The end of Pilates?

From sciencebasedmedicine.org:

Australia ends insurance subsidies for naturopathy, homeopathy, and more

“…based on the report, the Australian government has now removed coverage for all 17 therapies studied in the initial review. This move is part of an overall strategy to reduce the cost of private insurance for consumers, and boosting coverage for services like mental health.

 What this means is that while people can still choose to access these therapies, they cannot be offered benefits under these private insurance programs. Notably, not on the list are chiropractic, acupuncture and reiki, none of which were included in the initial review – it’s not clear to me what their current status is under these programs.

The full list of the evaluated  and evicted treatments:

Alexander technique, Aromatherapy, Bowen therapy, Buteyko (be careful to get the spelling right if you Google this one), Feldenkrais, Herbalism/western herbalism (but Chinese and Ayurvedic medicine were not reviewed), Homeopathy, Iridology, Kinesiology, Massage*, Naturopathy, Pilates, Reflexology, Rolfing, Shiatsu, Tai chi, and Yoga.

Plausibility…

The effect will come into place on 1 April 2019, from which point on it will become illegal for health funds to include the therapies in their coverage. It would seem that this decision will have important consequences for a number of therapy professions, physiotherapy most significantly, as many physios have built (quite literally with some of the magnificently renovated, natural-brick-exposed ‘studios’) their practices around Pilates as an intervention.

Interesting point made by the author at sciencebasedmedicine.org:

As I discussed earlier, the review didn’t consider plausibility in its review, which was a huge oversight. Practices like homeopathy and iridology are pure pseudoscience, while therapies like Pilates, yoga and tai chi are forms of exercise which have far more potential to offer some therapeutic benefits. The authors concluded, however, that the lack of evidence signaled that these treatments could not fairly be considered “evidence based”.

Magical movements and drinking your own Kool Aid?

Perhaps Pilates has become a victim of its own popularity, or, a casualty of the self-generated hyperbole surrounding it. While there seem to be some benefits, it’s not a magical movement with  any more mystical benefits than other forms of exercise (of course yoga and tai chi also fall into this category). But… I’m sure the idea of doing Pilates (or yoga or tai chi) was a motivator for at least some to get off the couch and do something (anything seems to be better than nothing in terms of activity/exercise), and, notwithstanding some dubious explanations as to its underlying causal mechanism of benefit, that isn’t all bad. Is it?

Interested to hear the thoughts of anyone out there who this might impact.

– Tim Cocks

*EDIT: Over on Facebook, as part of a lively discussion, it has been pointed out that the document released from the Department of Health does not list massage in the list of interventions that will no longer be supported. Massage was on the list of therapies in the original review and in the Implications for practice section for massage therapy the review stated “There is a paucity of good – quality studies of sufficient size that examine the effectiveness of massage therapy for many clinical conditions.. The evidence is uncertain or unknown for 43 of the 46 clinical conditions assessed in this overview.”, but it seems that massage has survived the cut. Apologies for any confusion. TC

 

Australian course schedule 2018

Canberra 14 – 15 April EP

Warrnambool 27 – 29 April EP | GMI

Newcastle 5 – 6 May MONIS

Bendigo 25 – 27 May EP | GMI

Noosaville 15 – 17 June EP | GMI

Cairns 10-12 August EP | GMI

Perth 7 – 9 September EP | GMI

Mildura 19 – 21 October EP | GMI

Melbourne 9 – 11 November EP3 | Butler, Moseley & P O’Sullivan

25 Responses to “The end of Pilates?”

  1. Alyssa Tait

    Hi Tim, I’m a physiotherapist and a naturopath with a practice very firmly rooted in evidence-based medicine. I’m feeling for my naturopathic colleagues right now, because while there are lemons in every profession, some of the naturopaths in my networks are worth their weight in gold, providing evidence-based nutritional treatment programs and helping people turn their health around in a way their doctor and dietitian couldn’t, and this initiative will hurt them and their patients. I’m lucky, because I started my career in a profession that the government has chosen to trust, rather than scrutinise – so I don’t think it will impact much on me. But I find it interesting that the government has taken such a broad brush approach – excluding naturopathy despite the fact that most of naturopathy is nutrition and herbal medicine, both of which have an enormous amount of research support. And unfortunately, we all know that there are plenty of physios practising in a way that is not evidence-based, and that if physiotherapy as a profession was scrutinised in the same way, the finding would be that there’s an awful lot of approaches under the physiotherapy banner that lack evidence as much as Bowen therapy does. To go further – in my field of pelvic and vaginal pain, there is little to no research support for many of the treatments offered by doctors…but are their practices being put under the microscope, and then being removed from Medicare rebates?

