Article By Jo Everill-Taylor B.Sc

With the ever increasing number of chronic illnesses in the UK the benefits of exercise in disease prevention and rehabilitation has become more and more popular.

This has opened up opportunities for exercise professionals to enter into a dynamic and rewarding field.

Government initiatives such as the National Service Framework for coronary heart disease and the National Quality Assurance Framework (NQAF) for exercise referral has boosted the credibility of exercise referral as a real and necessary branch of disease control.

The impact of this for trainers is that the people you train can present with many conditions and or co-morbidities such as postural dysfunctions, neurological conditions, orthopaedic irregularities, through to obesity and coronary heart disease.

Whatever the condition that the client/patient is referred to you for, they all have one thing in common – the need for a trained professional to design a safe and effective exercise programme for the client/patient.

Medical Conditions and Related Exercise Benefits and Implications

Musculoskeletal Conditions












  •  (OA) is the most common type of arthritis.
  • knees, the hips, hands, feet, and spine.
  • risk increases with age.
  • “tear, flare and repair”
  • By the age of 65, around 50% of people have OA in one or more of their joints, and around 10% have some disability caused by it.
  • 6 million working days lost annually
  • Cost to health service £5.2 billion (82,000 knee replacements in 2010)
  • Cartilage becomes thinner and softer, and shows signs of pitting and roughening. It may split in places.
  • Osteophytes: Surface forms too much new bone. Outgrowths called spurs. These bone spurs can change the shape of joints, which means they can’t move so well.

“Exercise Improves Balance in Older Adults with Knee Osteoarthritis”

More evidence that exercise improves balance: Researchers at Wake Forest University and the University of Tennessee tested 103 adults over age 59 to see if regular, long-term exercise improves balance in seniors with knee osteoarthritis.

Subjects were divided into three groups. The aerobic exercise group walked at 50 percent to 85 percent of heart-rate reserve for 40 minutes at a time, interspersed with short rest periods if necessary, three days a week.

The weight-training group lifted free weights three days per week. They performed two sets of 10 to 12 reps of nine different exercises to strengthen both the lower and upper body.

The control group attended health education classes.

Subjects exercised under supervision for the first three months, then continued on their own for 15 more months, with regular follow-up calls to keep them on track.

Both aerobic walking and weight training significantly improved postural stability compared to the control group, whose balance deteriorated over the year and a half.

When subjects stood with their eyes closed, weight trainers swayed the least. When standing on one leg with their eyes open, walkers were able to balance the longest.

Source: Journal of the American Geriatrics Society, 2000; 48, 2, 131-138

Spondylosis (Spinal











  • structure of the intervertebral discs may be compromised.
  • The anulus fibrosus (e.g. tyre-like) is composed of 60 or more concentric bands of collagen fibre termed lamellae.
  • ‘tyre tread’ or wear or tear.
  • Facet joint degeneration causes loss of cartilage and formation of osteophytes
  • Headaches at the back of head may develop and some patients report a loss of balance.
  • Sitting and activities associated with manual labour (repetitive movements) may aggravate pain












Rheumatoid Arthritis












  • Rheumatoid Arthritis is a systemic auto-immune disease and affects everyone in different ways.
  • It can affect the whole body and internal organs. 
  • Affects 0.8% of the UK adult population.
  • Affects approximately 3 times more women than men and onset is generally between 40 – 60 years of age although you can get the disease at any age.
  • There are around 12,000 children under the age of 16 with the juvenile form of the disease.
  • Any joint may be affected but it is commonly the hands, feet and wrists.

