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Good Life with OsteoArthritis in Denmark Programme

Original Editor - User:Céline Gueissaz

Top Contributors - Céline Gueissaz, Vidya Acharya and Alexandra Stead  

Introduction

Good Life with OsteoArthritis in Denmark (GLA:D®) is a international, not-for-profit and evidence-based initiative first established in Denmark in 2013.[1] [2] It combines neuromuscular exercise with patient education to translate osteoarthritis (OA) guidelines into routine clinical practice.[1]

The programme initially targeted people suffering from hip and knee OA.[2] [3] Since then, driven by the success of the hip and knee programme,[2][3] GLA:D® back was also developed, targeting individuals with persistent or recurring low back pain (LBP).[3][4]

Evidence-Based Rationale for GLA:D®

GLA:D® Hip and Knee

For over twenty-five years, international guidelines on hip and knee OA,[5][6] supported by an overwhelming body of evidence,[1][5][6][7] continue to clearly define the appropriate framework for the management and treatment of these disorder.[1][6] Managing hip or knee OA should involve a tailored, multifaceted plan in which non-pharmacological treatments are the cornerstone of care.[5] Promoting exercise, patient education and weight management is still considered to be the first line of treatment for individuals with knee and hip OA.[1][5][6][7]

Despite this, guideline-recommended care remains largely underutilised. Indeed, a significant proportion of patients (up to 40%) are being referred for orthopaedic consultation or placed on joint replacement surgery waiting lists without ever having received first-line treatment.[7] As GLA:D® combines patient education with a structured and supervised exercise component, it appropriately answers to those guidelines by providing an individualised and evidence treatment plan for people suffering from hip and knee OA.[1][2]

GLA:D® Back

Similarly to hip and knee OA, established clinical guidelines place patient education and physical activity at the forefront of LBP management.[3][4][8][9] The recommendations also include:[9]

  • Understanding the nature and likely progression of back pain
  • Staying active and maintaining working life
  • Supervised exercise
  • Acupuncture and manual therapy, either as a standalone treatment or in combination with exercise
  • Avoiding routine imaging referrals and opioid prescribing
  • Surgical intervention reserved for a small number of cases meeting very specific criteria

Guideline recommendations are, however, often not implemented in clinical practice,[9][10] due to several challenges:[9]

  • Adopting new clinical procedures is inherently complex
  • Guidelines are typically produced without practical tools to support their uptake
  • No consistently effective strategies for embedding guidelines into routine care have been established

This results in inconsistent treatment, inefficient use of resources and potential harm to patients.[10]

The GLA:D® Back programme was built upon the existing GLA:D® hip and knee programme, this time targeting individuals with persistent (i.e. lasting three months or more) or recurring (i.e. repeated episodes) LBP.[3][4][9] It helps them develop personalised self-management strategies aligned with their own goals and capacities.[3][9][10] Recommendations were similarly translated into a structured intervention combining group-based patient education and supervised exercise.[3][10] This makes it an appropriate multi-modal approach aligned with the WHO recommendation for non-surgical management of LBP.[9][8][10]

Chart of low back pain interventions color-coded by WHO recommendation: green for conditional recommendation in favor of use, red for conditional recommendation against use, amber for good practice, grey for no recommendation, and white for insufficient evidence. Categories include education, physical, psychological, medicines, and multi-component interventions.
Classification of LBP interventions recommended by the WHO Guideline Development Group

International Implementation

Following the successful adoption of the programme beyond Denmark, the GLA:D® International Network was formally established in 2018.[2] The network has since grown steadily. The programme currently serves patients in the following countries:[11]

Programme Characteristics

The three core components of both GLA:D® programmes are:[2][3]

  • Physiotherapist training
  • Supervised patient education and exercise sessions spanning at least six weeks
  • National registry data collection

Physiotherapist Training

Physiotherapists wishing to deliver the GLA:D® programmes complete a two-day certification course covering:[1][9]

  • The evidence base for OA or LBP management and clinical guidelines
  • The practical aspects of programme delivery, including patient education, neuromuscular exercise supervision and use of the GLA:D® registry