    Reply
    • timcocks0noi

      Hi Alyssa,
      Thanks for your comments. You raise many valid points and important questions. I don’t have the answers of course, but it seems that this is a worthwhile discussion and debate to have -my motivation for writing this post.
      KInd regards
      Tim

      Reply
  2. carrienewbold

    Had to click on the links to confirm… I didn’t see massage as one of the “banned” treatments within the doc on the health.gov.au site. Was it written elsewhere?

    Reply
    • timcocks0noi

      Hi there
      Massage was listed in the source material linked to in the post above, and was reviewed in the original undertaking, but you are correct in that it was not listed in the final document issued by the Department of Health. Have corrected this above.
      Thanks for pointing this out, Tim

      Reply
  3. Carla Muillins

    I am a pilates practitioner and came to the work in 1993 because of neurological pain. I have studied and practiced the work for years, attending my first NOI course around 2004. I work with a maximum of four clients an hour working people though their own programs and customizing work to needs. Most of my clients are Drs, Nurses and Allied Health Professionals wanting to overcome injuries , manage chronic injuries and pain.

    I consider myself ethical and research based constantly updating my knowledge and working with researchers. I am not a Physiotherapist etc. I started studying physiotherapy but choose not to continue the study because I did not want to be a manual therapist as the neurological issues means using my hands can be difficult. Recently a Phsyio Pilates practice operating with 6 reformers, and offering pre and post baby fat analysis as part of their pilates program. When this sort of garbage jumps onto the band wagon of pilates I can see why it develops a bad name. Sadly. the reforms are going to affect the good practitioners who take the time to do do the right thing, The dodgy physios well they will just use a differnt HICAPS code and not pay GST on the service because it is delivered by a physio.

    Reply
    • timcocks0noi

      Thanks Carla
      The Australian Physiotherapy Association have an interesting take on this – http://physiotherapy.informz.net/admin31/content/template.asp?sid=17887&ptid=453&brandid=2136&uid=505692328&mi=1821398&ps=17887

      “It is important to note that the APA agrees with the broad intent of the government’s PHI reform package—that funding needs to be focused on treatment where there is a sound evidence base showing benefit”

      but then…

      “The reform package measures have been set with the understanding that there is a clear difference between physiotherapist-instructed Pilates programs and those used by other practitioners. As a result, physiotherapists utilising Pilates methods in their patient treatment plans will not be affected by these changes.”

      Seems to me like a case of having and eating one’s cake. I’d be interested to know what the APA thinks the “clear difference” is…

      For what it is worth, I gave up my membership of the APA a very long time ago.

      Best
      Tim

      Reply
      • Carla Muillins

        Thank you Tim. My concern being that 6 people doing the same thing as instructed by a Physiotherapist in many practices is a gym program not requiring the skills of a Physiotherapist, and a waste of the health funds dollars. A customized program requiring different programming and adjustments for no more than four people at the same time is more appropriate. In the end we “pilates practitioners” will rename ourselves and will find our place offering the services that bridge between a medical and a health model. Our success has been because we listen to the needs of our clients and seek to understand their questions rather then impose an answers on the. It just saddens me that as a society we are making some practitioners unaccountable for their service. In the end health and society benefits from diversity or practice and thought. When one system is incentivized at the expense of others we run the risk of stagnating rather than progressing

        Reply
      • Caroline Farquhar

        Hi Tim, thank-you for your article – as a Pilates instructor with 7yrs teaching and clinical practice in London,UK who is now setting up a pilates service in a physiotherapy clinic in Canada this is a hot topic in many countries right now! :)
        It is not surprising, but, a never-ending frustration that Pilates and so many other practices that provide enormous rehabilitation gains & health benefits for clients, lack the “empirical data” to be deemed “proven” effective by the bureaucracies of government and insurance providers. My question: “Since they are lacking the empirical data that they value so highly as a base for their decision-making, why aren’t they funding proper research to generate the actual missing data?….”
        Apparently, it’s just much easier and more efficient to deny services based on opinion/lack of empirical data/profit motives, rather than do the work to check the bias….