Exercise Programming

  • Programme to improve joint stability.
  • Focus on technique and that all mvts are controlled>high risk of injury from de-conditioned muscles and poorly supported joints.
  • Be alert to the seat position on equipment and the angle of the joint during exercise.
  • Consider ease of getting on and off studio equipment
  • Clients should always be within the limitations of their pain threshold


  • Avoid loading the affected joint
  • Range of movement may be affected, never force the ROM of OA joints.
  • Do not encourage exercise of the affected joint on flare up days, except mobilisation/flexibility.
  • Avoid ballistic mvts.
  • Avoid high repetition

Prolapsed Disc










  • Commonly called a ‘slipped disc
  • Part of the inner softer part of the disc, the nucleus pulposus, herniates out through the annulus fibrosis.
  • Lumbar disk herniation occurs 15 times more often than cervical (neck) disk herniation, and it is one of the most common causes of lower back pain
  • Most common in L4/5 AND L5/S1
  • A prolapsed disc is sometimes called a herniated disc.
  • The bulging disc may press on nearby structures such as a nerve coming from the spinal cord.
  • Some inflammation also develops around the prolapsed part of the disc.
  • Disk herniation occurs more frequently in middle aged and older men, especially those involved in strenuous physical activity
  • Most cases of back pain are classed as ‘simple low back pain‘.
  • Caused by a minor problem to a muscle, ligament, or other structure in the back. For example, a strained muscle.

Exercise Prescription

  • Mobility
  • Improve core stability to support lumbar spine









  • Osteoporosis is said to exist when loss of bone density reaches a point where fracture is a possibility
  • Osteopenia is the term used when bone density has started to reduce and is a precursor to full-blown osteoporosis
  • One in two women and one in five men over the age of 50 in the UK will break a bone, mainly because of osteoporosis.
  • Most common sites for fractures are wrist, hip and spine.
  • After 40 years of age – atrophy
  • Mass shrinks – 70% of size in old age
  • Sharp decline in bone density – menopause
  • Less sharp decline in men
  • Women – lose 1% per year > 35 yrs
  • Onset of menopause 2 – 4% for 4-5 yrs

Exercise Prescription for Prevention of Osteoporosis

  • Bone loading: Can be as simple as walking!
  • weight-bearing exercise, either body weight or hand weights.
  • ACMS recommends best results with clients progressing to relatively high weights and fewer repetitions(75% 1RM)
  • Postural exercises to prevent rounding of shoulders and upper back.

 Exercise Prescription for the Osteoporotic Client

  • Postural work for shoulders/upper back
  • Stretch/open up the chest and neck muscles
  • Adapt mat work to suit the client
  • Include spinal extension work
  • Include mobility work
  • Include balance work to prevent falls
  • Include strength training for both upper and lower body to maximise benefits
  • Stretch hip flexors

Contraindications for Osteoporotic Clients

  • Avoid spinal flexion, rotation and lateral flexion
  • Avoid placing the wrists under pressure
  • Avoid working on uneven surfaces
  • Avoid spinal compression
  • Avoid hip abduction
  • Avoid high impact activities/ballistic movement
  • Avoid standing on 1 leg for any length of time-places vulnerable hips at risk.
  • Another cause of low bone density hip fracture is turning on a planted foot. Clients should be educated about turning their feet with the body when they change directions in standing.


Forward flexion causes excessive compression force on the anterior (or front) surface of the vertebral bodies, where most of the trabecular bone is located. In those with low bone density of the spine, the weakened bone cannot withstand such force and fractures may—or will—occur.

Compression forces on the vertebrae are also excessive during side-bending of the thoracic and upper-lumbar spine.

Forward flexion, side-bending and— especially—forward flexion combined with rotation are therefore contraindicated for clients with osteoporosis—and hence for clients with osteopenia.

Spinal extension is a different story. The posterior surface of the vertebral bodies contains the pars interarticularis, the pedicals and the lamina, which have a higher composition of cortical bone and are at less risk for fracture. These areas do get compressed as the spine moves into extension, but the movement is much less risky than flexion because of the strength of cortical bone.

Research studies show that people with stronger back extensor muscles had higher bone density in their spines (Sinaki et al.1986).

Another found that strong back extensors correlated with fewer vertebral fractures and increased bone mineral density (Sinaki et al. 1996 & 2002).

