“ How do Pilates Trained Physiotherapists utilize and value Pilates Exercise for MSK conditions? A Qualitative Study

Background: Pilates is a popular exercise therapy approach offering numerous benefits, including muscular strength, flexibility, control, and core stability. Pilates has been widely utilized in the prevention and rehabilitation of a variety of musculoskeletal disorders. Objectives: The aim of this study was to explore the experiences and opinions of Pilates trained NHS and private practice physiotherapists in the UK, regarding the perceived benefits, risks, delivery and rationale for this exercise method. Methods: This qualitative study used a self-designed electronic survey to retrieve the views of 30 physiotherapists, who had undertaken formal Pilates Instruction training, recruited by a purposive and snowball sampling method. Questions were either multiple choice or open-ended, examined via thematic analysis. Results: Physiotherapists identified the most important benefits of Pilates as reduction in fear-avoidance, improving bodily awareness and increasing muscular strength. Exercises that promote general movement were highlighted as being particularly useful, with a majority recommending daily practice for optimum benefit. Participants recognized lack of core strength as a key indicator, whereas others criticized excessive focus on this principle. Conclusions: Physiotherapists identified a range of inter-linked benefits and recognized that Pilates is hugely modifiable. Individualizing exercises can further encourage participation and negate the restriction of some health conditions. NHS and Private Practice Therapists utilize Pilates in a similar way, although rationales for its use may differ, as the justification for Pilates exercise may be evolving. Pilates appears a valuable methodology in the NHS, which can help patients engage with activity.

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for individuals with a range of MSK (musculoskeletal) disorders (Byrnes, Wu, & Whillier, 2018) and has become commercially recognized and accessible through various professional institutions. The Australian Physiotherapy & Pilates Institute (APPI) is a globally run organization licensed in 16 countries, delivering over 17 000 classes per year, as a "graduated system of specific exercise rehabilitation" (Appihealthgroup.com, 2019).
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 (28.9%) live with a musculoskeletal condition in the UK (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. Several systematic reviews have quantitively 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 randomized 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 addition, qualitative research evaluating Pilates as a treatment approach is limited, 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. A qualitative approach could also gain understanding of how physiotherapists utilize Pilates for a range of conditions other than LBP (Wells, Kolt, Marshall, & Bialocerkowski, 2014b). This study aims to investigate the variation in Pilates delivery 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.

| METHODS
A self-designed qualitative questionnaire survey was used to investigate opinions and views among 30 Chartered Physiotherapists practicing in the UK, who had undertaken formal training in Pilates exercise therapy to treat people with MSK conditions. The study utilized a qualitative phenomenological approach, as this was an appropriate method to capture and collate physiotherapist's experiences, and gain further understanding of their beliefs and rationale (Kumar, 2012). Carpenter and Streubert Speziale (2007)), describes phenomenology as "a science whose purpose is to describe a particular phenomenon or the appearance of things, as lived experiences" (p.43).
Considered both a philosophical discipline and research method, the outcome of a phenomenological study is a detailed description of themes that capture the essential meaning of a 'lived' experience, including an individual's beliefs, meanings and attributes (Moser & Korstjens, 2018), in this instance, therapist's views and opinions regarding Pilates exercise therapy. This approach to data collection allows analysis of an individual's experiences without restriction of pre-existing theoretical pre-conceptions (Smith & Osborn, 2015).
Qualitative methodology has numerous advantages including rich and detailed data retrieval with greater depth of focus to one particular area and is suited to evaluating intricacies of a situation or method (Legard, Keegan, & Ward, 2003). This methodology is appropriate as quantitative methods may not explain why physiotherapists select specific Pilates exercises over others or determine suitability for participants with certain health conditions. It also allows for consensus or differences of opinion with rationale and sharing of common practices.

| SURVEY DESIGN
The questionnaire for this study was constructed to retrieve the desired views and opinions from physiotherapists. The questionnaire was designed by the lead researcher, with assistance from the secondary author. Both researchers had completed previous Pilates instruction training and had significant experience in conducting Pilates classes for individuals with MSK conditions. The study was crosssectional as data was collected from a snapshot in time (Setia, 2016).
During development, the SRQR (Standards for Reporting Qualitative Research) checklist was used to ensure research quality and transparency (O'Brien, Harris, Beckman, Reed, & Cook, 2014), the questionnaire was also piloted before use with experienced Pilates-trained physiotherapists. This resulted in minor amendments to question wording to improve flow, salience and ease of understanding. Piloting additionally tested face validity (Burns et al., 2008), promoting trustworthiness and usefulness of results.
The questionnaire was delivered in an electronic format via Google Forms (Appendix A). The first section consisted of a participant consent form, followed by a demographic data section. The main body of the survey consisted of four multiple choice questions followed by open questions allowing free text input, the aim being to facilitate sufficient narrative in participant's responses to provide a wealth of useful data and enable thematic analysis.

