How do Pilates Trained Physiotherapists Utilise and Value Pilates Exercise for MSK Conditions: A Qualitative Study

Pilates is a popular exercise therapy approach that focuses on strength, core stability, flexibility, muscle control, and posture (Wells et al., 2014). This approach has evolved over time, to form a valuable therapeutic tool in the prevention and rehabilitation of a variety of injuries (Di Lorenzo, 2011). More recently, Pilates has become increasingly popular due to its wide-ranging health benefits for individuals with a range of MSK (musculoskeletal) disorders, as well as other conditions (Byrnes, Wu, \& Whillier, 2018). This method has become more commercially recognised and accessible through various professional institutions. The Australian Physiotherapy \& Pilates Institute (APPI), is a globally run organisation licensed in sixteen countries, delivering over 17000 classes per year, as a "graduated system of specific exercise rehabilitation" (Appihealthgroup.com, 2018).

In the UK, Pilates based exercise therapy is used within both the National Health Service (NHS) and private healthcare sectors in the management of low back pain (LBP), general MSK pain, and various degenerative conditions (Yamato et al. 2015). An estimated 17.8 million people live with a musculoskeletal condition in the UK, around 28.9% of the total population (Global Burden of Disease network, 2016). Over 8.75 million people aged 45 and over have sought treatment for osteoarthritis (Arthritis Research UK, 2013), for which the main management strategy is exercise-based therapy. MSK healthcare services are under increasing pressure to provide care to the ageing population, and tackle the healthcare impact associated with inactivity (Hubbard et al., 2004). Group based exercise such as class Pilates, offers an accessible opportunity to increase activity levels in such individuals (Karlsson, Gerdle, Takala, Andersson, \& Larsson, 2018).

There is considerable evidence that Pilates has numerous physical benefits and may improve self-management of MSK conditions. This includes a wealth of quantitative research, several systematic reviews have demonstrated positive improvements on pain, quality of life and functionality (Aladro-Gonzalvo, Araya-Vargas, Machado-Díaz, \& Salazar-Rojas, 2013; Byrnes et al., 2018). However, of the Randomised Controlled Trials (RCTs) reviewed, high levels of heterogeneity were reported, in terms of sample (sub-types of back pain), exercise selection, delivery and frequency of treatment.

In contrast to this, there is a dearth of qualitative research evaluating Pilates as a treatment approach, mostly focusing on LBP populations (Gaskell \& Williams, 2018). These methods can be valuable to review the definition, scope and rationale of Pilates treatment methods used by Physiotherapists, to provide optimum rehabilitation. Use of a qualitative approach could also gain understanding of how Physiotherapists utilise Pilates for a range of conditions other than LBP (Wells et al., 2014). Therefore, this study aims to investigate the variation in Pilates delivery and why, and in line with previous qualitative studies, further explore the perceived benefits, risks and rationale for this exercise approach. This is the first study to review NHS and private physiotherapists in their use of Pilates group exercise.