Between Recognition and Regulation: The Kinesiologist in Italy and the United States

1. Introduction

The kinesiologist is a boundary figure. The profession sits at the intersection of sport, health and rehabilitation, drawing on movement science, exercise physiology and motor learning, yet belonging fully to none of the institutional domains that those fields have constructed for themselves. This in-between position is not incidental. It is the structural condition of the profession, and it explains much of the regulatory difficulty that this article examines.

Across Western legal systems a recurring pattern appears. The knowledge base of kinesiology is mature; the university programmes are well established; the professional communities are organised and vocal; and yet the legal status of the practitioner remains uncertain. There is a recognition gap. The gap is not the absence of competence, nor the absence of demand, nor the absence of professional self-awareness. The gap is the failure of the regulatory apparatus to convert an established field of knowledge into a well bounded, publicly accountable profession. In this respect the kinesiologist differs from the physician, the nurse, the physiotherapist and the dietitian, all of whom occupy regulatory categories that the public can read and the state can enforce.

This article focuses on two systems: Italy and the United States. The choice is deliberate. Both are large, advanced economies with mature university systems and active professional communities. Both have generated substantial academic and institutional literature on the kinesiologist figure. Yet the two have pursued divergent regulatory paths. Italy has legislated. The United States has not, except in a single state. The Italian state has named the profession in a statute, the Codice dello Sport, and has defined distinct professional profiles tied to specific university degrees. The American system, by contrast, has allowed the market to organise the profession through private certification, with the state largely absent. The comparison is instructive precisely because the two systems fail in opposite directions while arriving at a common destination.

The argument of this article can be stated directly. Both Italy and the United States have produced regulatory frameworks that acknowledge the kinesiologist without securing the profession. The Italian framework offers legislative recognition without institutional enforcement. The American framework offers institutional enforcement, through accreditation and certification, without legislative recognition. The two deficits mirror one another. In Italy a title exists in law but no professional order administers it, no register enumerates its holders, and no disciplinary mechanism polices its boundaries. In the United States a dense ecology of certifications performs the social function of regulation, signalling competence to employers and consumers, yet without the legal authority that would make those signals binding, exclusive or enforceable. The issue is not whether either system recognises the profession. Both do, in their own idiom. The issue is whether recognition, in the absence of a coherent regulatory architecture, can deliver the protections that regulation exists to provide.

Those protections are the recurring concern of the analysis. Regulation of a health-adjacent profession is not an end in itself. It serves the public, the patient, the athlete, the casual participant who walks into a gym and cannot tell a certified personal trainer from a clinical exercise physiologist. The vulnerable subject is the ethical fulcrum of the entire inquiry. When the European Observatory describes regulation as the set of laws defining minimum educational requirements, entry to practice, title protection, scope of practice and continuing professional development, it frames these instruments as devices for assuring safe, effective and patient-centred care. The kinesiologist, in both Italy and the United States, operates in a space where several of these instruments are missing or weak. The consequence is borne not by the profession alone but by the people the profession serves.

The structure of the article follows the logic of the comparison. Section 2 defines kinesiology as a profession, separating its disciplinary identity, as a body of knowledge about human movement, from its professional identity, as a regulated occupation with a defined scope. This section situates Italy and the United States within a brief international panorama that includes the Canadian province of Ontario, which regulated kinesiology in 2013, the British clinical exercise physiology movement, which achieved formal recognition in 2024, and the Australian accredited exercise physiologist model. Section 3 reconstructs the Italian framework in detail, tracing the legislative path from Law No. 4/2013 on unregulated professions through Law No. 3/2018, the Legge Lorenzin, to Legislative Decree No. 36/2021 and its corrective instruments. It then analyses the structural deficit, a title without an order, and the fragmentation of the educational architecture. Section 4 reconstructs the American framework, beginning from the regulatory vacuum produced by the constitutional allocation of professional regulation to the states, examining the singular Louisiana exception, mapping the certification landscape, and reading the labour market evidence that exposes the terminological and regulatory confusion at the heart of the American system. Section 5 conducts the comparative analysis proper, identifying three shared structural failures and three divergent regulatory paths, and developing the central concept of the legitimacy deficit. Section 6 turns to reform, proposing trajectories for each system and stating the conclusions.

A methodological note is necessary. This article adopts a qualitative socio-legal comparative approach. It does not measure outcomes statistically, nor does it survey practitioners. It reads texts: statutes, decrees, administrative rulings, accreditation standards, certification requirements and the secondary literature that interprets them. The comparison is structural rather than functional in the narrow sense. It asks how each system has arranged the institutional components of professional regulation, title protection, scope-of-practice definition, registration, accreditation, certification, disciplinary control, and where those components are present, absent or misaligned. The method draws on the comparative institutional tradition exemplified by Robertson et al. (2021), who analyse health professional scope-of-practice regulation across the United States, Canada, Australia and the United Kingdom, and who show that systems facing similar challenges may regulate through tasks, through protected titles, or through both. That distinction, between task-based and title-based regulation, runs through the present analysis. It allows the kinesiologist to be located within a broader map of how states choose to make professions legible. The analysis indicates that neither Italy nor the United States has completed that work, and that the reasons differ in each case while the consequence converges.

This contribution therefore argues a single, sustained thesis across two jurisdictions. Recognition is not regulation. A name in a statute is not an order. A certification is not a licence. The defence of the kinesiologist as a profession requires distinguishing legislative acknowledgement from institutional enforcement, market signalling from legal authority, and professional identity from professional sovereignty. Without those distinctions the profession remains, in both countries, recognised but unsecured.

2. Defining Kinesiology as a Profession

2.1. Disciplinary Identity and Professional Identity

Kinesiology names a science before it names a profession. As a discipline it is the study of human movement, integrating biomechanics, exercise physiology, motor control and motor learning, and the behavioural and social dimensions of physical activity. The disciplinary identity is secure. University departments, peer-reviewed journals, doctoral programmes and an international research literature all attest to a coherent field. The professional identity is a different matter. A discipline becomes a profession when its knowledge is institutionalised into a defined occupational role, bounded by entry requirements, a scope of practice, an ethical code and a mechanism of accountability. The distinction is not pedantic. It is the hinge of the entire regulatory problem.

The point is not that kinesiology lacks a knowledge base. It does not. The point is that a knowledge base, however mature, does not by itself generate a regulated profession. The transition from disciplinary identity to professional identity requires an act of institutional construction that only the state, or a body authorised by the state, can perform. That act establishes who may use a title, what that title-holder may and may not do, who keeps the register, and who removes the incompetent or the dishonest from practice. Where this act is incomplete, the profession exists socially and intellectually but not institutionally. This is the condition of the kinesiologist in both Italy and the United States.

The disciplinary core itself spans several territories. Movement science describes the mechanics and physiology of human motion. Exercise physiology examines the body’s adaptive responses to physical stress, and in its clinical form addresses chronic disease, rehabilitation and medically supervised exercise. Motor learning concerns the acquisition and refinement of skilled movement. These territories overlap with medicine, with physiotherapy, with sports coaching and with public health, and the overlap is the source of both the profession’s value and its vulnerability. Value, because the kinesiologist can integrate across domains that more narrowly defined professions cannot. Vulnerability, because integration without a protected boundary invites encroachment, substitution and subordination.

2.2. The International Panorama in Brief

Three jurisdictions outside Italy and the United States show the range of possible regulatory outcomes, and they function in this article as reference points rather than as objects of full analysis.

