care professionals, the patient, family members, and caregivers. Periodic reevaluation should be implemented. Finally, non-pharmacological therapies are considered essential at all stages of disease management.

The specific recommendations cover exercise, orthoses, insoles, footwear, and physical modalities. The task force issued a strong recommendation in favor of land-based and aquatic exercises. It conditionally recommended valgus orthoses for patients with a varus deformity, and it conditionally recommended the use of adapted footwear. Medial insoles received a conditional recommendation in favor, while lateral insoles received a conditional recommendation against. Therapeutic ultrasound was the only intervention to receive a strong recommendation against.

The strength labels distinguish between interventions the panel judged firmly supported and those where evidence or applicability is more limited. A strong recommendation in favor of land-based and aquatic exercise places movement therapies at the center of conservative care, consistent with the guideline’s stated aim of reducing pain and improving function. The split verdict on insoles, favoring medial over lateral wedges, and the conditional endorsement of adapted footwear similarly reflect a cautious reading of the available literature.

By framing the verdict as a strong recommendation against, the panel signaled that the evidence did not support its continued use, in contrast to the more permissive conditional stances taken on orthoses, insoles, and footwear.

The task force was explicit that its conclusions rest on more than the systematic review alone. In its conclusions, the society stated that, although the updated recommendations were based on a systematic literature review, expert opinion was also considered in the decision-making process. The panel further emphasized the need for better designed studies to improve knowledge in this field, an acknowledgment that the evidence base for many non-pharmacological interventions in knee osteoarthritis remains limited.

The guideline arrives at a time when treatment options for knee osteoarthritis remain constrained. The authors note in their abstract that there are neither disease-modifying drugs nor safe and effective long-term painkillers for these patients, leaving non-pharmacological treatment as the backbone of care.

For patients and clinicians, the practical takeaway is that exercise in land-based and aquatic settings carries the strongest endorsement in the new guidance, while mechanical aids such as valgus orthoses, medial insoles, and adapted footwear are conditionally supported for selected patients. Therapeutic ultrasound is advised against. The society also stresses that care should be individualized, periodically reevaluated, and shared among professionals, patients, families, and caregivers, with non-pharmacological therapies applied at all stages of the disease.

Subject of Research: Updated national guideline recommendations for non-pharmacological treatment of knee osteoarthritis

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

Article References: Fuller, R., Landim, J. I. V. D., Paiva, E. S., Neubarth, F., da Silva, G. F. M., da Silva, H. C., Coimbra, I. B., Provenza, J. R., da Costa Oliveira, L. E., da Silva, M. R. L. G., Fernandes, M. I., de Assis, M. R., Toscano, M. A. F., Silva, M. B. G., Dorio, M., Barreto-Neto, N., de Cássia Corrêa Miguel, R., Antônio, S. F., Pinto, A. C. M. D., … Rocha, F. A. C. (2026). 2025 Recommendations of the Brazilian society of Rheumatology for the non-pharmacological treatment of knee osteoarthritis. Advances in Rheumatology. https://doi.org/10.1186/s42358-026-00582-8

Image Credits: AI Generated

DOI: 10.1186/s42358-026-00582-8

Keywords: knee osteoarthritis, clinical guideline, Brazilian Society of Rheumatology, non-pharmacological treatment, exercise therapy, orthoses, insoles, therapeutic ultrasound, systematic review, Delphi process, rehabilitation, pain management