        Reply
  4. Katrina

    I’m all for people getting off their backsides and exercising for wellness and health. I hope that gym memberships are still (partially at least) covered. I use Pilates exercises as part of my exercise prescription as an adjunct, and also attend Pilates classes myself.
    Prevention is better than cure, we need to promote the health promoting aspects of all exercise.

    Reply
    • timcocks0noi

      Thanks Katrina
      I think you draw out some key points around activity/exercise as well as prevention and health promotion. This was certainly an interesting aspect of the therapies chosen for the original review – lumping active/physical approaches with homeopathy and iridology, amongst others.
      My best
      Tim

      Reply
  5. Bridget Young

    Tim, what do the pain gurus have to say about cutting massage, tai chi and yoga from pain control regimens? Why have cuts been made after only an “initial” report? I certainly hope David Butler has some influence; we all know that massage, tai chi and yoga are very important pain interventions to those of us trying to manage with fewer pills. Man, I hope this trend is not catching to the Canadian government.

    Reply
    • timcocks0noi

      Hi Bridget
      Thanks for your comment. Two quick things – no gurus here, and it seems that massage survived the cut – I’ve made an edit above!
      On to your excellent point, the ‘voice’ of people experiencing persistent pain does seem to be missing from the review – this is a danger of RCTs and Systematic Reviews.
      My best
      Tim

      Reply
  6. Bec

    Hi Tim
    There are many important key principals that The Pilates teaching style and philosophy deliver that unfortunately can’t be measured with RCTs and systematic reviews. (Or haven’t yet been measured). These being :
    – cognition required to perform the motor Actions (often movements are unknown to clients so are more likely to hold their concentration and create and develop new motor pathways that are attached to safe and positive thoughts, beliefs, perceptions and contexts). This of course is not unique to Pilates programs but Pilates at least provides a platform for this type of motor learning. One does not have to be an expert in motor control to deliver Pilates with the cognitive results mentioned above still having posistive effects.
    – Pilates philosophy and teaching style provides patients with the opportunity to explore and unpack movement through the process of sensory feedback (assisted with equipment in clinical Pilates) and reflection and enquiry of self, thoughts, associated movements. Again, this is not unique to Pilates exercise but is facilitated through the teaching style that it delivers.
    – Pilates offers an opportunity to practice mindfulness in the practical setting. That is, noticing oneself in the present moment. Being aware of the body in space and challenged through exercise in terms of balance, strength, endurance or coordination, without having the opportunity to revert to habitual motor patterns, enhances cognititive processes and gives us the opportunity and space to challenge our thoughts, beliefs, and perceptions relating to specific movement. Obviously this is also not unique to Pilates, but it is a Consistent outcome of Pilates which is what separates it from some other forms of exercise where one might more easily ‘drift off’. One day maybe we can produce some literature relating the effects of Pilates similar to mindfulness….
    – Pilates Is GMI in action. A good teacher will challenge laterality, practice visualisation, explore imagined movements and thoughts and feelings surrounding movement as they progress toward functional movement. Of course, again this is not unique to Pilates but a consistent part of every Pilates program.

    So it comes to this. The Pilates philosophy offers consistency in so many positive motor control concepts, the most prominent being it’s effects on cognition. Because of this, one doesn’t have to be very good at teaching it to get amazing positive results for patients. It’s not better than other forms of exercise so it’s difficult to measure its success. However it is remarkably consistent in it’s approach, it’s adaptable, and it’s reliable. It can make a pretty crap physio/therapist into one who begins to reflect and consider cognition in a biopsychsocial sense. And if it doesn’t do that, the nature of the exercises themselves facilitate patients to make cognitive change. That’s pretty interesting and exciting stuff right there…..