Ontario provides the clearest case of completed professional construction. On 1 April 2013 Ontario became the first jurisdiction in the world to regulate kinesiology as a health profession, under the Regulated Health Professions Act 1991 and the Kinesiology Act 2007. The College of Kinesiologists of Ontario administers entry to practice, maintains the register, sets practice standards and disciplines members. The scope-of-practice statement defines kinesiology as the assessment of human movement and performance and its rehabilitation and management. Crucially, the title is protected: no person other than a member may hold themselves out as qualified to practise as a kinesiologist in Ontario. Braniff et al. (2012) situate this transition within a SWOT framework, assessing how other health professionals perceived the regulation of kinesiologists, and they show that the addition of kinesiology as a regulated health profession was not perceived as a threat by existing stakeholders but as the formalisation of a needed partner in chronic disease prevention. The Ontario model is significant for the present analysis because it demonstrates that the full architecture, title protection, defined scope, register, discipline, can be assembled for kinesiology specifically, and not only for the older health professions.

The United Kingdom offers a more recent and more targeted construction. Crozier et al. (2024) report on the establishment of clinical exercise physiology as a regulated healthcare profession through the work of Clinical Exercise Physiology UK. Following a 2021 call to action, the profession implemented regulation, developed an industry-recognised scope of practice, created a master’s-level curriculum framework, and aligned with the Academy for Healthcare Science practitioner standards of proficiency and continuing professional development. Crozier et al. (2024) frame this as a deliberate progress narrative: the construction of a regulated profession from a previously unregulated occupational base, achieved through individual registration and institutional master’s degree accreditation. The British case matters because it concerns the clinical end of the movement-science spectrum, the territory where the kinesiologist comes closest to the patient, and because it shows regulation being built profession-first rather than discipline-first.

Australia presents a third configuration. The accredited exercise physiologist operates within a national framework in which Exercise and Sports Science Australia accredits university programmes and the practitioner gains recognition for clinical exercise delivery, including eligibility for public and private health funding pathways. The Australian model regulates substantially through accreditation and professional standards rather than through a single statutory title act, and it sits within the broader Australian pattern that Robertson et al. (2021) describe, in which protected titles, medication management and certain protected acts are regulated while much else is guided by professional standards and codes of conduct. The lesson of the Australian case is that the components of regulation can be distributed across accreditation bodies, professional associations and funding institutions, producing a functioning system without a single point of statutory control.

These three cases bracket the comparison. Ontario shows full statutory professionalisation. The United Kingdom shows targeted clinical professionalisation. Australia shows distributed accreditation-based regulation. Against this range, Italy and the United States appear as the two systems that have moved least far toward a coherent outcome, despite the scale of their economies, the maturity of their universities and the strength of their professional communities.

2.3. The Threshold of Professional Closure

The transition from a discipline to a regulated profession is, in the sociological literature on the professions, a movement toward closure. Closure is the process by which an occupation secures control over entry, over the title and over the tasks that define it, excluding those who lack the recognised qualification. The classic professions, medicine and law foremost among them, achieved closure long ago and defend it through licensure, registration and disciplinary control. Kinesiology has not achieved closure. It occupies the threshold, and the threshold is an uncomfortable place. On one side lies the open market, where anyone may offer movement and fitness services under unprotected labels. On the other side lies the closed profession, where title and task are reserved. The kinesiologist stands between the two, claiming the knowledge of a profession without the protections of one.

This intermediate position generates a characteristic instability. An occupation on the threshold of closure is vulnerable to two pressures simultaneously. From below, it faces competition from unregulated providers, personal trainers, fitness instructors, wellness coaches, who offer overlapping services without the qualification and at lower cost. From above, it faces subordination by the closed professions, the physician and the physiotherapist, who possess the protected scope and who define the kinesiologist’s activity as ancillary to their own. The threshold occupation is squeezed. It cannot exclude those below because it lacks title protection, and it cannot expand against those above because it lacks an autonomous scope. The instability is not a transitional phase that resolves itself with time. It is a stable disequilibrium that persists until the institutional act of closure is performed or abandoned.

The two systems under analysis embody two different relationships to this threshold. Italy has taken a legislative step toward closure by naming the profession and tying it to degrees, yet it has stopped short of the institution, the order, that would complete the closure. The United States has not legislated closure at all, except in Louisiana, and instead has allowed private certification to perform a partial, voluntary substitute for closure, a market closure rather than a legal one. Neither has crossed the threshold fully. The analysis of the two frameworks that follows can be read as an account of two incomplete movements toward closure, distinguishing the legal closure that Italy has begun from the market closure that the United States has improvised, and distinguishing both from the completed closure that Ontario has achieved.

2.4. Why Italy and the United States

The justification for the central pairing rests on three considerations. First, both are large and advanced economies with extensive university provision in movement and exercise science, producing graduates in numbers that make the regulatory question economically and socially consequential. Second, both possess active professional communities, in Italy organised around bodies such as the Comitato Italiano Scienze Motorie and the wider scienze motorie graduate movement, in the United States around associations such as the American College of Sports Medicine, the National Strength and Conditioning Association and the American Society of Exercise Physiologists. Third, and decisively, the two systems have taken opposite institutional routes while producing the same unresolved result. Italy has legislated and failed to institutionalise. The United States has institutionalised privately and failed to legislate.

This divergence makes the pairing analytically productive. A comparison between two systems that succeeded would teach little beyond confirmation. A comparison between two systems that failed in the same way would teach little beyond repetition. The interest lies in two systems that failed in mirror-image ways, because the mirror reveals what each lacks by showing what the other has. Italy has the legal text the United States lacks. The United States has the empirical and accreditation infrastructure Italy lacks. Neither has assembled the whole. The analysis indicates that the missing architecture is, in each case, precisely what the other system partially supplies, and this is the structural observation that the comparative section develops. The task here is preliminary: to establish that kinesiology is a profession in search of its institutional form, and that the search distinguishes disciplinary identity from professional identity, knowledge from authority, and recognition from regulation.

3. The Italian Framework

3.1. The Legislative Path: From Law No. 4/2013 to Legislative Decree No. 36/2021

The Italian story is a story of legislation that names a profession without finishing it. To understand the current configuration it is necessary to trace the sequence of instruments, because each one resolved a fragment of the problem while deferring the whole.

Law No. 4/2013 established the general framework for unregulated professions in Italy, those occupations not organised into a professional order, the ordine or collegio that characterises the Italian regulatory tradition for medicine, law, engineering and similar fields. The law allowed unregulated professions to organise into voluntary associations and to certify the competence of their members against technical standards. For kinesiology this framework was available but insufficient. It permitted self-organisation; it did not confer a protected title, an exclusive scope or a statutory identity. The kinesiology gap, in this first phase, was the gap between voluntary self-regulation and state recognition. Law No. 4/2013 placed the kinesiologist among the professions that exist without an order, alongside a long list of consultants and technicians, and in doing so it located the profession in a regulatory category defined by what it lacks.

