Evolution of Pilates Part 2:Education, qualifications and efficacy
Dr Penelope Latey 2024
Cert Pilates(UK, USA), Dip Pilates Movement Therapy, MSc, PhD
Abstract
This paper is Part 2 of two on the evolution of Pilates. The scope of this discussion paper explores the development of various educational business and other stakeholders that have contributed to the diversification of Joseph Pilates ‘Controlology’ to the current landscape of Classical Pilates, Comprehensive, therapeutic, and clinical Pilates and gym/fitness large group Pilates. The pedagogical pathways supplied by Pilates teacher training businesses, levels of qualifications, accreditation bodies, professional associations are discussed.
The growing body of information on the positive effect of Pilates for managing some conditions and problems may be linked to modifications to the method, increasing consumer interest in Pilates and advertorials by training businesses. Research reports, Pilates provided by a comprehensively trained experienced instructor is the most effective intervention for chronic low back pain in reducing pain and improving function; more effective than physical exercise rehabilitation for improving functional mobility and balance for some neurological conditions; and has a greater effect than general exercise on balance and reducing the risk of falling in the older adult.
However, none of the positive findings on Pilates research for managing specific conditions or pathologies is likely to have efficacy or be safe when provided in a gym large group class setting or by Pilates instructors with only a mat or reformer certification, whatever other professional qualifications the provider may have. Distinguishing between levels of education, accreditation and skills of GymPilates, the complementary modality of comprehensive and therapeutic Pilates, and clinical Pilates that is part of a conventional health professions treatment toolbox provides consumers and stakeholders an accurate provision of service. These differences need to be recognisable for students, clinicians, consumers, public health funding bodies and private health insurance funds.
The Pilates profession(s) require accurate descriptors of provision of service, transparent independent regulation with improved consistent higher education, for safe ethical practice.
Key words: Pilates, mind-body exercise, rehabilitation, fitness, Allied Healthcare, Complementary Medicine, Education, and training.
1.1.1 The business of Pilates education
Some Pilates teacher training businesses offer both comprehensive courses to enable individuals to become Pilates teachers and courses specifically for registered allied health care workers, as well as short repertoire courses. Most offer remote and face to face learning, some course providers offer 100% online training [1, 2]. They may have their own training centres in numerous countries. Many align themselves with specific Pilates equipment manufacturers [3]. This commercial relationship may have contributed to the promotion of the group reformer gym Pilates classes, with little attention paid to the effect of using different spring resistance [4], or the inherent dangers of minimal supervision when using reformers in a large group setting.
One USA based business provides a range of Pilates courses internationally, with training for fitness instructors, independent Pilates teachers and allied health care workers [5]. Another international Pilates training business provides courses described as “clinical Pilates” offers a similar range of courses [1]. Both businesses offer comprehensive training that may take anywhere between a few weeks to up to a year to complete. They require theory assessments, online or pre-recorded or face-to face practical exams. They also offer short repertoire courses on mat and Pilates equipment.
A clinical Pilates educational business based in Australia provides courses only to allied health workers [6]. They use a “Movement Based Classification” system to assess the client for functional bias [7]. Kwok and colleagues suggest that clinical Pilates is a safe and effective way to manage low back pain [8] however they provide little evidence for the efficacy of this structural approach to Pilates. The duration of these courses are one to three weekends and participants are certified by the training provider.
Similarly, in the UK and Europe, various Pilates education providers also offer a range of teacher training for fitness instructors, independent Pilates teachers and allied health care workers [9]. Courses range from one day mat certification to 1,000 hours comprehensive training [10]. Many of the Pilates education businesses in the UK and USA are directly linked to Pilates associations [9, 11].
1.1.2 Qualifications
Pilates providers may hold a government accredited Level 3 or 4 Certificate, Diploma, Advanced Diploma or University Graduate Certificate and may be full members of a professional association or have no accreditation or affiliation. Pilates associations recognise various qualifications, require members to adhere to their scope of practice and ethical code to maintain registration. While some associations internally distinguish levels of training, between GymPilates group class providers and levels of comprehensive or therapeutic Pilates, members’ qualifications can be unclear to the public. As a result, the consumer may have a compromised perception of the different qualifications of Pilates providers.
Some Pilates associations provide oversight on course content, and assessments [11-13]. But as an unregulated industry it is uncertain if all competencies are met. What is more concerning is the increased promotion of primarily online courses (Figure 1), as guidance on complex physical performance skill, safe equipment use and practice of professional interactions with clients are not available due to the nature of the delivery mode. Translating virtual teaching to real time and space human interaction cannot be addressed online. Further, no independent reviews on courses have been published on, validity of assessment procedures, skills and risk factors or levels of competency to apply Pilates to clients. Therefore, determining if an online course equips participants to provide Pilates safely, and effectively remains uncertain.