    Reply
  7. steve bradley

    Surely the advances in neuroscience of recent decades demonstrate that symptoms are generated by the cns, are associated with movement disorders (which are learned- think of the success of constrained movement therapy) and the cns cannot be changed by external interventions in any longterm meaningful way- it must be changed within- whether it be education for pain or relearning safe movement. Any movement is better than passive interventions alone, this decision looks like baby out with the bath water

    Reply
  8. pauline lucas

    If these are eliminated from our health coverage we should have our payments reduced considerably already we are paying more in gaps than ever before. Accupuncture phisio naturopathy r all natural remedies” is this just another ploy by our government to dope us up on more pills to fill their coffers. If these procedures diden’t work i would understand, but they have been proven.

    Reply
  9. davidboltononoi

    When our brain has weighed up the World and concluded, within the context of the situation past, present and future that pain is worthwhile, it creates the said experience and, we need to listen very closely to what it is actually expressing. There might be a serious pathology brewing. Maybe an injury has occurred. Maybe healing is finished but pain continues. Maybe, maybe, maybe. The point is would you walk into a board meeting blurting out solutions without knowing what the origin of the problem was? Clinical reasoning is the key stone to any “medical” intervention. To do this we must have a high level of “Medical Knowledge” as achieved, after the long and arduous educational pathways followed by such professionals as Physiotherapists, Osteopaths, Chiropractors, Doctors etc. In addition copious hours of continuing professional development and personal reading slowly form a professional, humble enough to think they might be capable to maybe, create a healing environment and relief. It is an enormous responsibility not to be taken lightly. Once we have diagnosed our patient and drawn up a working hypothesis of there unique experience, the next question is:-What has to change within this being to bring about healing? Then we ask ourselves:-How can that change be brought about, what can we do and what can the patient do? The question of resources follows on from there. Only then can a bespoke intervention be considered. That might include massage, exercise, Pilates or standing on ones head with an aqualung strapped to there back whilst singing God save the queen. In the hands of medical professionals all modalities have a place. If you don’t have the knowledge to clinically reason you don’t have the right to intervene into the patients pain. If you don’t know how to cook stay out the kitchen…!

    Reply
    • Carla Muillins

      When you talk about pilates though, how many physios deliver their classes in a way that requires clinical reasoning. I see endless physio practices with 6 to 10 reformers in a room having everyone doing the same thing . That is NOT showing clinical reasoning, it is about making money of a name, and is essentially running a gym. How this can be described as a physiotherapy activity is the question that is still left unanswered. When the activity is NOT customized and appropriately adopted to the individuals need then it should not be given special status, which is essentially what these reforms are giving to under trained physios. As to your comment about pilates teachers not having clinical reasoning you are obviously dealing with the wrong practitioners. The APMA requires their members to have University level anatomy, 1000 hours of instruction and supervision in the pilates method, just to be a base level teacher. We regularly attend training specifically on our work from topics as diverse as working with cancer patient, glute med tendonopathy to NOI group courses on top of all our other studies and work. When it comes to delivering pilates as a mode of movement intervention we have the clinical reasoning skills and the respect for other professionals that mean we consult on treatment plans and progress. As a person who takes pride in her work and her clinics I like to see that the same level of integrity and quality to individual clients is given to all those who seek out pilates as one part of their long term health strategies. These reforms fail to do this.

      Reply
      • Paul

        Carla,

        Just a few queries in relation to your response:

        Is there evidence that an individualised exercise program is more superior to a generalised exercise program for most health conditions?
        Why can’t you still have clinical reasoning while treating 6 – 10 people at a time? E.g. a patient has PFJ pain so I am going to increase the capacity for their knee to take load, strengthen their gluteals etc, why can’t they do this with 8 other people in a class
        Isn’t exercise a core treatment modality of physiotherapy? Why does it have to be limited to small numbers of people at one time