Law No. 3/2018, known as the Legge Lorenzin, reformed the healthcare professions and reorganised the system of health profession orders. This was the moment at which kinesiology might have entered the healthcare perimeter. It did not. The Lorenzin reform addressed the recognised health professions and created mechanisms for identifying new ones, but the kinesiologist remained outside. The exclusion was consequential. It placed the profession on the far side of the boundary that separates the sanitario, the healthcare professional integrated into the National Health Service and subject to its regulatory apparatus, from the non-sanitario, the professional who operates in the adjacent space of wellness, fitness and sport. Article 6 of Law No. 3/2018 nonetheless established a procedure through which new healthcare professions could be recognised, and this procedure, as the analysis below shows, became the channel through which advocates would later pursue healthcare status for the preventive and adapted profile. The Lorenzin reform thus simultaneously excluded the kinesiologist and created the legal doorway through which a part of the profession might one day enter.

Legislative Decree No. 36 of 28 February 2021, the centrepiece of the so-called sport reform and commonly known as the Codice dello Sport, changed the legal landscape. For the first time an Italian statute named the chinesiologo and instituted distinct professional figures. Article 41 establishes four profiles. The chinesiologo di base requires the three-year degree in Scienze delle attività motorie e sportive, class L-22, and its professional activity covers the conduct, management and evaluation of individual and group motor activities of a compensatory, educational, recreational and sporting character, together with personal training and non-competitive athletic preparation. The chinesiologo delle attività motorie preventive ed adattate requires the master’s degree in class LM-67, and its activity covers the design and delivery of motor programmes for psychophysical wellbeing across age groups and physical conditions, the prevention of postural defects, post-rehabilitation functional recovery aimed at optimising physical efficiency, and adapted motor activity for differently abled persons or for individuals in clinically controlled and stabilised health conditions. The chinesiologo sportivo requires the master’s degree in class LM-68 and covers the design, coordination and technical direction of athletic preparation in competitive contexts up to the highest levels. The manager dello sport requires the master’s degree in class LM-47 and covers the programming and management of sports facilities and events. Article 42 governs assistance in motor and sporting activities and, in its post-corrective text, requires that paid motor and sporting courses be coordinated by a kinesiologist or by an instructor of a specific discipline holding the relevant qualifying requirements, with administrative sanctions for violation.

The significance of Article 41 is easily stated and easily misunderstood. It is significant because it writes the word chinesiologo into the law of the state and ties each profile to a specific academic class. It is misunderstood when this naming is read as full professionalisation. D’Elia et al. (2022) frame the reform as a genuine innovation, observing that it recognises the working professional profiles of the basic kinesiologist, the preventive and adapted physical activities kinesiologist, the sports kinesiologist and the sports manager. Yet the same recognition that names the profiles leaves the institutional machinery unbuilt. Article 41 itself anticipates this incompleteness. It defers to a Conference between the State, the Regions and the autonomous provinces the criteria for recognising equivalent qualifications, and it defers to a decree of the President of the Council the implementing provisions concerning the training path and the professional profile. The statute, in other words, recognises the profession and then delegates the construction of its substance to instruments that arrive later, partially, and unevenly.

Decree-Law No. 163 of 5 October 2022 provided integrative and corrective provisions. Among these it refined Article 41, introducing a provision under which the LM-67 professional, or another professional with specific competencies, supervises adapted physical activity in groups and structured individual physical exercise. This corrective is important because it begins to articulate a healthcare-adjacent role for the preventive and adapted profile, positioning the LM-67 kinesiologist in relation to the palestre della salute, the health gyms, where adapted physical activity and structured exercise are offered in collaboration with physicians specialised in sports and exercise medicine, in physical and rehabilitative medicine and in nutrition science, and with healthcare professionals such as the physiotherapist and the dietitian. The corrective decree thus sharpens the boundary between the kinesiologist and the established health professions even as it draws the kinesiologist nearer to the clinical setting. The LM-67 professional collaborates; the LM-67 professional does not autonomously treat.

Ministerial Decree No. 1649 of 19 December 2023 reformed the university curricular framework, addressing the educational architecture that underpins the profiles. This instrument belongs to the educational analysis below, but its place in the legislative sequence should be marked here: it is the moment at which the state turned from naming the profession to specifying the training that produces it. The sequence is therefore cumulative and incomplete. Law No. 4/2013 located the profession among the unregulated. Law No. 3/2018 excluded it from the healthcare perimeter while opening a recognition procedure. Legislative Decree No. 36/2021 named it and instituted its profiles. Decree-Law No. 163/2022 corrected and extended the profiles. Ministerial Decree No. 1649/2023 reformed the curriculum. At no point in this sequence did the state establish a professional order, a national register or a disciplinary mechanism. The legislative path produced a title without the institution that would administer it.

3.2. The Structural Deficit: Title Without Order

The defining feature of the Italian framework is the title without the order. The chinesiologo exists in statute. The Ordine Nazionale dei Chinesiologi does not exist. This absence is not a technicality. In the Italian regulatory tradition the order is the institution that performs the core functions of professional self-government under state authority: it keeps the register, it controls entry, it sets and enforces ethical standards, and it disciplines members. Without an order these functions are either unperformed or performed by voluntary bodies whose decisions lack legal force.

The consequence is a peculiar legal situation, and it follows directly from the architecture of Italian professional law. Where a profession has no order, a person holding the qualification recognised by law may exercise the profession without enrolling in any register, because there is no register to enrol in. The recognition under Article 41 confers the right to use the title and to perform the described activities on the basis of the degree alone. A graduate of the L-22 class may call themselves a chinesiologo di base the day after graduation and may practise, because the law that recognises the qualification also, in the absence of an order, dispenses with mandatory enrolment. This is recognition without gatekeeping. It is the opposite of the Ontario model, where no person may hold themselves out as a kinesiologist unless registered with the College. In Italy the title is recognised but not reserved through an enrolment mechanism, and the boundary that should separate the qualified from the unqualified is correspondingly porous.

The enforcement gap compounds the problem. Article 42, in its corrective form, requires paid motor and sporting activities to be coordinated by a kinesiologist or a qualified instructor, and it attaches administrative sanctions to violations. The sanction mechanism introduced through the corrective legislation provides for administrative fines in a range running from the order of one thousand to ten thousand euro for non-compliance. Yet a sanction attached to the coordination requirement of facilities is not the same as a title-protection offence enforced against individuals who falsely present themselves as kinesiologists. The Italian system sanctions the structure that fails to engage a qualified coordinator; it does not, through the same mechanism, robustly police the individual who appropriates the title without the qualification. The result is an enforcement architecture aimed at the facility rather than at the title, and the protection of the public depends on the diligence of facility operators and regional inspection rather than on a professional order empowered to act against impostors.

The fiscal dimension reveals the boundary from another angle. The position of the kinesiologist with respect to value added tax, the imposta sul valore aggiunto, turns on whether the activity falls within the healthcare perimeter, since healthcare services attract VAT exemption. The Agenzia delle Entrate, in Risoluzione n. 9 of 24 February 2026, addressed the fiscal treatment of the kinesiologist’s activity, and the relevant point for this analysis is structural rather than technical: the kinesiologist is positioned outside the healthcare perimeter for the purpose of the exemption, which confirms in fiscal law the exclusion that Law No. 3/2018 effected in health-professions law. The kinesiologist is not, for these purposes, a sanitario. The fiscal authority’s treatment is therefore not a mere administrative matter. It is a second institutional confirmation that the profession sits outside the health-system boundary, with consequences for how the service is priced, how it is perceived and how it competes with the exempt services of physiotherapists and physicians.