Figure 1: Teaching online can compromise supervision skills
2.1 Accreditation
2.1.1 Large group GymPilates accreditation
Many international Pilates education providers and fitness education businesses in conjunction with various professional associations have successfully negotiated to include recognition of some Pilates certificates as qualifications within National Registers of Exercise Professionals. These fitness industry Pilates courses offer accreditation for GymPilates group mat or Reformer classes. Some Pilates courses for fitness and personal trainers are advertised as delivering education from one to five weekends online and include assessment plus self-mastery and observation [1, 2, 9, 14]. It is unclear what percentage of time is spent on course content, quizzes or student review of information.
In the UK the National Occupational standards (NOS) for Pilates was established in 2005 and entitle Pilates teachers to be included in a Register of Exercise professionals. These Nationally agreed standards were developed by the Skills Sector Council (Skills/Active), the Register of Exercise Professionals, a number of Pilates training providers and awarding bodies. As a consequence a Level 3 Certificate in teaching Mat qualification is accepted as meeting NOS standards [15]. Similarly, in the United States of America, The National Commission for Certifying Agencies (NCCA) has a Registry of Exercise Professionals® who must hold current NCCA-Accredited Certifications offered by CREP® and include a personal trainer level of certification, the Nationally Certified Pilates Teacher offered by the National Pilates Certification Program [16].
In Australia there are numerous Registered Training Organisations (RTO) under the Australian Qualification Framework, providing a range of Pilates courses from online mat or reformer repertoire to comprehensive training. Currently AUSactive a fitness industry association is encouraging Pilates instructors to join their organisation, as certified to deliver Pilates repertoire and/or teach Pilates [17]. AUSactive approved Pilates courses are delivered by some international Pilates course provider businesses [1, 18].
2.1.2 Comprehensive and therapeutic Pilates accreditation
Various national and international professional associations accredit comprehensive and therapeutic Pilates teachers. Examples of Pilates associations include the Pilates Method Alliance in the USA [11], Society for the Pilates Method [19], the Pilates Foundation in the UK and Europe [20],and the Pilates Association Australia [12]. These bodies screen the applicants’ educational qualifications to determine eligibility and may be aligned with various course providers. Some associations have various levels of membership linked to levels of qualification, which possibly increases confusion for both the profession and consumer. The comprehensive or therapeutic accreditation requirements are substantial. Education includes completion of primarily face to face lectures and seminars, supervised personal and workplace practice, and may take two or more years to complete [5, 18, 20], To remain a member of some Pilates associations ongoing continuing education and adherence to ethical practice is required, however no evidence of external independent auditing has been discovered.
2.1.3 Allied health Pilates accreditation
Registered Allied Health care providers are increasingly using components of Pilates within their treatment plans. Pilates training for registered allied health care professions is extremely variable and self-determined. Some undertake external training courses before or after completion of their undergraduate degree. However, it is unclear if there are significant differences in teacher training curriculum between comprehensive and allied health Pilates education [18]. Some countries accept the provision of Pilates by allied health care workers such as in the UK and Brazil where physiotherapists provide Pilates within their government funded health schemes and private health insurance funds [21]. Since 2015, the Australian federal government have been undertaking a review of Natural Therapies including Pilates. A government directive [22] meant Pilates, regardless of who delivered it, stopped being eligible for benefits provided by private health insurance funds (PHIF) under any policy eligible for government subsidy (through the Private Health Insurance Rebate). However, interestingly physiotherapists lobbied government such that physiotherapists (and other allied health workers) could provide Pilates-based treatments that were able to be rebated by PHIFs as long as it was within their scope of practice and that treatment did not entirely consist of Pilates (circular PHI 69/18)[23]. These two criteria have yet to be clarified.
The quality and consistency of Pilates training for many allied health care workers are currently unknown. Topics on general exercise prescription are provided at undergraduate level, but at the time of writing minimal evidence could be found on the provision of Pilates education at an undergraduate level [24]. Some registered allied health workers do complete comprehensive Pilates training and undertake post-graduate research on the efficacy of Pilates. However, there appears to be no external auditing of Pilates qualifications or skills by registered allied health organisations.
A qualitative study on Pilates-trained physiotherapists suggests Pilates appears to be a valuable methodology in the UK National Health Service (NHS), which can help patients engage with activity [21]. However, the efficacy of the method may be dependent on the experience and skill of practitioners [25] and it remains unclear what Pilates qualifications are required to become recognised as a Pilates-trained physiotherapist within the NHS framework.
