ec077ab43f914fa3ee317e6d4b5e01f2 jcm-15-03047.pdf 0881aec769c7e1df97e19ad8b4f6b48065a4980c jcm-15-03047.pdf 8a6a6372b5da196af79419c6317be29865003480afbfb9161589c65708330a4f jcm-15-03047.pdf Title: From Real-World Practice to an Ideal Rehabilitation Pathway in Osteoarthritis: A Delphi Consensus on Patient Itineraries Subject: Background: Care for knee osteoarthritis (KOA) is frequently fragmented, and pathway-level decisions within Physical Medicine and Rehabilitation (PM&R) are influenced by local organizations. The objective of this study was to identify areas of agreement and disagreement among PM&R experts and to translate these into a clinically interpretable, function-oriented care pathway for knee osteoarthritis (KOA) within rehabilitation services. Methods: A two-round Real-Time Delphi study was conducted using the SmartDelphi web platform. A steering committee of five PM&R physicians developed a 37-item questionnaire covering referral/access, functional and outcome assessment, conservative management, escalation/referral thresholds, and follow-up/discharge. Round 1 was online (SERMEF osteoarthritis working group; 46 invited, 40 completed; 87.0%) with responses collected until 30 April 2025. Round 2 was an in-person, facilitated validation round on 30 May 2025 at the SERMEF Congress (A Coruña; 85 invited, 70 completed; 82.4%). Items were rated on a 6-point Likert scale; consensus strength was defined by interquartile range (IQR): strong (0–1) vs. weak (2). No patient-level data were collected; participant characteristics were comparable across rounds, suggesting consensus refinement reflected deliberation rather than panel shifts over time. Results: Consensus supported a longitudinal, function-first pathway that was structured into five phases: entry/referral to PM&R; comprehensive functional assessment using a minimum outcomes dataset (pain VAS/NRS, WOMAC function, quality-of-life scale); multimodal conservative rehabilitation combining exercise/physiotherapy, education/self-management support, and indicated oral/topical therapies; reassessment-guided escalation in non-responders, reserving interventional PM&R techniques, multidisciplinary musculoskeletal pain-unit management, or orthopedic evaluation for persistent pain and/or functional limitation; and longitudinal monitoring with defined discharge criteria. Conclusions: SERMEF PM&R experts converged on an implementation-oriented, outcomes-driven KOA itinerary centred on functioning, conservative multimodal care, structured reassessment, and explicit discharge planning. Keywords: knee osteoarthritis; physical medicine and rehabilitation; Delphi consensus; real-time Delphi; care pathway; rehabilitation itinerary Author: Helena Bascuñana-Ambrós, Alex Trejo-Omeñaca, Carlos Cordero-García, Sergio Fuertes-González, Juan Ignacio Castillo-Martín, Michelle Catta-Preta, Jan Ferrer-Picó, Josep Maria Monguet-Fierro and Jacobo Formigo-Couceiro Creator: LaTeX with hyperref Producer: pdfTeX-1.40.25; modified using OpenPDF 1.4.2 CreationDate: Thu Apr 16 13:24:46 2026 CEST ModDate: Thu Apr 16 13:28:58 2026 CEST Custom Metadata: yes Metadata Stream: no Tagged: no UserProperties: no Suspects: no Form: none JavaScript: no Pages: 17 Encrypted: no Page size: 595.276 x 841.89 pts (A4) Page rot: 0 File size: 2952961 bytes Optimized: no PDF version: 1.7 name type encoding emb sub uni object ID ------------------------------------ ----------------- ---------------- --- --- --- --------- CEUWMR+URWPalladioL-Ital Type 1 Custom yes yes yes 175 0 PDTLUH+CMSY10 Type 1 Builtin yes yes yes 176 0 PLBZEP+URWPalladioL-Bold Type 1 Custom yes yes yes 177 0 