Against this exclusion advocates have pursued the Article 6 pathway of Law No. 3/2018. The Comitato Italiano Scienze Motorie and allied bodies have petitioned the Ministero della Salute to recognise the LM-67 profile, the kinesiologist of preventive and adapted physical activities, as a healthcare profession through the procedure that Article 6 establishes for the identification of new health professions. The logic of the petition is coherent with the profile’s content: the LM-67 kinesiologist works with individuals in clinically controlled and stabilised conditions, supervises adapted physical activity and structured exercise, and operates adjacent to rehabilitation. Raiola and colleagues, in the institutional literature, formulate the hypothesis of distinguishing two professional profiles of kinesiologist, with the three-year figure oriented toward primary and secondary prevention and potentially configurable as a basic healthcare profession devoted to health promotion through physical exercise. The petition thus seeks to move part of the profession across the boundary that the Lorenzin reform drew, using the doorway that the same reform left open.

The political signals have been encouraging and inconsequential in equal measure. The Conferenza della Commissione Salute in the State-Regions framework, in July 2023, addressed the kinesiologist question and produced a political signal toward recognition. A signal is not a statute. A conference conclusion in the State-Regions system carries political weight and administrative momentum, yet it does not, by itself, create a healthcare profession, establish an order or amend the fiscal perimeter. The risk that recurs throughout the Italian framework is the risk of stasis: a sequence of recognitions, petitions, corrective decrees and political signals that accumulate acknowledgement without producing the institutional structure that would make acknowledgement effective. The structural deficit is therefore not the absence of recognition. The structural deficit is the gap between recognition and institution, between the title that the law confers and the order that the law has not created, between the political will that the conferences express and the legal consequence that the statutes withhold.

3.3. The Educational Architecture and Its Fragmentation

The Italian profession rests on a four-tier educational structure that maps directly onto the four profiles. The three-year L-22 degree produces the chinesiologo di base. Three master’s classes produce the three advanced profiles: LM-67 for the preventive and adapted kinesiologist, LM-68 for the sports kinesiologist, and LM-47 for the sports manager. This degree-based hierarchy is the load-bearing element of the Italian model. The profession is defined not by examination, not by licensure, not by registration, but by the academic title held. The degree is the credential, the gatekeeper and the boundary all at once.

A structure that places the whole regulatory weight on the degree exposes the profession to whatever variation exists across the degree-granting institutions. That variation is substantial. D’Elia et al. (2024) examine the university training of the sports and physical activity kinesiologist comparatively, and they identify an imbalance in the curricular weighting between biomedical credits and the credits attributed to exercise and sport sciences across different universities. The ECTS allocation, the European Credit Transfer and Accumulation System measure of curricular weight, varies in ways that produce graduates with materially different competence profiles despite holding nominally equivalent degrees. D’Elia et al. (2024) show that this is not a marginal inconsistency. It goes to the substance of what the title certifies, because a degree-based profession is only as coherent as the degrees that constitute it. Where one university weights biomedical content heavily and another weights it lightly, two holders of the same class graduate with different capacities while bearing the same legally recognised title.

This fragmentation is structurally serious in a system that has chosen the degree as its sole regulatory instrument. In a licensure system a common examination can correct for curricular variation, because every candidate must pass the same test regardless of where they studied. In a registration system common entry standards can perform the same correction. Italy has neither. The degree is the gate, and if the gate is built to different specifications in different places, the profession admits practitioners of uneven competence under a single name. Ministerial Decree No. 1649/2023, in reforming the curriculum, addresses this problem at its root, attempting to harmonise the educational content that produces the profiles. The reform is therefore a necessary response to the fragmentation that D’Elia et al. (2024) document, yet its effectiveness depends on implementation across an autonomous university sector, and harmonisation by decree is not the same as harmonisation in practice.

The deeper problem with a purely degree-based regulatory instrument is that it locates the guarantee of competence at the point of graduation and provides no mechanism for maintaining it thereafter. A regulated profession requires continuing professional development, the periodic renewal of competence over a career, and it enforces this requirement through the register and the disciplinary mechanism. The Italian degree, once obtained, is permanent. It does not expire, it is not renewed against updated standards, and in the absence of an order there is no body empowered to require the practising kinesiologist to demonstrate continuing competence. The degree certifies what the graduate knew at the moment of graduation; it certifies nothing about what the practitioner knows a decade later. This temporal gap is a structural feature of degree-based regulation, and it is one that licensure and registration systems address routinely through mandatory continuing education tied to the maintenance of the licence or the registration. Italy has the entry credential and lacks the maintenance mechanism, so that the competence the framework guarantees is the competence of the new graduate rather than the competence of the practising professional.

The equivalency risk operates at a second level, the level of public and stakeholder understanding. D’Elia et al. (2022) study the perception of stakeholders in non-professional football regarding the new working profile of the sports kinesiologist, and they reveal confusion about what the profile is, what it does and how it differs from the figures that already populate the sporting field, the coach, the athletic trainer, the physiotherapist. The confusion is not the fault of the stakeholders. It is the predictable result of introducing a legally recognised profile into a field already crowded with overlapping roles, without a register that would identify its holders or a protected boundary that would distinguish them. D’Elia et al. (2022) identify, in effect, the demand-side counterpart of the supply-side fragmentation that D’Elia et al. (2024) document. On the supply side the degrees vary; on the demand side the stakeholders cannot reliably tell what the title means. Both findings converge on the same conclusion: a degree-based profession without an order, a register and a protected title generates uncertainty at the point of production and at the point of consumption alike.

The educational architecture therefore reproduces, at the level of training, the structural deficit identified at the level of regulation. The profession is recognised in law and elaborated in curriculum, yet the elaboration is fragmented across institutions and opaque to the stakeholders who would employ or consult the practitioner. The four-tier structure offers a clear logical hierarchy on paper: a basic three-year profile, two specialised master’s profiles for prevention-and-adaptation and for sport, and a management profile. In practice the hierarchy is undercut by curricular variation, by the absence of a register that would make the tiers publicly legible, and by the persistent uncertainty about which tier corresponds to which competence in which setting. The Italian framework has built the staircase and omitted the building. What the analysis indicates is that legislative recognition and curricular elaboration, however genuine, cannot substitute for the institutional functions that an order would perform, distinguishing title protection from scope-of-practice regulation, certification of competence from recognition of degree, and professional recognition from professional sovereignty. The Italian system has the recognition and lacks the sovereignty. The next section turns to a system that has built much of the practical infrastructure of sovereignty, accreditation, certification, employer demand, while lacking the legislative recognition that Italy possesses.

3.4. Regional Variation and the Unfinished Delegation

A further dimension of the italian fragmentation deserves separate treatment, because it concerns the territorial structure of the Italian state. Article 41 of Legislative Decree No. 36/2021 defers important elements of implementation to instruments that involve the Regions. The criteria for recognising equivalent qualifications are to be established through an Accord in the State-Regions Conference, and the structural and organisational requirements for the realisation of the health gyms, the palestre della salute, where the LM-67 kinesiologist would operate, are left to the Regions and the autonomous provinces. This delegation embeds regional variation into the very design of the framework. What the kinesiologist may do, where the kinesiologist may do it, and under what structural conditions, depends in part on regional implementation that has proceeded unevenly across the Italian territory.

The palestre della salute illustrate the problem. The health gym is the institutional setting in which the preventive and adapted kinesiologist comes closest to the healthcare system, delivering adapted physical activity and structured exercise to individuals in clinically controlled and stabilised conditions, in collaboration with physicians and healthcare professionals. Yet the realisation of these settings depends on regional initiative, and the legislative provision that contemplates them does not by itself create them. A profile defined in national statute thus acquires its operative content only where a Region has built the institutional setting that the statute envisages. In Regions that have moved, the LM-67 kinesiologist has a defined place; in Regions that have not, the same legally recognised profile operates in a setting that the law contemplates but the territory has not provided. The recognition is national; the realisation is regional and partial.

