Obesity

Telling someone with knee osteoarthritis and a high body weight to walk more addresses neither the joint pain that makes walking hurt nor the deconditioning that makes it exhausting. The advice is correct in principle and unusable in practice.

A programme that works starts from what the person can currently do without pain, and builds load in a form the joints tolerate.

Aquatic exercise and anti-gravity treadmill work, both of which reduce joint load substantially and allow real conditioning to start. Progressive resistance training, which preserves muscle during weight loss and is the part most often omitted.

Dietetic assessment and a realistic eating plan. Management of the specific musculoskeletal problems — knee and hip osteoarthritis, back pain, plantar heel pain — that are limiting activity.

Weight loss removes lean mass as well as fat. In a trial in older adults with obesity who were dieting, those who also did resistance training lost 2 to 3% of their lean mass, against 5% with aerobic exercise alone, and gained more strength 2.

This is why we measure body composition and functional capacity rather than weight alone, and why the strength component is not optional.

We do not offer rapid weight loss protocols, meal replacement programmes sold as medical treatment, or any intervention promising a specific weekly loss. Those are not rehabilitation.

Where bariatric surgery or medical weight management is appropriate, that is a separate medical pathway and rehabilitation supports it rather than competing with it.

Exercise advice that ignores painful knees fails quickly, and weight advice that ignores the mechanical limitation fails just as reliably.

The programme starts with modalities that work under load — water, seated and supported work, gradual progression — so that activity becomes possible before it becomes effective.

Medicines such as semaglutide and tirzepatide produce larger weight losses than lifestyle change alone, and part of what is lost is muscle 3. A 2026 systematic review of 35 trials found that a median of about 28% of the weight lost on these medicines came from lean or muscle tissue, above the expected level in about two thirds of the trials; none of the trials measured physical function objectively 3. Muscle loss beyond the expected level was also seen with weight loss from diet and lifestyle alone 3.

That makes the rehabilitation side more important, not less. Resistance training reduces the muscle lost during weight loss 2. It is therefore built in from the start, protein intake is reviewed by the dietitian, and strength and body composition are measured along the way rather than weight alone. Decisions about the medicine itself stay with the prescribing physician.