Barriers to Adherence to Clinical Practice Guidelines in the Non-Surgical Management of Knee Osteoarthritis among Older Adults: A Systematic Review

Abstract

Knee osteoarthritis (KOA) is a leading cause of pain, disability, and reduced independence among older adults. Although clinical practice guidelines consistently recommend education, structured exercise, weight management, and other non-surgical strategies as first-line care, implementation remains inconsistent. This systematic review identified and synthesised barriers to adherence with guidelines for non-surgical KOA management among adults aged 60 years and older. Guided by a pre-specified protocol and PRISMA reporting principles, searches were conducted in PubMed/MEDLINE, CINAHL, Embase, and Web of Science from database inception to December 2025. Eligible studies examined factors limiting guideline-concordant care. Two reviewers independently screened records, extracted data, and mapped barriers to the Theoretical Domains Framework, followed by narrative synthesis. Twenty-two studies were included. Barriers were concentrated in four areas: limited clinician knowledge and skills; beliefs and expectations regarding exercise, weight management, passive care, or surgery; social and professional influences, including inconsistent interdisciplinary messages; and environmental constraints, such as brief consultations, fragmented referral pathways, limited allied health access, and reimbursement barriers. Findings indicate that guideline adherence is shaped by interacting clinician, patient, professional, and system-level factors. Effective implementation requires integrated educational, behavioural, and service-redesign strategies tailored to older adults.