This unfinished delegation compounds the structural deficit identified above. It is not merely that Italy has a title without an order. It is that the operative content of the title, for the most clinically engaged profile, depends on a chain of subordinate instruments and regional actions that the framework anticipates without guaranteeing. The result is a profession whose legal definition is uniform across the national territory and whose practical reality varies from Region to Region, distinguishing the uniformity of the statute from the unevenness of its realisation, the national recognition of the profile from the regional construction of its setting, and the legislative ambition of healthcare integration from its territorial delivery. The Italian framework has, in this respect, written a profession that the state has only partly built and that the Regions have only partly furnished.

4. The American Framework

4.1. The Regulatory Vacuum: A System by Default

The American framework begins from absence. There is no federal regulation of the kinesiologist, and there is no federal regulation of the exercise professional more broadly. This is not an oversight. It follows from the constitutional architecture, which reserves the regulation of professions to the states through their police power over health, safety and welfare. Health professions in the United States are regulated state by state, each through its own scope-of-practice statutes that define the services a professional may provide and the conditions under which they may be provided. The consequence for kinesiology is a vacuum that the states have, with one exception, declined to fill.

The vacuum is a system in itself, a system by default. In the absence of statutory regulation, the question of who may call themselves a kinesiologist, an exercise physiologist or a personal trainer, and who may perform the associated activities, is answered not by law but by the market. Anyone may use most of these titles. Anyone may offer most of these services. The state does not protect the title, does not define the scope, does not maintain a register and does not discipline the incompetent. What fills the space is private certification, and the central institutional fact of the American system is that certification has assumed the social function of regulation without acquiring its legal authority. This is the American mirror of the Italian deficit. Where Italy has legal recognition without an enforcing institution, the United States has an enforcing ecology of private institutions without legal recognition.

The constitutional architecture deserves a closer statement, because it explains why the American deficit takes the form it does. The regulation of professions in the United States rests on the police power of the states, the reserved authority over the health, safety and welfare of their populations. There is no general federal authority to license or to protect the title of a health profession, and the federal role in the health workforce operates indirectly, through funding conditions, reimbursement rules and the accreditation requirements attached to federal programmes, rather than through direct licensure. The consequence is a patchwork. Each state decides, for each occupation, whether to regulate and how. For the established health professions the patchwork has converged, over a century, toward near-universal licensure with broadly similar scopes. For the kinesiologist and the exercise professional it has not converged at all, because the states have, with the Louisiana exception, declined to enter the field.

This declining is itself a regulatory choice, not a neutral absence. A state that does not regulate an occupation has decided that the risk to the public does not warrant the apparatus of licensure, or that the political cost of regulation exceeds its benefit, or simply that the occupation has not generated the organised demand that drives professional regulation forward. The principle of proportionate regulation, sometimes called right-touch regulation, holds that the degree of regulation should match the level of risk to consumers. The American non-regulation of the exercise professional reflects, in effect, a collective judgement that the risk is low enough to leave to the market. The clinical exercise physiology movement contests precisely this judgement, arguing that the clinical end of the spectrum, where the practitioner works with chronic disease and rehabilitation, carries a risk that the market alone cannot manage, distinguishing the low-risk general fitness setting from the higher-risk clinical setting, and distinguishing the state’s discretion not to regulate from a considered assessment of the harm that non-regulation permits.

4.2. Louisiana as the Singular Exception

Louisiana is the one state that has crossed the line into statutory regulation, and it has done so for a narrowly defined figure. The Louisiana Administrative Code, title 46, part XLV, chapter 37, regulates the clinical exercise physiologist, and the Louisiana State Board of Medical Examiners administers the licensure. The requirements are demanding and revealing. To obtain initial licensure as a clinical exercise physiologist a candidate must have completed a master’s degree in an exercise studies curriculum at an accredited institution that, at the time of graduation, was approved by the American College of Sports Medicine or by the board; must be certified as an exercise specialist or registered clinical exercise physiologist by the American College of Sports Medicine, having passed the relevant ACSM examination; and must have completed an internship of three hundred hours in exercise physiology under the supervision of a licensed exercise physiologist. The Louisiana statute, in other words, does not invent its own competence standard. It borrows the ACSM standard and gives it the force of state law.

This borrowing is the most instructive feature of the Louisiana model. It demonstrates how the private and the public can be coupled: a state takes a private certification, the ACSM credential, and converts it from a market signal into a licensure requirement. In Louisiana the clinical exercise physiologist title is protected by statute, the scope is defined by regulation, and the state holds the disciplinary power. For this one figure, in this one state, the full architecture of regulation exists. Everywhere else in the United States, and for every other figure within the movement-science family, it does not. Louisiana is therefore not merely an exception; it is a proof of concept. It shows that the American constitutional structure permits statutory regulation of the clinical exercise professional, that such regulation can be built on the existing private certification infrastructure, and that the obstacle to its spread is political and institutional rather than constitutional.

4.3. The Certification Landscape

In the forty-nine states without statutory licensure for the figure, the certification landscape is the regulatory system in all but name. Several bodies dominate, and the National Commission for Certifying Agencies, the NCCA, functions as the de facto standard-setter by accrediting the certifications themselves. The NCCA does not regulate practitioners. It accredits the bodies that certify practitioners, and in doing so it performs a second-order function: it certifies the certifiers. This layered structure, NCCA above the certifying bodies, certifying bodies above the practitioners, is the private architecture that substitutes for public regulation.

The American College of Sports Medicine offers the credentials closest to the clinical end of the spectrum. The ACSM Certified Exercise Physiologist, the ACSM-EP, requires a bachelor’s degree in exercise science, exercise physiology or kinesiology. The ACSM Certified Clinical Exercise Physiologist, the ACSM-CEP, requires either a master’s degree in clinical exercise physiology with six hundred hours of clinical experience or a bachelor’s degree in exercise science or equivalent with twelve hundred hours of clinical experience, and it positions the holder as an allied health professional who uses prescribed exercise and health-behaviour interventions for individuals with chronic diseases. The Registered Clinical Exercise Physiologist, the RCEP, marks the most advanced clinical tier. These ACSM credentials form a graded ladder from the general to the clinical, and they map, loosely, onto the kind of distinctions that the Italian profiles attempt to draw between the base and the preventive-and-adapted figures.

The National Strength and Conditioning Association occupies the performance end. The Certified Strength and Conditioning Specialist, the CSCS, is the association’s flagship credential, oriented toward athletic performance and strength training, and the NSCA Certified Personal Trainer, the NSCA-CPT, addresses the general fitness setting. The National Academy of Sports Medicine, NASM, offers a widely held Certified Personal Trainer credential together with a suite of specialisations. The American Council on Exercise, ACE, likewise centres on a Certified Personal Trainer credential aimed at the general fitness market. Across these bodies the credentials proliferate, overlap and segment the field by setting, by population and by intensity of clinical involvement, yet none of them carries legal exclusivity. A NASM or ACE personal trainer certification signals competence to an employer and a consumer; it does not reserve a title or define a scope enforceable against non-holders.