| ETHICS, RECRUITMENT AND SURVEY PROCESS
The University Ethics Committee (Ref HSR1617-150) approved the study prior to participant recruitment, which took place via two methods. Firstly, the lead researcher directly contacted NHS Healthcare providers (Managers of MSK Physiotherapy Departments) via email or phone to gain consent to contact their staff, details and aims of the study were also explained fully at this point. NHS providers were identified from the online list of NHS Authorities and Trusts, aiming initially within the North West of England, then recruiting geographically further to achieve sufficient responses. Once consent was gained from NHS MSK managers, emails were sent with the appropriate hyperlink to the online survey, which managers were requested to then disseminate within their departments.
The second method utilized a purposive/snowball sampling approach to recruit physiotherapists in private practice. Pilates trained physiotherapists were directly contacted and onward dissemination to suitably qualified colleagues encouraged. When completing the survey, participants were required to give informed consent by selecting the relevant selection box, as well as electronically signing with their name. Survey information specified that participant's responses would remain anonymous and confidential, and that they also had the right to withdraw from participation at any time, by simply not completing the questionnaire, and exiting the electronic form. Access to the survey data was accessible only via password protected Google Account.
Completed online survey responses were collected between February and June 2019.

| SELECTION CRITERIA
To participate in the study participants had to: 1. Have undertaken some form of formal Pilates instruction training, such as the Matwork Foundation Pilates courses with the APPI or BCP (Body Control Pilates, 2018). Physiotherapists did not have to be a fully certified instructor to participate in the study, however, they must have completed a minimum of one formal Pilates instruction course.
2. Be registered with the HCPC (Health and Care Professions Council) to currently practice as a physiotherapist without restriction in the UK, in keeping with the rationale of previous studies (Allen, 2014;Brennan & French, 2008;Wells et al., 2014b). Wells et al. (2014b) advocated that including only physiotherapists with formal Pilates training guaranteed similar standards of practice of participants, as standards and qualification level may vary otherwise.
Extending the survey to other practitioners, for example Pilates instructors who are not physiotherapists, would also make further comparisons challenging through data analysis.
3. Be computer literate, have e-mail access, time to commit to completion of the survey, and ability to understand written English language.

| DATA COLLECTION
A sample size of 30 survey responses were retrieved for this study. Sufficient responses were required to achieve qualitative data saturation and enable worthwhile analysis (Saunders et al., 2018). Data saturation refers to the collection of qualitative data until there are no new data emerging and redundancy occurs, in that no new analytical information arises any more, and the study provides maximum information on the phenomenon (Moser & Korstjens, 2018). Data saturation is considered a key principle in determining purposive sample size in health sciences research, however there is a lack of guidelines or tests of adequacy to determine how many sources are sufficient (Guest, Bunce, & Johnson, 2006). Moser and Korstjens (2018) propose that qualitative phenomenological studies require fewer than 10 interviews, whereas Creswell (1998)

| Participant Information
Demographic data such as length of time qualified as a physiotherapist, and type of Pilates instruction qualification, was summarized using descriptive statistics. All numerical data were inputted to Microsoft Excel and statistical calculations made to identify mean, range and standard deviation values where appropriate.

| Survey Multiple choice questions
Questions requiring participants to select a multiple-choice option regarding preferred treatment parameters, were similarly inputted and summarized via descriptive statistics to identify percentage agreements. Response frequency for each selected benefit of Pilates was summated to display the results in a ranking table.

| Open ended-questions
The main body of the survey comprised open-ended questions, providing qualitative data. This data was analyzed thematically (Braun & Clarke, 2006): via a proposed six-step process to ensure methodological quality (Maguire & Delahunt, 2017).
Narrative answers were hand screened individually, using a color-coding system to highlight participant's comments according to their similarity. Similar comments were coded together to provide emerging themes, which were then condensed or combined with other sub-themes dependent on distinction. Themes were repeatedly reviewed for coherence and appropriateness before Thematic analysis minimally organizes and describes a dataset in detail (Gale, Heath, Cameron, Rashid, & Redwood, 2013), and has been employed in qualitative research evaluating practitioners' views on physiotherapy interventions (Holden, Nicholls, Young, Hay, & Foster, 2009;Stenner, Swinkels, Mitchell, & Palmer, 2016;Ward, Stebbings, Sherman, Cherkin, & Baxter, 2014). Thematic analysis of all qualitative data was firstly completed by the lead researcher, this was then confirmed by the second author to identify and condense themes through repeated review of responses.
The second researcher had no active role in initial data collection to reduce bias.
Thematic analysis can usefully summarize key features of a large body of data and highlight similarities and differences across the data set (Attride-Stirling, 2001). This is advantageous in facilitating comparison of physiotherapist's views from an NHS background, and those who work in the Private sector, as patients have previously reported differences in their experiences of treatment received from the two providers (Bradbury, Bishop, Yardley, & Lewith, 2013;Wiles & Higgins, 1996).