Successful completion grants access to a comprehensive digital toolkit. This ensures consistent, guideline-based care regardless of clinical setting.[1] Additional treatments may be provided at the clinician's discretion, though these are not recorded in the registry.[1]

Programme Organisation

GLA:D® Hip and Knee

The programme consists of three core elements:[1][13][14]

  • Individual assessment sessions at the start and end of the programme
  • Two to three patient education sessions in the first two weeks
  • Twelve neuromuscular exercise sessions, conducted twice weekly over 6 weeks

Upon completion, patients are encouraged to maintain long-term physical activity, with personalised continuation strategies discussed at the three-month follow-up.[1]

[15]

GLA:D® Back

Diagram illustrating the core educational messages of the GLA:D Back programme, centred around a balance between capacity and demands. Key messages include: the back is made for movement, the back is strong, exercise strengthens the back, natural movements inhibit pain, bad posture and deformations are common, pain equals alarm but not harm, the brain can turn pain up and down, and action comes before improvement.
Core educational messages from the GLA:D® Back patient education sessions.

The GLA:D® Back programme mirrors the structure of the hip and knee programme, comprising:[3]

  • Individual assessment sessions at the start and end of the programme
  • Two group-based patient education sessions
  • Sixteen bi-weekly supervised group exercise sessions

The main difference from the hip and knee programme lies in the duration of the exercise component, which is of 8 weeks, two weeks more than GLA:D® Hip and Knee.[3]

Four progressive levels of lateral gluteal exercises from the GLA:D Back programme: Clam, Side step, Side leg lifting and Dynamic side plank.
A progression of lateral gluteal exercises shown across four levels of difficulty.

Data Collection

Data entry into the national registry is mandatory for both clinicians and patients, with outcomes collected at baseline, three and twelve months.[1][3][9]

Data is objectively measured, therapist-reported and patient-reported, covering:[1][3]

  • Pain
  • Pain medication
  • Function
  • Quality of life

The registry is continuously refined based on emerging evidence and feedback from both physiotherapists and patients. Individual results are accessible to clinicians and patients for benchmarking purposes.[1]

Registry data can furthermore be integrated with other databases, such as national registries, offering valuable opportunities to evaluate and improve clinical pathways.[1]

Indication

GLA:D® Hip and Knee

GLA:D® Hip and Knee is indicated for individuals presenting with:[1][14]

  • Knee and/or hip complaints
  • A resulting need to seek healthcare

GLA:D® Back

GLA:D® Back is aimed at individuals:

  • whose daily life and function are affected by persistent or recurring low back pain[9]
  • who would benefit from improved self-management skills[9]
  • with and without radiating leg pain[4]

Enrolment can be decided collaboratively between the clinician and patient. [9]

Clinical Evidence

GLA:D® Hip and Knee

A 2020 study with 28370 patients across Denmark, Canada and Australia found that the GLA:D® Hip and Knee produced substantial and consistent improvements in pain and physical function across all three countries.[13] No clinically relevant differences were observed between patients with hip and knee OA.[13]

From baseline to immediately after treatment, around 43–47% of participants achieved clinically significant pain relief.[13] Improvements were recorded in:[13]

  • Pain intensity (26–33%)
  • Walking speed (8–12%)
  • Chair stand performance (18–30%)
  • Joint-related quality of life (12–26%)

Those results are supported by other more recent studies. In a 2025 study conducted in Canada, GLA:D® demonstrated statistically significant improvements in pain, function and quality of life compared to usual care over 12 months.[16] However, these improvements remained below the minimally important change, which is the threshold for a difference that patients actually notice and value.[16]

Another observational and registry-based cohort study of individuals with knee OA from 2024 found that among participants initially reporting moderate to severe walking difficulties:[14]

  • Over half (51.4%) experienced minimal or no walking difficulty at three months (using the EuroQol 5-dimension 5-level walking item)
  • This improved further to 58.3% at twelve months