The problem is that clients intuitively avoid spinal extension because of the “bone on bone” feeling at the end range during back arching.

They tend to like flexion because it feels soft owing to the cushioning of the disks.

 So avoid flexion, improve extension!

Pilates Exercise Prescription for Osteoporosis

Example exercise session for those suffering from OP. Planned to avoid spinal flexion, spinal rotation and side leg abduction. Keep back neutral for supine abdominal work.

Prep Phase: Gentle standing mobilisation moves and balance work:

  • Rocking forwards and back- laughing policeman
  • Toy soldier (shoulder mobiliser)
  • V-stretch (chest opener)
  • Knee and hip mobiliser ( such as monkey squat)
  • Shoulder shrugs
  • Toe taps, semis circles
  • Standing hamstring stretch
  • Controlled sit down- not rolling so no spinal flexion.

Main phase: Go to the floor safely using side of body or hinge down with hands for support

1) Finding neutral, heel slides   










Use these to check for a neutral alignment and the ability to switch on core muscles to hold the back in position.

2) Shoulder blade retraction into mat   








To encourage proper posture throughout the day. Squeeze shoulder blades into the mat beneath you.

3) Adapted 100








Head must stay on the floor to avoid spinal flexion

Focus on ribs to hips feeling of stability with abs drawn down

Legs can go lower/straight as strength and control improves.

4) Adapted Shoulder Bridge        









Rather than using this for spinal segmentation, use it to activate the buttocks. Ensure the back stays flat and the hips hinge up to the ceiling. Extra challenges to pelvic stability can be added in with leg extensions (ships mast).

5) Adapted single leg stretch   









Head must stay on the floor to avoid spinal flexion

Focus on ribs to hips feeling of compression with abs drawn down

Legs can go lower as strength and control improves.

6) Modified clam stretch 










This is a fantastic chest opener which is really important for this group of clients, but you must not go over too far or there is spinal rotation. You can add a band to work upper back muscles. Remember to do both sides.

You could do “swimming” in between to add a nice transition.

7) Swimming prep and full 









This can be split into upper or lower body only depending upon the desired outcome of the session. Ensure abs are still drawn in, and extension is controlled.

8) Side Leg Series   









The focus should be on the drawing up and in of the top leg to fire the obliques and lower back strengtheners. Consider a combination of kicks forwards and back as well as small circles. Do not lift top leg up and down to avoid abduction which is contraindicated. Head can be supported on a block/towel. Do not put too much pressure on the wrists. Lift lower leg too to work inner thigh and challenge stability.

9) Leg circles into adapted scissors (use band to support leg)










These must stay small to avoid leg abduction. The leg can be bent at the knee to aid stability/control.

The leg should go lightly down to the floor and back in giving a hamstring stretch too. Ensure the pelvis stays in neutral. A resistance band will give support and an extra workload on the downward phase.

10) All 4’s abdominal hollowing/Pointer variations

11) Leg Pull/Shoulder Stability

From here come up to standing carefully by transferring on to the knees so as to avoid spinal flexion. Add in kneeling or standing hip flexor stretch.

Manual Resistance Ideas for OA/RA

 Manual Resistance is an alternative to the more conventional forms of resistance in the strength training program.

  • The resistance is provided by a training partner, or spotter, rather than a bar or a machine.
  • This style of training could be incorporated into your regular workouts or in situations where no equipment and/or facilities are available.
  • By using manual resistance, the spotter can adjust the amount of resistance applied to compensate for the lifter’s level of fatigue. 
  • The spotter, in conjunction with the lifter, can also control the speed of the movement.  
  • This form of training can be an incredibly valuable asset when working with exercise referral clients.
  • You can work around any injury by providing the resistance at different angles and with different hand positions.
  • Caution must be used if there is a history of high bold pressure- isometric contraction.

 Why not book now for your exercise referral diploma and learn more about exercising for controlled conditions.  Alternatively, you may like to qualify in Pilates Therapy.