Thirty UK physiotherapists who had undertaken formal training in
Pilates exercise completed the electronic survey. Demographic data and descriptive statistics for the sample are detailed in Table 1.
Thematic analysis of narrative responses revealed six key themes: 1. Exercises that promote mobility and encourage general The importance of gluteal exercises including bridging and clams were the most frequently cited followed by transversus abdominis activation, and low-level supine work including pelvic tilting and scissors. Eight physiotherapists reported these exercises were easy for patients to complete at home and required only simple instruction to achieve understanding.

| Theme 2: Individual Pilates practice should be completed daily
Despite general consensus regarding the optimum parameters for Pilates classes (Table 2), there was diversity in opinion concerning how often exercises should be practiced individually. A majority acknowledged that frequency is dependent on desired treatment effect, such as development of strength, flexibility or recruitment. 60% of participants felt daily repetition is the most beneficial approach; "I generally advise at least once daily whilst their symptoms are flared, then slowly wean off to maybe once weekly once their symptoms are settled in order to maintain their progress" [P4]. Several NHS physiotherapists acknowledged the importance of creating routine and familiarization: "To maintain the benefits I would recommend doing them once a day long term and find an exercise they can combine easily into their schedules, so it's a realistic and achievable goal" [P22].

| Domain two -Benefits of Pilates
Participants reported that Pilates exercise offers a wide range of health benefits. Over 20 different MSK conditions were highlighted specifically, with a majority in agreement that this intervention can benefit LBP. Other commonly cited conditions were hip pathologies and anterior knee pain. Physiotherapists were asked to select what they felt were the most important health benefits from a selection agreed by consensus in an earlier Australian study (Wells et al., 2014a) ( three" it received one vote, these were totaled to identify the most popular recognized benefits.

| Theme 3: Benefit: Reduces fear avoidance and improves body awareness
A third of participants agreed that improving body awareness was the single most important benefit of Pilates exercise followed by reducing fear avoidance. Three physiotherapists also suggested how these two benefits are interlinked: "Improving body awareness certainly helps movement patterns, encouraging normal functional movements is a huge part of rehab. This in turn can reduce fear avoidance and again encourage movement" [P30], and: "Many patients find that the controlled nature of Pilates means they can work within pain free ranges and slowly increase on them. Body awareness/postural control with the right guidance can be largely improved, making even small corrections can turn a movement which was painful into one that wasn't" [P4]. A key factor observed by five therapists in abolishing fearful behaviors was developing patient confidence: "The first significant change patients have reported to me in feedback from classes is increased confidence to move normally and move in ways which they were previously fearful of" [P7], this held close association with increasing exercise participation.

| Theme 4: Indicated in individuals who lack core stability, strength and spinal control
Thirteen therapists highlighted that lack of core stability or spinal control was a key indicator that people would benefit from Pilates: "weak anterior and posterior sling muscles, weak core muscles" [P6], another

| Domain three -Risks and Contraindications
Therapists acknowledged that there are few contraindications to Pilates exercise, seven participants also specified that Pilates can be adapted to avoid risk to the patient. However, some key conditions were recognized that may completely preclude participation, such as unstable cardiovascular issues, recent fracture and recent surgeries.

| Theme 5: Situations where Pilates exercises were considered less useful
Six therapists stated that excessive focus on elements such as core activation and positioning can lead to symptom aggravation. "Sometimes the pure Pilates form is too specific and may cause patients to be too body aware and move in ways that can perpetuate a pain cycle" [P2], this was reflected in other participant's comments: "Thinking they need to brace their core muscles to move can cause unnecessary tension and pain" [P19], and that: "The main risk associated with Pilates is that it is taught in a "purist" fashion i.e. too much emphasis on "neutral spine" and implying that the only safe way to move or exercise is in these specific  Most reported that patients with yellow flags can greatly benefit from Pilates and this also did not preclude participation. "I think Pilates can be a great way to self-manage psychosocial complaints.