PLOLAK+VnURWPalladioL Type 1 Custom yes yes yes 178 0 URQNHI+URWPalladioL-Roma Type 1 Custom yes yes yes 179 0 OOCCKM+PalatinoLinotype-Italic CID TrueType Identity-H yes yes yes 232 0 OOCCHL+PalatinoLinotype-Bold CID TrueType Identity-H yes yes yes 233 0 OOCCHM+PalatinoLinotype-Roman CID TrueType Identity-H yes yes yes 234 0 OOCCKM+PalatinoLinotype-Italic CID TrueType Identity-H yes yes yes 264 0 OOCCHL+PalatinoLinotype-Bold CID TrueType Identity-H yes yes yes 265 0 OOCCHM+PalatinoLinotype-Roman CID TrueType Identity-H yes yes yes 266 0 PDXFNG+PazoMath-Bold Type 1 Builtin yes yes yes 308 0 OOCCKM+PalatinoLinotype-Italic CID TrueType Identity-H yes yes yes 318 0 OOCCHL+PalatinoLinotype-Bold CID TrueType Identity-H yes yes yes 319 0 OOCCHM+PalatinoLinotype-Roman CID TrueType Identity-H yes yes yes 320 0 OOCCKM+PalatinoLinotype-Italic CID TrueType Identity-H yes yes yes 363 0 OOCCHL+PalatinoLinotype-Bold CID TrueType Identity-H yes yes yes 364 0 OOCCHM+PalatinoLinotype-Roman CID TrueType Identity-H yes yes yes 365 0 Jhove (Rel. 1.28.0, 2023-05-18) Date: 2026-05-06 03:07:55 CEST RepresentationInformation: jcm-15-03047.pdf ReportingModule: PDF-hul, Rel. 1.12.4 (2023-03-16) LastModified: 2026-05-05 13:02:24 CEST Size: 2952961 Format: PDF Version: 1.7 Status: Well-Formed and valid SignatureMatches: PDF-hul MIMEtype: application/pdf PDFMetadata: Objects: 505 FreeObjects: 1 IncrementalUpdates: 0 DocumentCatalog: ViewerPreferences: HideToolbar: false HideMenubar: false HideWindowUI: false FitWindow: true CenterWindow: false DisplayDocTitle: false NonFullScreenPageMode: UseNone Direction: L2R ViewArea: CropBox ViewClip: CropBox PrintArea: CropBox PageClip: CropBox PageLayout: SinglePage PageMode: UseNone Outlines: Item: Title: Introduction Item: Title: Materials and Methods Children: Item: Title: Study Design and Digital Platform Item: Title: Questionnaire Development Item: Title: Participants, Eligibility, and Recruitment Item: Title: Delphi Procedure and Rating Scale Item: Title: Data Collection Item: Title: Consensus Criteria Item: Title: Statistical Analysis Item: Title: Ethical and Data Protection Considerations Item: Title: Results Children: Item: Title: Delphi Participants Rounds 1 and 2 Item: Title: Construction of the Function-Oriented KOA Rehabilitation Pathway Children: Item: Title: Entry and Referral Phase Item: Title: Comprehensive Functional Assessment Phase Item: Title: Structured Conservative Intervention Phase Item: Title: Escalation and Interventional Decision-Making Phase Item: Title: Longitudinal Monitoring and Discharge Planning Phase Item: Title: Mapping of Delphi Consensus Statements to the Rehabilitation Pathway Model Item: Title: Stability of Responses Across Rounds Item: Title: Discussion Children: Item: Title: Function-First Framing and Measurement Strategy Item: Title: Conservative Multimodal Care as the Backbone Item: Title: Escalation and Interventional Positioning Item: Title: Service Configuration, Referral Routes, and Multidisciplinary Models Item: Title: Discharge Criteria and Longitudinal Follow-Up as Quality Levers Item: Title: Implications for Implementation Item: Title: Strengths and Limitations Item: Title: Future Directions Item: Title: Conclusions Item: Title: References Info: Title: From Real-World Practice to an Ideal Rehabilitation Pathway in Osteoarthritis: A Delphi Consensus on Patient Itineraries Author: Helena Bascuñana-Ambrós, Alex Trejo-Omeñaca, Carlos Cordero-García, Sergio Fuertes-González, Juan Ignacio Castillo-Martín, Michelle Catta-Preta, Jan Ferrer-Picó, Josep Maria Monguet-Fierro and Jacobo Formigo-Couceiro Subject: Background: Care for knee