There are registered allied health care workers who provide therapeutic Pilates as a mind-body movement modality. However, many physiotherapists advertise that they provide clinical, or physio-based Pilates, and it remains uncertain if the mind-body component of therapeutic Pilates is provided in a clinical setting. Some allied health care clinics rely on specifically employed Pilates teachers or therapy assistants [26] who may or may not be comprehensively trained to provide Pilates. Many allied health Pilates providers do not belong to any Pilates associations. So, information on accreditation and continuing education competencies for the safe effective practice of clinical allied health provided Pilates is limited.
3.1 Discussion
The popularisation, and diversification of the method has led to a confusing range of provision of service and types of Pilates. While some Pilates literature states there are only two types of Pilates - mat and reformer Pilates [27] aside from mat classes for dancers, Joseph Pilates did not teach large group classes. Now a simple internet search on Pilates will bring up numerous types of Pilates. Some search results include different brands or Pilates businesses as separate types and are more about promotion rather than information. What is noteworthy is the lack of clear information on the actual qualifications of the Pilates provider, which leads to the questions qualified or certified how and by whom?
Many fitness, exercise and Pilates associations recognise various Pilates certifications. But even when certification is acquired it is uncertain if all requirements are met as competency in workplace practice is difficult to verify. GymPilates certifications are not consistent and training in safe equipment use may be questionable. Some reformer courses include minimal practice on a reformer, with qualifications attained via a repeatable until pass, online quiz [2].
There is no research on the therapeutic effect, efficacy, or safety of large group GymPilates. GymPilates mat or reformer sessions are usually at a fast pace, precluding awareness through breath, and with no mind–body coordination through the practice of focused attention [28]. GymPilates is not a complementary health modality. Similar to other general exercise modalities [29] it can only be effective safe exercise for the problem-free client (Figure 2). Consumers and providers need a clear understanding of the significant differences between GymPilates group exercise and comprehensive or therapeutic Pilates as a complementary health modality.
Figure 2: Large group fitness follow-along Mat class
There is a substantial body of research on the efficacy of Pilates exercise applied therapeutically either in a comprehensive studio setting or in small group population specific sessions. Pilates exercise programs provided by fully trained experienced Pilates teachers can reduce pain and disability [30, 31], improve some mental health outcomes [32], and psychological wellbeing [33, 34] and is the most effective intervention for low back pain [35-37]. In addition, Pilates can improve strength, joint function, and reduce disability in some chronic diseases [38-40], and for post-stroke rehabilitation [41]. Pilates also has a greater effect than general exercise on balance and reducing the risk of falling [42] and is more effective than physical exercise rehabilitation for improving functional mobility and balance in Parkinson’s disease [28]. The considerable body of evidence on the significant reduction of low back pain and effective management of disability associated with other chronic conditions primarily provided by comprehensive therapeutic Pilates teachers [43] suggests that consistent, adequate support and recognition of these Pilates teachers by both public and private health insurance funds is overdue.
Comprehensive and therapeutic Pilates encourages mindful movement, coordinated breathing with improved motion control, muscle sequencing from the Center and functional posture to maintain wellness [44]. The scope of practice of a comprehensive Pilates provider may vary depending on the providers experience and education. While comprehensive Pilates providers primarily focus on maintaining mind-body wellness, therapeutic Pilates practitioners, with additional experience and education may focus on managing pain, the consequences of chronic diseases and conditions, or age-related decline, to facilitate a clients’ ability to sustain functional activities over a life span. The reputation that Pilates is beneficial may be entirely based on its success as a comprehensive mind-body movement system with modifications to exercises, individual exercise prescription and careful supervision [45], not because it is a subset tool in the fitness coach or allied health professional’s toolbox. Positive research findings on the efficacy of Pilates have been accompanied by the caveat that effectiveness does not appear to be contingent on being provided by a physiotherapist [39].
Is the rapid inclusion of Pilates in mainstream healthcare, based on the increase in use by the general population and minimal training similar to the inclusion of dry needling [46] by mainstream medicine? Furthermore, do the discursive claims that allied health provided Pilates being substantially distinctive from other types of Pilates [47, 48] hold up under analytic scrutiny? Currently there are no specific competencies, skills or education requirements for allied health provided Pilates.
Many registered allied health providers are pivoting towards a better understanding of chronic disease management which includes many aspects of complementary medicine such as promoting mind-full behavioural change in a holistic manner[49]. Exercise providers and personal trainers are both attempting to capture the Pilates exercise as wellness market. Some in these professions may be missing the wholistic mind-body integrated system that is fundamental to complementary medicine. Indeed, complementary and conventional medicine have significant conceptual differences which are still barriers to integration [50].