| Theme 6: Pilates during the 1 st Trimester of Pregnancy and Yellow Flags are only a precaution
Becoming more aware of the 'here and now' in postural/body awareness, allowing designated 'me time' to reduce constant stresses, and benefits of group exercise" [P25]. One Therapist added: "I feel these types of people would benefit from Pilates as its low level and not over strenuous, I've previously used it to overcome fear avoidance and catastrophizing" [P13]. Physiotherapists reported a range of health benefits of Pilates, identifying that reduction of fear avoidance, improving bodily awareness and improving muscular strength being the three most important benefits from a selection agreed by consensus in an earlier Australian

| DISCUSSION
Study (Wells et al., 2014a). There was considerable cross-over of narrative themes, suggesting how benefits of Pilates are strongly linked.
Reducing fear-avoidance and improving exercise participation held a close association. Encouraging people with MSK conditions to engage with some form of activity facilitates lifestyle change and promotes self-management (Gardner et al., 2017) reducing dependency on healthcare providers for treatment as demonstrated by Hubbard et al. (2004). Regular exercise and successful self-management are positive steps towards relieving healthcare pressures.
In the present study, therapists identified that an individual with poor core stability and strength may benefit from Pilates, which corroborates with findings of a large-scale questionnaire of instructors (Allen, 2014). The principle of core activation often referred to as "centering" in APPI taught Pilates practice, was not ranked highly in comparison to other benefits in this study. Excessive focus on core activation and positioning was described by six participants as a possible risk, leading to hypervigilance, unnecessary core bracing and possibly perpetuating a pain cycle. This is a novel concept but perhaps mirrors the recent "paradigm-  Vasseljen, 2010). This suggests that the rationale and practice of Pilates exercise maybe evolving, improvements in pain and disability demonstrated in systematic reviews (Byrnes et al., 2018;Wells, Kolt, Marshall, Hill, & Bialocerkowski, 2013) may be attributed to other global benefits highlighted in this study (such as facilitating movement) rather than "core stability". of concern, given that women often self-refer to Pilates (particularly in private physiotherapy practice) without medical referral, therefore screening of absolute contraindications may be important in safeguarding practice.
Pilates is possibly an underused approach within the NHS; such an accessible exercise method can significantly influence patient's engagement with activity, and help individuals achieve recommended levels of exercise. Reduction in activity levels in elderly populations, and those with lifelong conditions is a prominent issue (Woolf & Pfleger, 2003), enabling these individuals to increase participation in exercise and activity is a vital way of combatting this crisis (Taylor, 2014 (Hurley, Walsh, Mitchell, Nicholas, & Patel, 2012;Underwood, 2004).
A limitation of the present study was the purposive sampling method, considering the associated potential selection bias (Sharma, 2017), in addition to the level of evidence this study generates (expert opinion). However, this approach was warranted in order to gain suitably qualified, and therefore reliable views from Pilates trained physiotherapists. Although considered the lowest level of research evidence (Howick et al., 2011) this is negated somewhat by the benefits of qualitative research, investigating real world and lived experiences, and providing rich insight into therapists' viewpoints that quantitative research could not achieve (Legard et al., 2003).

How to complete this questionnaire.
For the purposes of gaining valuable and informed opinion one of this project's inclusion criteria is that participants must have undertaken some form of Pilates instruction training. This is not specific to any institution or training provider (i.e. BCP or APPI), as long as some type of training has been completed for example -APPI Foundation Matwork Level 1.
The first section is the participant consent form. Please read this to give your consent to participate, by ticking the selection box.
The questionnaire then follows in the next sections.
Several questions are to retrieve demographic datathis will not be used to identify you in the final project write-up or publication.
Some questions are comprised of multiple-choice questions.
Please make your selections by ticking the appropriate box.
Other questions are open-ended questionsrequiring text input response. Please type your responses in the text box for each section.
Please feel free to answer with as much text detail as you feel is required to explain your selection or rationale, all responses are valuable to achieve this project's aim in gaining further insight as to why physiotherapists hold certain views.
Your informed opinions and experience could potentially influence how Pilates is delivered individually and in class formats in the future.
The questionnaire should take approximately 15 minutes to complete.
You can withdraw at any time, simply do not complete the survey.
All your responses are confidential, the only people who will examine completed surveys for data analysis will be the lead researcher () and the project supervisor at the University of(). The study is a research project completed as part of a Masters in Advanced Physiotherapy Degree at the University of.
Your involvement in this research project is greatly appreciated, if you would like to find out more or discuss the study in any more detail, please do not hesitate to contact me on the above email or on.
Contact information for researchers: (Removed as part of submission blinding) Research Participant Consent Form.