Above this field sits the United States Registry of Exercise Professionals, USREPS, a voluntary registry that aggregates holders of NCCA-accredited certifications into a single searchable record. The Coalition for the Registration of Exercise Professionals, CREP, maintains the registry. The logic of USREPS is transparency: it offers employers, consumers and policymakers a way to verify that an individual holds an accredited credential, and it aspires to the quasi-regulatory function of a public register. Yet the registry is voluntary, and a voluntary register is not a regulatory register. It records those who choose to be recorded and who already hold accredited credentials; it does not bound the profession, because nothing compels entry and nothing prevents an uncredentialled person from practising under an unprotected title. USREPS is therefore the American attempt to manufacture, through private coordination, one of the institutional functions, the public register, that statutory regulation would provide. It is an instructive half-measure: the form of a register without the legal force that would make the register the gate to the profession.

4.4. The Job Market Evidence

The clearest empirical window onto the American system is the labour market, and Bartlett et al. (2024) provide it. Through a content analysis of job postings for exercise professionals in the United States, examining a corpus of advertised positions, Bartlett et al. (2024) identify a systemic mismatch between the degree requirements that employers state and the certification expectations they impose. The two do not align. Employers ask for degrees and certifications in combinations that reveal no shared understanding of what qualifies a person to do the work, because no shared understanding exists. Bartlett et al. (2024) sort the postings into four employment categories, academic positions, general fitness roles, athletic performance roles and clinical exercise specialist roles, and they show that the qualification expectations differ across these categories in ways that track the absence of any unifying credential standard.

The most telling finding concerns terminology. Bartlett et al. (2024) demonstrate that employers use the terms kinesiology, exercise science and exercise physiology interchangeably, treating degrees in these fields as substitutable for one another in job requirements. This interchangeability is the linguistic symptom of a regulatory absence. Where a profession is regulated, its title is fixed and its degree pathway is specified, and the labour market inherits that fixity. Where a profession is unregulated, the labour market is free to treat cognate terms as equivalents, and it does. The terminological conflation that Bartlett et al. (2024) document is therefore not a mere usage habit. It is the trace, in the language of employers, of the regulatory vacuum that the American system has left unfilled. The conflation runs in both directions: a degree in kinesiology may satisfy a posting that names exercise science, and a posting that names exercise physiology may accept a holder of either. The terms float free of any fixed referent because no institution has fixed them.

This evidence is significant for the comparative argument because it gives the American deficit an empirical sharpness that the Italian deficit, documented largely through legal and curricular analysis, does not possess in the same form. Bartlett et al. (2024) measure the consequence of non-regulation in the currency of the labour market, the mismatch between stated degree requirements and certification expectations across hundreds of real postings. The Italian literature shows fragmentation in curriculum and confusion among stakeholders; the American literature shows the same underlying disorder expressed as terminological substitution and qualification mismatch in hiring. Both describe a profession whose boundaries the relevant institutions have failed to fix, distinguishing measured labour-market disorder from inferred regulatory disorder, yet pointing to a single cause.

The four employment categories that Bartlett et al. (2024) identify repay closer attention, because each exposes the regulatory vacuum from a different angle. The academic category, encompassing teaching and research positions, predictably privileges advanced degrees and is the most credentialled segment of the field, yet it is also the segment furthest from the practitioner who serves the vulnerable subject directly. The general fitness category, encompassing personal training and group exercise roles, is the most populous and the least regulated, the segment in which an uncredentialled individual most easily presents to the public as a competent professional. The athletic performance category, encompassing strength and conditioning roles in collegiate and professional sport, leans on the NSCA credential and is the most coherent segment in its credential expectations. The clinical exercise specialist category, encompassing roles in cardiac rehabilitation, chronic disease management and medically supervised exercise, is the segment closest to the patient and the one in which the absence of statutory regulation is most consequential, because the consequences of incompetence are most severe.

The significance of this categorisation lies in its incoherence as a whole. Bartlett et al. (2024) identify that employers across these four categories impose qualification expectations that do not align with one another and that do not map onto any agreed national standard. A clinical role and a general fitness role may both be advertised under cognate titles, may both accept degrees in kinesiology or exercise science or exercise physiology interchangeably, and may differ in their certification expectations in ways that reflect the idiosyncrasy of the employer rather than any settled understanding of the competence required. The labour market, in other words, has not generated through its own operation the boundaries that regulation would impose. It has instead produced four loosely defined segments whose qualification expectations overlap, diverge and conflict, and the burden of navigating this incoherence falls on the jobseeker, the employer and, ultimately, the public served by whoever is hired. Bartlett et al. (2024) thus provide not merely evidence of a mismatch but a map of the terrain that regulation would have to order, distinguishing the academic from the general, the performance-oriented from the clinical, and the credential the employer requests from the competence the role demands.

4.5. The Clinical Exercise Physiology Movement

Against this background a counter-movement has formed, oriented toward raising the standard of the clinical exercise professional through accreditation. The American College of Sports Medicine has led the principal initiative. The ACSM certification board adopted, in 2020, a requirement that candidates for the ACSM-EP and ACSM-CEP credentials graduate from exercise science or exercise physiology programmes accredited by the Commission on Accreditation of Allied Health Education Programs, CAAHEP, with implementation scheduled for August 2027. The board frames this as a strategic elevation of educational quality and an effort to position exercise physiologists within the healthcare continuum. The CAAHEP alignment is consequential because it imports, into the certification pathway, a programmatic accreditation standard of the kind that governs established allied health professions. It moves the ACSM credential from a test of individual competence toward a credential underwritten by accredited education, narrowing the gap between certification and the institutional structure of a regulated profession.

The National Strength and Conditioning Association has pursued a parallel initiative through the Council on Accreditation of Strength and Conditioning Education, CASCE. Beginning in 2020 and 2021, programmes could apply for CASCE accreditation, and the association determined that, effective in 2030, candidates for the CSCS examination must hold a bachelor’s degree from a programme accredited by an NSCA-approved accrediting agency in a strength-and-conditioning-related field. The NSCA frames this change explicitly as aligning the CSCS with other allied healthcare professions, including physicians, nurses, physical therapists and athletic trainers. The CASCE initiative therefore mirrors the ACSM-CAAHEP move at the performance end of the spectrum, attaching programmatic accreditation to the flagship credential and tying eligibility to graduation from an accredited programme.

These two initiatives, ACSM-CAAHEP and NSCA-CASCE, constitute the building blocks of a national accreditation floor. They are not regulation. They are private requirements that condition private credentials on accredited education. Yet they reproduce, within the private system, two of the functions that a regulated profession performs publicly: the accreditation of education and the conditioning of entry on that accreditation. The external reference point for this movement is the British clinical exercise physiology model. Shepherd and Saynor (2022) argue that exercise is medicine but does not need to be prescribed by a physician, and they situate the clinical exercise professional as a recognised expert whose role should be acknowledged in its own right rather than subordinated to physician prescription. Shepherd and Saynor (2022) treat the American model as a contested international benchmark, a system whose certification infrastructure is advanced yet whose lack of statutory regulation leaves the clinical exercise professional without the recognition that the British and other systems have begun to confer. The American clinical movement thus looks outward to the United Kingdom and Australia for the recognition it lacks at home, even as those systems look to the American certification infrastructure as a resource.