osteoarthritis (KOA) is frequently fragmented, and pathway-level decisions within Physical Medicine and Rehabilitation (PM&R) are influenced by local organizations. The objective of this study was to identify areas of agreement and disagreement among PM&R experts and to translate these into a clinically interpretable, function-oriented care pathway for knee osteoarthritis (KOA) within rehabilitation services. Methods: A two-round Real-Time Delphi study was conducted using the SmartDelphi web platform. A steering committee of five PM&R physicians developed a 37-item questionnaire covering referral/access, functional and outcome assessment, conservative management, escalation/referral thresholds, and follow-up/discharge. Round 1 was online (SERMEF osteoarthritis working group; 46 invited, 40 completed; 87.0%) with responses collected until 30 April 2025. Round 2 was an in-person, facilitated validation round on 30 May 2025 at the SERMEF Congress (A Coruña; 85 invited, 70 completed; 82.4%). Items were rated on a 6-point Likert scale; consensus strength was defined by interquartile range (IQR): strong (0–1) vs. weak (2). No patient-level data were collected; participant characteristics were comparable across rounds, suggesting consensus refinement reflected deliberation rather than panel shifts over time. Results: Consensus supported a longitudinal, function-first pathway that was structured into five phases: entry/referral to PM&R; comprehensive functional assessment using a minimum outcomes dataset (pain VAS/NRS, WOMAC function, quality-of-life scale); multimodal conservative rehabilitation combining exercise/physiotherapy, education/self-management support, and indicated oral/topical therapies; reassessment-guided escalation in non-responders, reserving interventional PM&R techniques, multidisciplinary musculoskeletal pain-unit management, or orthopedic evaluation for persistent pain and/or functional limitation; and longitudinal monitoring with defined discharge criteria. Conclusions: SERMEF PM&R experts converged on an implementation-oriented, outcomes-driven KOA itinerary centred on functioning, conservative multimodal care, structured reassessment, and explicit discharge planning. Keywords: knee osteoarthritis; physical medicine and rehabilitation; Delphi consensus; real-time Delphi; care pathway; rehabilitation itinerary Creator: LaTeX with hyperref Producer: pdfTeX-1.40.25; modified using OpenPDF 1.4.2 CreationDate: Thu Apr 16 13:24:46 CEST 2026 ModDate: Thu Apr 16 13:28:58 CEST 2026 ID: 0xfec45c848b294d0bad0210ec649f25c7, 0x264c54be6a4457f711d967499fc34348 Filters: FilterPipeline: FlateDecode Fonts: Type1: Font: BaseFont: PDTLUH+CMSY10 FontSubset: true FirstChar: 21 LastChar: 21 FontDescriptor: FontName: PDTLUH+CMSY10 Flags: Symbolic FontBBox: -29, -960, 1116, 775 FontFile: true ToUnicode: true Font: BaseFont: PLBZEP+URWPalladioL-Bold FontSubset: true FirstChar: 3 LastChar: 243 FontDescriptor: FontName: PLBZEP+URWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true ToUnicode: true Font: BaseFont: PLOLAK+VnURWPalladioL FontSubset: true FirstChar: 177 LastChar: 177 FontDescriptor: FontName: PLOLAK+VnURWPalladioL Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true ToUnicode: true Font: BaseFont: URQNHI+URWPalladioL-Roma FontSubset: true FirstChar: 2 LastChar: 250 FontDescriptor: FontName: URQNHI+URWPalladioL-Roma Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true ToUnicode: true Font: BaseFont: PDXFNG+PazoMath-Bold FontSubset: true FirstChar: 68 LastChar: 68 FontDescriptor: FontName: PDXFNG+PazoMath-Bold Flags: Symbolic FontBBox: -10, -266, 829, 695 FontFile: true ToUnicode: true Font: BaseFont: CEUWMR+URWPalladioL-Ital FontSubset: true FirstChar: 2 LastChar: 121 FontDescriptor: FontName: CEUWMR+URWPalladioL-Ital Flags: Symbolic FontBBox: -170, -305, 1010, 941 FontFile: true EncodingDictionary: Differences: true ToUnicode: true Pages: Page: Sequence: 1 Annotations: Annotation: Subtype: Link Rect: 34, 204, 124, 223 Annotation: Subtype: Link Rect: 88, 77, 152, 84 Annotation: Subtype: Link Rect: 34, 64, 119, 72 Annotation: Subtype: Link Rect: 34, 773, 179, 809 Annotation: Subtype: Link Rect: 515, 773, 560, 809 Annotation: Subtype: Link Rect: 178, 663, 189, 677 Annotation: Subtype: Link Rect: 305, 663, 316, 677 Annotation: Subtype: Link Rect: 435, 663, 446, 677 Annotation: Subtype: Link Rect: 426, 650, 437, 663 Annotation: Subtype: Link Rect: 183, 636, 194, 649 Annotation: Subtype: Link Rect: 357, 636, 369, 649 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 2 Annotations: Annotation: Subtype: Link Rect: 430, 579, 437, 588 ActionDest: 139 Annotation: Subtype: Link Rect: 375, 482, 382, 491 ActionDest: 139 Annotation: Subtype: Link Rect: 385, 482, 392, 491 ActionDest: 139 Annotation: Subtype: Link Rect: 513, 398, 519, 407 ActionDest: 139 Annotation: Subtype: Link Rect: 520, 398, 527, 407 ActionDest: 139 Annotation: Subtype: Link Rect: 193, 189, 200, 198 ActionDest: 139 Annotation: Subtype: Link Rect: 264, 173, 369, 185 Annotation: Subtype: Link Rect: 500, 175, 507, 184 ActionDest: 139 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 3 Annotations: Annotation: Subtype: Link Rect: 420, 681, 524, 693 Annotation: Subtype: Link Rect: 220, 642, 227, 651 ActionDest: 139 Annotation: Subtype: Link Rect: 274, 502, 281, 511 ActionDest: 139 Annotation: Subtype: Link Rect: 281, 502, 288, 511 ActionDest: 139 Annotation: Subtype: Link Rect: 553, 111, 560, 123 ActionDest: 28 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 4 Annotations: Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 5 Annotations: Annotation: Subtype: Link Rect: 217, 686, 224, 698 ActionDest: 33 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 6 Annotations: Annotation: Subtype: Link Rect: 276, 298, 283, 307 ActionDest: 46 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 7 Annotations: Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 8 Annotations: Annotation: Subtype: Link Rect: 254, 669, 261, 681 ActionDest: 63 Annotation: Subtype: Link Rect: 295, 669, 302, 681 ActionDest: 304 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 9 Annotations: Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 10 Annotations: Annotation: Subtype: Link Rect: 278, 711, 285, 723 ActionDest: 63 Annotation: Subtype: Link Rect: 514, 601, 521, 613 ActionDest: 63 Annotation: Subtype: Link Rect: 486, 393, 493, 405 ActionDest: 63 Annotation: Subtype: Link Rect: 376, 339, 383, 351 ActionDest: 63 Annotation: Subtype: Link Rect: 274, 243, 281, 255 ActionDest: 63 Annotation: Subtype: Link Rect: 194, 117, 201, 129 ActionDest: 63 Annotation: Subtype: Link Rect: 235, 117, 242, 129 ActionDest: 304 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 11 Annotations: Annotation: Subtype: Link Rect: 427, 463, 434, 475 ActionDest: 305 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 12 Annotations: Annotation: Subtype: Link Rect: 216, 714, 223, 726 ActionDest: 92 Annotation: Subtype: Link Rect: 317, 90, 324, 99 ActionDest: 139 Annotation: Subtype: Link Rect: 324, 90, 331, 99 ActionDest: 139 Annotation: Subtype: Link Rect: 332, 90, 344, 99 ActionDest: 396 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 13 Annotations: Annotation: Subtype: Link Rect: 288, 658, 295, 667 ActionDest: 