Pilates is not a reserved or trademarked name with standardised competencies for safe practice. Anyone can state they provide Pilates or Pilates training. The ever-expanding group of stakeholders, whether they are Pilates professionals, course providers, equipment manufacturers or allied health providers, appear to have little incentive to coordinate their efforts to support comprehensive or therapeutic Pilates as a profession. For example, evidence of effective treatment for chronic musculoskeletal conditions includes a significant body of research by independent experienced comprehensive Pilates teachers [39], but these providers’ services are not covered by insurance [43]. Consumers may be financially persuaded to opt for inexpensive GymPilates classes or use their Private Health Insurance funding to attend an allied health clinic where employees may or may not be adequately trained in the modality. Are some stakeholders quietly cutting up the popular pie of Pilates into GymPilates and allied health, clinical Pilates? The consequences being that the independent comprehensive or therapeutic Pilates studio providing tailored supervision, based on Joseph Pilates philosophy that is the foundation of this mind-body movement modality, will no longer be viable.
Unfortunately, the Pilates industry has minimal self-regulation. Participants and teachers can be injured by inappropriate exercise prescription, inadequate supervision, and poor equipment safety. It is critical that patient/participant safety remain paramount for regulators [51]. The lack of clarity around education, and actual safe effective practice is further complicated as distinguishing competency to practice between experienced apprenticeship trained Pilates teachers, certified Diploma or advanced Diploma comprehensive or therapeutic Pilates remains clouded by commercial conflicts of interest. Learning functional movement assessment skills that underpin therapeutic Pilates tailored exercise prescription and supervision skills (Figure 3) may be listed in course brochures, but independent confirmation of this skill acquisition is often unverified. Those interested in training as a Pilates professional, often relying on internet advertorials when choosing a training course. The development of independent, international training guidelines and higher education for specific Pilates professional competencies is an important area for investigation and urgent development.
Figure 3: Balance task used in therapeutic Pilates client assessment
Comprehensive and therapeutic Pilates is a mind-body exercise modality that focuses on interactions among body (movement and posture), breath, and mind (meditative component) [28]. Pilates is a relatively recent addition to the disciplines of mind-body exercise [52], but its principles have always incorporated long standing eastern meditative movement philosophy [53]. Increasing consumer uptake and the ever-expanding body of research on Pilates supports this mind-body exercise system of person-centered [54] wellness as effective for managing many chronic problems [36, 37, 55] and conditions associated with ageing [33, 56].
However, for those with chronic problems exercise choice and adherence remains challenging. As Reid and colleagues note: the risks of physical activity for people living with long-term conditions may be overstated with routine preparticipation screening by an allied health care worker posing an unnecessary barrier to engagement with self-directed physical activity. The need for medical guidance, as opposed to clearance, should be determined by individuals with specific concerns about active symptoms [57]. The exceptionally high adherence rates reported for those practicing Pilates with chronic conditions [39] warrants consideration. Client informed choice of Pilates teacher, with equivalent funding, whoever the provider may improve exercise adherence for people living with chronic problems. This needs to be supported with consistent higher educational standards and oversight of Pilates providers.
4.1 Limitations
The regulatory bodies, Pilates associations and teacher training bodies identified in this commentary were limited to those that were readily available and identified through publicly available search engines; additional Pilates associations and Pilates training provider businesses may exist.
Some Registered Training Organisation courses and National Certification Bodies recognise both short and comprehensive training certification. However, the actual type of certification, or quality of certification including hours of study undertaken, assessment of competencies or skill acquisition of many service providers is unable to be independently verified limiting the certainty of accreditation or skill of providers.
5.1 Conclusion
The evolution of the Pilates method has in part led to its popularisation. The changes in pedagogical orientation have also contributed to the substantial diversification of the Pilates profession. The Pilates profession has been fragmented by various training providers, professional associations, equipment manufacturers, the fitness industry, and allied health care businesses.
Uncoupling the economic relationships between some course provider businesses, equipment manufacturers and non-specific exercise based professional associations would enable the development of Pilates specific skills, a consistent scope of practice and transparent regulatory framework to maintain safe practice. This could be achieved with regulatory assistance to independent Pilates associations and confirming educational competencies of Pilates teachers with highly scrutinised courses such as those provided by universities. Tertiary Pilates courses facilitates collaborative research on Pilates potentially improving the standards of care for those with chronic conditions.
Distinguishing between GymPilates, the complementary modality of comprehensive and therapeutic Pilates, and clinical Pilates that is part of a conventional health professions treatment toolbox provides consumers and stakeholders an accurate provision of service. Ensuring that accessibility is not limited by financial incentives to the few, nor skewed towards supporting those with a pre-existing but not necessarily relevant registration or qualification, the profession of comprehensive therapeutic Pilates requires consistent higher education and transparent regulation.
Declaration of interest: none.
Passionate about the holistic connection of mind, body, and spirit, Penny advocates for a person-centered, therapeutic Pilates approach to enhance overall well-being. You can find Penny here.
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