4.6. The Advocacy Landscape

A distinct advocacy field surrounds these developments. The American Society of Exercise Physiologists, ASEP, advances the Exercise Physiologist Certified credential, the EPC, and argues for the exercise physiologist as a profession with a defined identity distinct from the broader fitness market. The National Council on Strength and Fitness, NCSF, advocates for employer requirements mandating NCCA-accredited certification, seeking to convert the NCCA accreditation standard into a de facto hiring floor through employer practice rather than statute. These advocacy positions share a common strategic premise: in the absence of statutory regulation, the profession can approximate regulation by persuading employers and the market to treat accredited certification as mandatory.

The argument that recurs across this advocacy is the consumer protection argument. The claim is that the public cannot distinguish a credentialled clinical exercise physiologist from an uncertified personal trainer, that the conflation exposes vulnerable individuals, those with chronic disease, the elderly, the rehabilitating, to advice and intervention from unqualified persons, and that the state therefore has an interest in protecting consumers through title protection or licensure. This is the same vulnerable-subject logic that animates the Italian petitions to the Ministero della Salute, expressed in the idiom of American consumer protection rather than Italian healthcare-profession recognition. In both systems the advocacy ultimately rests on the figure of the person who cannot tell competence from its imitation, and who bears the risk of that inability. The American clinical and advocacy movement has built much of the practical infrastructure that a regulated profession would require, accredited education, graded certification, a voluntary register, an evidentiary case from the labour market, while lacking the one thing that Italy possesses and that only the state can grant: legislative recognition of the profession. The system is empirically grounded and constitutionally constrained, advancing through accreditation and employer demand while the statutory step that Louisiana alone has taken remains, elsewhere, untaken.

5. Comparative Analysis

5.1. Three Shared Structural Failures

Two systems, opposite roads, three common failures. The coincidence is not coincidental at all. These failures are the structural residue of the same unfinished construction, and they remain visible despite the divergence of the routes that produced them.

Take the first. In neither system is the title of kinesiologist, or its national equivalent, reserved in a way that prevents unqualified individuals from operating, and this absence of a unified title-protection mechanism is the foundational shared failure. Italy recognises the title in Article 41 of Legislative Decree No. 36/2021, yet the recognition is not paired with an enrolment requirement enforced by an order, so the boundary between qualified and unqualified is policed, if at all, through facility-level coordination requirements rather than through individual title protection. In the United States the title is, in most states, not protected at all, and the labour market treats kinesiology, exercise science and exercise physiology as interchangeable terms, a pattern that, as Bartlett et al. (2024) demonstrate across 615 job postings, reflects something structural rather than incidental. The Italian failure is recognition without reservation. The American failure is the absence of recognition altogether. The effect, though, is identical: a person without the appropriate qualification may, in practice, present to the public as a competent movement professional, and the public has no legally guaranteed signal that separates the qualified from the unqualified.

The second shared failure is the conflation of certification with regulation. In the United States this conflation is overt and structural, because private credentialing, through ACSM, NSCA, NASM and ACE under NCCA accreditation, performs the social function of regulation, signalling competence and segmenting the field, without the legal authority that would make those signals exclusive or enforceable. Italy arrives at the same place by a different door. The degree functions as the certification, and recognition under Article 41 confers the right to practise, yet without an order the system leans on the academic credential to do the regulatory work an order would otherwise do, and the curricular fragmentation that D’Elia et al. (2024) document shows how unreliable a regulator the degree becomes once its content varies across institutions. So in both systems a credential, the private certification in America, the university degree in Italy, stands in for regulation while lacking the institutional apparatus that regulation requires. The conflation, to be precise, is the mistaking of a signal of competence for a guarantee of accountability.

There is a further complication, and it is the third shared failure: the subordination of the profession to allied health hierarchies. In both systems the kinesiologist is positioned beneath the physiotherapist or physical therapist and beneath the physician, and that positioning constrains the autonomous scope of practice. The Italian corrective instrument, Decree-Law No. 163/2022, places the LM-67 kinesiologist in a collaborative relationship with physicians and with healthcare professionals such as the physiotherapist and the dietitian within the palestre della salute, while the Agenzia delle Entrate ruling confirms the kinesiologist’s position outside the healthcare perimeter. The American picture rhymes with this. The ACSM-CEP is designated an allied health professional, and the NSCA frames its CASCE accreditation initiative explicitly as aligning the CSCS with other allied healthcare professions positioned below the physician. Against precisely this subordination, Shepherd and Saynor (2022) argue that the clinical exercise professional should be recognised in their own expertise rather than treated as dependent on physician prescription. The subordination, then, is not a natural fact about the profession’s competence. It is an artefact of how each regulatory system has positioned the kinesiologist relative to the established health professions, and it tells us more about institutionally assigned rank than about actual capacity.

5.2. Three Divergent Regulatory Paths

The shared failures coexist with three structural divergences, and the divergences are as instructive as the commonalities, since they show that the same destination can be reached from opposite directions.

Consider first the relationship between legislation and enforcement. Italy offers legislative recognition without institutional enforcement; the United States offers institutional enforcement without legislative recognition. This is the central mirror of the comparison. The Italian state has named the profession and defined its profiles in statute, yet it has not built the order that would enforce the boundary, whereas the American system has built, through private accreditation and certification, an enforcement ecology that conditions credentials on accredited education and signals competence to the market, even though the state has not, outside Louisiana, recognised the profession in law. The point is not that one approach is enforcement and the other recognition. The point is that each has exactly what the other lacks, so the Italian text and the American infrastructure, combined, would approximate the architecture that neither possesses alone.

The second divergence concerns how the profession differentiates itself internally.

Italy organises the profession as a degree-based vertical hierarchy: the L-22 base profile beneath the LM-67, LM-68 and LM-47 master’s profiles, each tied to a specific academic class. The United States organises the field as a certification-based horizontal fragmentation, with ACSM, NSCA, NASM and ACE credentials that segment the field by setting and population rather than by an agreed vertical hierarchy of competence. A useful way to frame this is by what each structure gets right and wrong. The Italian structure is legible in principle, a clear ladder of degrees, but undercut by curricular variation and the absence of a register; the American structure is responsive to market segments but incoherent as a whole, because the credentials proliferate horizontally without a unifying standard of seniority or scope. One system has a hierarchy without a register. The other has a register, in USREPS, without a hierarchy.

The third divergence concerns orientation. The Italian framework is public-sector oriented, animated by the ambition to integrate the kinesiologist, and the LM-67 profile in particular, into the National Health Service through the Article 6 pathway of Law No. 3/2018 and the palestre della salute. The American framework is private-sector oriented, driven by employer demand and the credentialing market, as the labour-market evidence of Bartlett et al. (2024) makes plain. The Italian profession looks to the state for its status; the American profession looks to the employer and the consumer. Much of the divergence in path follows from this divergence in orientation. A profession that seeks public-sector integration pursues legislative recognition and healthcare-profession status, while a profession that operates in a private market pursues accreditation and certification that the market will reward. Italy has pursued recognition and neglected infrastructure; the United States has built infrastructure and lacked recognition. The orientations are opposite, the deficits are complementary, and the destination, a profession recognised or credentialled but not secured, is shared.