It is important to note that to date, all studies on GLA:D® are observational. They lack a randomised and controlled arm, meaning uncertainty remains as to whether improvements are specifically attributable to GLA:D® or to other uncontrolled factors.[13] [17] However, the fundamental parameters of GLA:D® are built upon countless RCTs on hip and knee OA. As Roos et al. argue, conducting further trials is unlikely to alter the established efficacy of exercise therapy for knee OA.[13] Instead, the focus must shift to implementing these findings in clinical practice.[13]

GLA:D® Back

Because GLA:D® can be considered as a relatively new intervention, studies specifically evaluating the programme are still lacking. GLA:D® Back is nonetheless framed around the education and structured exercise components.[4] This combination yielded clinically meaningful improvements in patients with chronic LBP following intervention.[18]

One 2023 observational study focused on people with non-specific LBP, with or without overlapping symptom of lumbar spinal stenosis (LSS), found that:[19]

  • Among the 655 participants included in the study, just over a quarter (28%) reported symptoms overlapping with LSS.
  • Disability: Over twelve months, disability scores improved in all participants regardless of lumbar spinal stenosis symptom status
  • Back pain intensity: Over twelve months, back pain intensity improved consistently irrespective of lumbar spinal stenosis symptom status
  • Leg pain intensity: leg pain intensity improved over time in both groups regardless of lumbar spinal stenosis symptom status, though those with overlapping symptoms reported worse leg pain at all time points (3-month, 6-month and 12-month follow-up)

Another GLA:D® registry study from 2024 in Denmark, with outcomes also measured at baseline, three, six and twelve month follow-up, found comparable results:[4]

  • Radiating leg pain was present in 45% of participants (1915 out of 4147)
  • The majority of participants in both groups had experienced LBP for over twelve months at baseline
  • Participants with LBP and leg pain presented with more indicators of poor prognosis compared to those with LBP alone (assessed with the STarT Back assessment tool and number of comorbid pain areas)
  • Despite this, both groups showed comparable improvements in pain intensity, disability and fear of movement
  • Improvements were most notable in the first three months and stabilised thereafter until twelve months
  • Neither group showed improvements in self-efficacy (measured by The Arthritis Self-Efficacy Scale)

Overall, these studies share the same limitation as those for GLA:D® Hip and Knee. Their large, real-world samples based on the programme's registry confer good external validity.[4][13] However, the lack of a control group compromises internal validity,[13] and results should therefore be interpreted with caution.

Implications

These findings hold significant value for rehabilitation professionals, health policy makers and future research.

For Clinical Practice

For the individual clinician, the primary practical implication is the ability to offer a structured, evidence-based programme that appropriately responds to current guidelines.[1][5][6][20] Moreover, the programme requires minimal infrastructure and can be implemented across a variety of settings, including existing outpatient clinics.[17]

For Health Service Delivery

From a healthcare policymaker standpoint, current evidence suggests a standardized treatment programme as GLA:D® can be successfully adapted to diverse populations and healthcare systems.[13]

Moreover, several studies demonstrated that GLA:D® Hip and Knee is cost-effective, supporting large-scale implementation in primary care.[14][17][21] [22] Particularly, one Canadian study estimated that providing the GLA:D® programme to people waiting for total joint replacement could save up to 8.5 million Canadian dollars just in the first year.[22] The authors concluded that publicly funding programmes such as GLA:D® for individuals awaiting total joint replacement consultation would:[22]

  • Reduce surgical rates
  • Improve equitable access to evidence-based care for OA
  • Generate net cost savings

It is also interesting to reflect on the potential economic benefits of GLA:D® related to OA diagnosis. Indeed, the use of routine imaging for knee and hip OA remains widespread and drives healthcare costs up.[23] However, recent guidelines reiterate that imaging should be avoided unless atypical features or signs of an alternative condition are present.[20] OA should only be diagnosed with clinical testing in patients:[20]

  • Aged 45 or older
  • Presenting with activity-related joint pain
  • Either no morning stiffness or stiffness lasting less than 30 minutes.