139 Annotation: Subtype: Link Rect: 296, 658, 308, 667 ActionDest: 396 Annotation: Subtype: Link Rect: 308, 658, 320, 667 ActionDest: 396 Annotation: Subtype: Link Rect: 291, 574, 303, 583 ActionDest: 396 Annotation: Subtype: Link Rect: 304, 574, 316, 583 ActionDest: 396 Annotation: Subtype: Link Rect: 277, 505, 289, 514 ActionDest: 396 Annotation: Subtype: Link Rect: 426, 395, 433, 404 ActionDest: 139 Annotation: Subtype: Link Rect: 433, 395, 445, 404 ActionDest: 396 Annotation: Subtype: Link Rect: 446, 395, 458, 404 ActionDest: 396 Annotation: Subtype: Link Rect: 295, 311, 307, 320 ActionDest: 396 Annotation: Subtype: Link Rect: 307, 311, 319, 320 ActionDest: 396 Annotation: Subtype: Link Rect: 476, 201, 483, 210 ActionDest: 139 Annotation: Subtype: Link Rect: 484, 201, 495, 210 ActionDest: 396 Annotation: Subtype: Link Rect: 496, 201, 508, 210 ActionDest: 396 Annotation: Subtype: Link Rect: 210, 77, 216, 86 ActionDest: 139 Annotation: Subtype: Link Rect: 217, 77, 229, 86 ActionDest: 396 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 14 Annotations: Annotation: Subtype: Link Rect: 401, 717, 413, 726 ActionDest: 396 Annotation: Subtype: Link Rect: 524, 606, 531, 616 ActionDest: 139 Annotation: Subtype: Link Rect: 531, 606, 543, 616 ActionDest: 396 Annotation: Subtype: Link Rect: 544, 607, 556, 616 ActionDest: 396 Annotation: Subtype: Link Rect: 240, 469, 247, 478 ActionDest: 139 Annotation: Subtype: Link Rect: 247, 468, 254, 478 ActionDest: 139 Annotation: Subtype: Link Rect: 255, 469, 266, 478 ActionDest: 396 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 15 Annotations: Annotation: Subtype: Link Rect: 366, 686, 378, 695 ActionDest: 396 Annotation: Subtype: Link Rect: 378, 686, 390, 695 ActionDest: 396 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 16 Annotations: Annotation: Subtype: Link Rect: 519, 332, 557, 343 Annotation: Subtype: Link Rect: 59, 320, 95, 330 Annotation: Subtype: Link Rect: 256, 281, 294, 292 Annotation: Subtype: Link Rect: 210, 244, 247, 254 Annotation: Subtype: Link Rect: 253, 244, 289, 254 Annotation: Subtype: Link Rect: 329, 179, 367, 190 Annotation: Subtype: Link Rect: 373, 179, 409, 190 Annotation: Subtype: Link Rect: 197, 128, 235, 139 Annotation: Subtype: Link Rect: 150, 103, 188, 113 Annotation: Subtype: Link Rect: 333, 77, 371, 88 Annotation: Subtype: Link Rect: 377, 77, 413, 88 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Page: Sequence: 17 Annotations: Annotation: Subtype: Link Rect: 59, 731, 96, 742 Annotation: Subtype: Link Rect: 102, 731, 138, 742 Annotation: Subtype: Link Rect: 519, 705, 557, 716 Annotation: Subtype: Link Rect: 59, 693, 95, 703 Annotation: Subtype: Link Rect: 418, 667, 456, 678 Annotation: Subtype: Link Rect: 462, 667, 498, 678 Annotation: Subtype: Link Rect: 59, 616, 96, 627 Annotation: Subtype: Link Rect: 102, 616, 138, 627 Annotation: Subtype: Link Rect: 59, 578, 96, 588 Annotation: Subtype: Link Rect: 102, 578, 138, 588 Annotation: Subtype: Link Rect: 211, 552, 249, 563 Annotation: Subtype: Link Rect: 255, 552, 291, 563 Annotation: Subtype: Link Rect: 371, 526, 407, 537 Annotation: Subtype: Link Rect: 59, 489, 96, 499 Annotation: Subtype: Link Rect: 102, 489, 138, 499 Annotation: Subtype: Link Rect: 478, 450, 515, 461 Annotation: Subtype: Link Rect: 521, 450, 557, 461 Annotation: Subtype: Link Rect: 237, 411, 275, 422 Annotation: Subtype: Link Rect: 423, 27, 560, 37 Checksum: 8fd8ad89 Type: CRC32 Checksum: ec077ab43f914fa3ee317e6d4b5e01f2 Type: MD5 Checksum: 0881aec769c7e1df97e19ad8b4f6b48065a4980c Type: SHA-1 Checksum: 8a6a6372b5da196af79419c6317be29865003480afbfb9161589c65708330a4f Type: SHA-256