Evidence-to-Recommendation Framework for 2026 ACE Clinical Guideline on the management of knee osteoarthritis — a joint effort with patients

ABSTRACT: This Evidence-to-Recommendation (EtR) framework underpins the ACE Clinical Guideline (ACG) for the management of knee osteoarthritis (OA), providing rationale and justifications for its recommendations. Knee OA is a prevalent and debilitating condition in Singapore, with significant disease burden and impacts on healthcare utilisation costs. The ACG addresses management gaps that contribute to suboptimal clinical outcomes, including insufficient uptake of conservative management, limited knowledge of community exercise and physiotherapist resources, and inappropriate use of complementary and alternative treatments. The Grading of Recommendations Assessment, Development and Evaluation framework was followed to develop seven evidence-based recommendations that cover comprehensive biopsychosocial assessments, mainstay management strategies, pharmacological treatment, referral to allied health professionals, complementary and alternative treatment, and specialist referrals. This EtR framework summarises the factors that have informed the direction and strength of the ACG recommendations, including balance of benefits and risks, certainty of evidence, patient preferences and values, resources and feasibility considerations, and acceptability.