As physiotherapists delivering the GLA:D® programme acquire the necessary diagnostic skills during the two-day training, they are fully aligned with these guidelines.[1] This suggests that the programme offers broader health economic benefits beyond just treatment outcomes by reducing unnecessary imaging, although further studies are needed to verify this.

Limitations and Future Research

GLA:D® Back, with its dual pillars of patient education and structured exercise, is anchored in evidence-based practice.[4][9][18] Available results from programme evaluation are promising.[4][19] However, appropriate studies with high internal validity are still lacking to draw solid practical implications of both GLA:D® programmes for clinical practice.

One last important point to consider is that most available studies on GLA:D® involve authors who contributed to the development of GLA:D® Hip and Knee and Back. It is possible that the authors' high regard for the programme introduced bias in the interpretation of results. Accordingly, further research by diverse research teams would help to corroborate these promising results and reinforce the evidence base for clinical application.

Summary

GLA:D® is an evidence-based not-for-profit initiative that originated in Denmark and is currently running in ten countries worldwide. The original programme targeted people with hip and knee OA, with the goal of bridging clinical guidelines and everyday practice. Indeed, many patients are still being referred for invasive procedures without ever having been offered first-line treatments. GLA:D® Back was subsequently developed with the same rationale and overarching structure targeting people with persistent or recurrent LBP. Despite being anchored in evidence-based practice studies evaluating the two programmes remain observational and limited. Results should therefore be interpreted with caution. Nevertheless, findings are promising in terms of clinical outcomes and suggest that programmes such as GLA:D® could play a meaningful role in transforming care delivery for patients with OA and LBP. These findings are of relevance not only to clinicians but also to healthcare policymakers seeking sustainable and cost-effective solutions for conditions that place a significant burden on individuals and healthcare systems alike.