        Regards,

        Paul

        Reply
        • Carla Muillins

          hello Paul, It is very easy to do big movements and small movements incorrectly. It is not unusual for people to have injuries because they don’t have a good body awareness and when they are given exercises to correct the injury they continue to do the exercise incorrectly. eg the old rotator cuff exercise series given to many people. When you actually look at the clients/patients doing the exercise there are many ways they can cheat. You can see them pulling the arm so forcefully that rather than focussing on the rotator cuff they are just using rhomboids. Alternatively their movement can be activating upper traps or they can be pulling the alignment of the humeral head in a way that all they are doing is stretching the anterior capsule of the shoulder. All of these little details are what a good pilates teacher focusses on when they work with clients in smaller groups in a focussed class individualised for that person. I am not saying a physiotherapist can’t do this but it is not possible when you have 8-10 people in a class doing general strength and conditioning work all doing the same thing. When I train pilates teachers we spent 100s of hours just on the how to achieve an alignment focus of the upper limb in dynamic movement we spend 100s more hours just feeling and experiencing the differences in bad alignment so that we can cue and focus. A good training course to get to a base level of pilates teaching is other 1000 hours of theory and practical trainign. Many physios feel that they can understand the system and process of pilates after a 16 hour weekend course. There are differences in our approaches. Both professions can learn from each other and can respect our skills. I have a lot of physiotherapists , osteopaths, doctors etc refer clients to us because we take the time to teach correct movement patterns not just give an exercise

          Reply
          • Paul

            Hi Carla,

            Some follow up points:

            What do you mean by doing big or small movements incorrectly? What is optimal movement? We have seen of research coming out recently showing that changing kinematics is not necessary for improving pain. The body has the potential to adapt to loads, see Dr. Greg Lehman https://www.youtube.com/watch?v=cnLxcEMdjVk&vl=en
            Given most patients see a physiotherapist for pain, with respect to your example of the shoulder, it has been shown that correction of shoulder movement is not necessary for a change in pain https://www.ncbi.nlm.nih.gov/pubmed/28652066
            Also I don’t think their are any studies have shown that teaching some one to pull their shoulder blade back and use their external rotators during Pilates will translate into changed kinematics when reaching for a plate in a cupboard or lifting a suitcase at the airport, people will often default to their preferred kinematics anyways
            I agree that there needs to be some specificity with exercise eg if you want to improve knee load tolerance you need to do an exercise that stresses the knee, if you want to improve hamstring load tolerance you need to strengthen the hamstring etc. I think though making exercises too specific can be nocebic eg telling people they can only do lunges with their left leg because they are a left side bias and if they use their right their energy flow will go out of whack and they will have chronic pain forever……
            Therefore I think its’s rational to have larger groups. Why not help more people at once if you can, it will also make it more cost effective for the patient. Or is it that we want to sound super technical so patients think we are doing something fancy that any personal trainer couldn’t learn in a 6 week course

            Reply
            • Craig Phillips

              Gotta step in here because we must point out that cognitive, explicit control of small muscles etc etc is not supported anywhere in evidence. Muscular control is subcortical and dictated by the central pattern generators (CPG’s) in the cord. Quite correct that conscious control will not change kinematics.
              There is excellent evidence that asymmetrical exercise will “balance” asymmetrical movements as this is where pathology has interfered.

              Even the strength model is flawed, (refer Sam Leslie PhD pilot studies) https://simplifaster.com/articles/direction-bias-gym-programming-athletic-performance/

              Reply
              • Paul

                Hi Craig,

                Thanks for your reply. I had a quick look at Sam’s study, unfortunately did not have full access to it to assess fully. A few points:
                – Study size looked quite small, groups only had 20 participants in each
                – Unsure whether examiners were blinded (could introduce bias)
                – Unable to see exercise description (one group may have worked harder/more hence the improvements)
                – Improvements seen were performance based (hopping etc), most physiotherapy patient’s come in with pain and are not really concerned if they can hop a little higher or further.

                Could you please clarify what you mean by “asymmetrical exercise will balance asymmetrical movements as this is where pathology has interfered” and also point me in the direction of such evidence

                I can understand that if a footballer continues to tear their right hamstring because this is their dominant leg, then yes it makes sense to give hamstring strengthening exercises to that side (I would also still continue to exercise the other side though)

                Reply
  10. Craig phillips

    CLINICAL PILATES vs PILATES.
    Good to see this has happened. We started Clinical Pilates some 30 yrs ago when nobody had heard of it but it has become “ mainstream” with everyone trying to be a physio. The difference with Clinical Pilates is that it is a movement based classification & treatment system, giving physios the ability to classify the patient & set a heterogenous exercise treatment. There are no generic
    Classes & it’s not core stability.
    It’s is an independently validated tool with .87 kappa inter rater reliability. This a serious high level treatment so the health reform exclusion is a bonus for properly trained Clinicians. Our focus is making high cost , chronic , complex patients ….. dare I say, easy to treat. Happy to continue this conversation. Cheers

    Reply

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