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 Skou ST, Roos EM. Good Life with osteoArthritis in Denmark (GLA: D™): evidence-based education and supervised neuromuscular exercise delivered by certified physiotherapists nationwide. BMC musculoskeletal disorders. 2017 Feb 7;18(1):72.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 GLA:D International. Good Life with osteoArthritis in Denmark [Internet]. GLA:D International; n.d. [cited 2026 May 11]. Available from: https://gladinternational.org/
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Kjaer P, Kongsted A, Ris I, Abbott A, Rasmussen CD, Roos EM, Skou ST, Andersen TE, Hartvigsen J. GLA: D® Back group-based patient education integrated with exercises to support self-management of back pain-development, theories and scientific evidence. BMC musculoskeletal disorders. 2018 Nov 29;19(1):418.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Khorami AK, Chiarotto A, Kongsted A, Hartvigsen J, Koes BW. Characteristics and outcomes of patients with low back pain with and without radiating leg pain following the GLA: D back program. Musculoskeletal Science and Practice. 2024 Oct 1;73:103144.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SM, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and cartilage. 2019 Nov 1;27(11):1578-89.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Moseng T, Vlieland TP, Battista S, Beckwée D, Boyadzhieva V, Conaghan PG, Costa D, Doherty M, Finney AG, Georgiev T, Gobbo M. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis: 2023 update. Annals of the rheumatic diseases. 2024 Jun 1;83(6):730-40.
  7. ↑ 7.0 7.1 7.2 Gibbs AJ, Gray B, Wallis JA, Taylor NF, Kemp JL, Hunter DJ, Barton CJ. Recommendations for the management of hip and knee osteoarthritis: a systematic review of clinical practice guidelines. Osteoarthritis and cartilage. 2023 Oct 1;31(10):1280-92.
  8. ↑ 8.0 8.1 World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. World Health Organization; 2023 Dec 7. Available at: https://www.who.int/publications/i/item/9789240081789
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 9.12 Kongsted A, Ris I, Kjaer P, Vach W, Morsø L, Hartvigsen J. GLA:D® Back: implementation of group-based patient education integrated with exercises to support self-management of back pain-protocol for a hybrid effectiveness-implementation study. BMC musculoskeletal disorders. 2019 Feb 18;20(1):85.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 Fernandez M, Young A, Kongsted A, Hartvigsen J, Barton C, Wallis J, Kent P, Kawchuk G, Jenkins H, Hancock M, French SD. GLA: D® Back Australia: a mixed methods feasibility study for implementation. Chiropractic & Manual Therapies. 2022 Apr 7;30(1):17.
  11. ↑ GLA:D International. International Programs [Internet]. n.d. [cited 2026 May 12]. Available from: https://gladinternational.org/home/international-programs/
  12. ↑ GLA:D Suomi [Internet]. 2025 [cited 2026 May 12].
  13. ↑ 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 Roos EM, Grønne DT, Skou ST, Zywiel MG, McGlasson R, Barton CJ, Kemp JL, Crossley KM, Davis AM. Immediate outcomes following the GLA:D® program in Denmark, Canada and Australia. A longitudinal analysis including 28,370 patients with symptomatic knee or hip osteoarthritis. Osteoarthritis and Cartilage. 2021 Apr 1;29(4):502-6.
  14. ↑ 14.0 14.1 14.2 14.3 King LK, Young JJ, Grønne DT, Bricca A, Roos EM, Skou ST, Hawker GA. GLA:D to be walking better: change in self-reported difficulty walking after exercise therapy and education in persons with knee osteoarthritis. The Journal of Rheumatology. 2024 Oct 1;51(10):1033-8.
  15. ↑ SquareOne Physiotherapy. GLA:D Program for Arthritis [Video]. YouTube; 2020 Jul 10. Available from: https://www.youtube.com/watch?v=W3Bya67iXWs
  16. ↑ 16.0 16.1 Mazzei DR, Whittaker JL, Faris P, Wasylak T, Marshall DA. Real‐world cost‐effectiveness of a standardized education and exercise therapy program for hip and knee osteoarthritis compared to usual care. Arthritis Care & Research. 2025 Jul 12;77(10):1194.
  17. ↑ 17.0 17.1 17.2 Health Quality Ontario. Structured education and neuromuscular exercise program for hip and/or knee osteoarthritis: a health technology assessment. Ontario health technology assessment series. 2018 Nov 2;18(8):1.
  18. ↑ 18.0 18.1 Ho EK, Chen L, Simic M, Ashton-James CE, Comachio J, Wang DX, Hayden JA, Ferreira ML, Ferreira PH. Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis. bmj. 2022 Mar 30;376.
  19. ↑ 19.0 19.1 Young JJ, Kongsted A, Hartvigsen J, Ammendolia C, Jensen RK. Similar improvements in patient-reported outcomes for non-specific low back pain patients with and without lumbar spinal stenosis symptoms following a structured education and exercise therapy program. BMC Musculoskeletal Disorders. 2023 Oct 25;24(1):839.
  20. ↑ 20.0 20.1 20.2 Wood G, Neilson J, Cottrell E, Hoole SP. Osteoarthritis in people over 16: diagnosis and management—updated summary of NICE guidance. Bmj. 2023 Jan 24;380.
  21. ↑ Grønne DT, Roos EM, Ibsen R, Kjellberg J, Skou ST. Cost-effectiveness of an 8-week supervised education and exercise therapy programme for knee and hip osteoarthritis: a pre–post analysis of 16 255 patients participating in good life with osteoArthritis in Denmark (GLA: D). BMJ open. 2021 Dec 1;11(12):e049541.
  22. ↑ 22.0 22.1 22.2 Mazzei DR, Whittaker JL, Faris P, Wasylak T, Marshall DA. Estimating Budget Impact and Joint Replacement Avoidance by Implementing a Standardized Education and Exercise Therapy Program for Hip and Knee Osteoarthritis in a Publicly Insured Health Care System. Arthritis Care & Research. 2025 Jun;77(6):744-52.
  23. ↑ Sherman SL, Gulbrandsen TR, Lewis HA, Gregory MH, Capito NM, Gray AD, Bal BS. Overuse of magnetic resonance imaging in the diagnosis and treatment of moderate to severe osteoarthritis. The Iowa orthopaedic journal. 2018;38:33.
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