5.3. The Legitimacy Deficit in Comparative Perspective

A point of method should be registered before the diagnosis proper. The three shared failures and the three divergent paths are not independent findings; they are two readings of the same structure. The shared failures describe what the two systems have in common when read against the model of a completed profession: neither protects the title, neither separates certification from regulation, neither secures an autonomous scope. The divergent paths describe how the two systems came to share those failures by opposite routes, one through legislation without institution, the other through institution without legislation. Here the comparison becomes instructive, because the relationship between the two readings is the analytical core of the whole exercise. It is not that Italy and the United States happen to resemble one another. It is that two structurally opposite strategies converge on the same deficit, and the convergence reveals that the deficit is not an accident of either strategy but a consequence of leaving the regulatory architecture incomplete in any of its essential components. The point is not that the two systems are similar. The point is that their dissimilarity makes their shared failure more instructive, because it shows that the failure does not depend on the route taken to it.

The concept that unifies these observations is the legitimacy deficit.

By legitimacy deficit this article means a condition in which a profession possesses formal acknowledgement, whether legislative recognition or market-wide certification, without the substantive institutional basis that would make that acknowledgement effective in protecting the public and securing the practitioner’s autonomy. Formal legitimacy without substantive basis is the common pathology, and it manifests differently in each system while sharing a single logical structure.

For the comparative-institutional vocabulary that this diagnosis needs, Robertson et al. (2021) are the obvious reference. In their analysis of health professional scope-of-practice regulation across the United States, Canada, Australia and the United Kingdom, they distinguish systems that regulate through tasks or activities from systems that regulate through protected titles, and they note that some systems use both. This distinction maps onto the kinesiologist comparison with some precision. Italy has begun to regulate through title, naming the chinesiologo, yet it has not completed the title-based architecture, because it has no order to administer the protected title. The United States, outside Louisiana, regulates the kinesiologist through neither task nor title, leaving the field to private certification, and even the Louisiana exception borrows a private certification standard, the ACSM credential, to fill the content of its statutory title. Robertson et al. (2021) show that effective regulation, whether task-based or title-based, requires an institution that sets standards, maintains a register, monitors competence and manages discipline. Neither Italy nor the United States, the latter outside its single licensing state, has assembled this institutional core for the kinesiologist.

The Ontario evidence is decisive on the question of perception. Braniff et al. (2012) are worth quoting more precisely here: their SWOT analysis of regulated kinesiology in Ontario examines how other health professionals perceive the regulation of kinesiologists, and they find that the regulated profession was not perceived as a threat but as a needed contributor to chronic disease prevention and to multidisciplinary care. This matters for the comparative argument, because it counters the implicit assumption that the subordination of the kinesiologist reflects a genuine professional consensus about the limits of the profession’s competence. It does not. Where the profession has been properly regulated, as in Ontario, the surrounding professions accommodate it as a partner. The subordination observed in Italy and the United States is therefore better understood as a product of incomplete regulation than as a settled judgement about the kinesiologist’s capacity, and the distinction between perceived rank and actual value is exactly what the Ontario case throws into relief.

At the centre of the legitimacy deficit, in both systems, stands the vulnerable subject. The patient with a stabilised chronic condition who is referred to adapted physical activity; the athlete whose preparation is entrusted to a self-described expert; the ordinary member of the public who joins a gym and cannot tell a certified clinical exercise physiologist from a personal trainer with a weekend qualification: these are the figures who bear the cost of the deficit. The available evidence suggests that the inability to distinguish competence from its imitation is not a marginal inconvenience but the operative harm that regulation exists to prevent. In Italy the harm is mediated by the facility-coordination requirement and by curricular fragmentation; in the United States it is mediated by terminological conflation and the proliferation of credentials. In both, the harm lands on the same subject. The legitimacy deficit is, at bottom, a deficit measured against the protection of that person, and the failure of formal acknowledgement to translate into substantive protection is the failure that both systems share.

5.4. The Missing Architecture

It is now possible to state what a coherent regulatory model would require, and to locate each system against that requirement. A coherent model comprises five components: title protection, which reserves the use of the professional title to qualified persons; scope-of-practice definition, which specifies what the title-holder may and may not do; a professional register, which enumerates the qualified and makes them publicly identifiable; continuing professional development requirements, which maintain competence over time; and a disciplinary mechanism, which removes the incompetent and the dishonest. These five components are the architecture of a regulated profession. The European Observatory’s account of health professions regulation enumerates substantially the same elements, minimum educational requirements, entry to practice, title protection, scope of practice and continuing professional development, as the levers through which regulation assures safe and effective care.

Measured against this architecture, Italy is closer to the model in one respect and structurally incomplete in others. It has a legislative basis, which is the hardest component to create and the one the United States lacks nationally. It has, in Article 41, a statutory title and an implied scope tied to each profile. What it lacks is the institutional superstructure: no order, no national register, no mandatory continuing professional development regime enforced by a professional body, no disciplinary mechanism operating against individuals who misuse the title. The Italian model has poured the foundation, the legislative recognition, and has not raised the building. Its incompleteness is the incompleteness of a structure begun at the level of law and abandoned before the level of institution.

The American approach is, by contrast, more empirically grounded and more constitutionally constrained. It possesses elements of the architecture in private form: programmatic accreditation through CAAHEP and CASCE, graded certification through ACSM and the NSCA, a voluntary register through USREPS, and an evidentiary case from the labour market through Bartlett et al. (2024). What it lacks is the legislative recognition that would convert these private functions into public regulation, and because the constitution allocates professional regulation to the states, this conversion can occur only state by state, as it has occurred only in Louisiana. The American model has raised much of the building, the accreditation, the certification, the register, on private land, without legal title to the ground beneath it. Its incompleteness is the incompleteness of a structure built at the level of institution and lacking the level of law.

The missing architecture is therefore differently missing in each case.

That the two absences are complementary is what clarifies the diagnosis. Italy needs the institution that the United States has built privately; the United States needs the legislation that Italy has enacted. Neither needs to invent the missing component from nothing, because each can observe it functioning in the other and, more completely, in Ontario, the United Kingdom and Australia. The obstacle in both systems, the analysis indicates, is not conceptual but institutional and political: the components are known, their assembly is visible elsewhere, and what remains is the will and the mechanism to complete the structure, distinguishing the design of reform from its execution, the availability of a model from the decision to build it, and professional recognition from professional sovereignty.

5.5. Certification, Licensure and the Problem of the Signal

A final comparative observation concerns the relationship between certification and licensure, because the confusion between the two is the conceptual heart of both systems’ difficulties. A certification is a signal. It communicates to an employer, a consumer or a regulator that the holder has met a standard set by a private body. A licence is an authority: it grants the holder the legal right to practise and, where coupled with title protection, reserves that practice to those who hold it. The two are routinely confused, and the confusion is not innocent, because it allows a system that produces signals to present itself as if it produced authority.

The United States exhibits the confusion in its purest form. The certification ecology, ACSM, NSCA, NASM, ACE, under NCCA accreditation, produces signals of considerable sophistication, graded, accredited and increasingly tied to accredited education through the CAAHEP and CASCE initiatives. A signal, however sophisticated, is not an authority. The holder of an ACSM-CEP is certified; outside Louisiana the holder is not licensed, and the title carries no legal exclusivity. The American system has refined the signal to a high degree while leaving the authority almost entirely to the market. Italy exhibits a different confusion, in which the degree functions as both the educational qualification and, in the absence of an order, the de facto authorisation to practise, so that the academic credential is asked to perform the work of both certification and licence at once. The degree signals competence and, by virtue of Article 41, authorises practice, yet it does so without the registration and disciplinary apparatus that would make the authorisation enforceable against misuse.

Neither a refined signal nor a degree-based authorisation can substitute for the coupling of certification with licensure that a regulated profession requires. The signal informs the market; it does not bind it. The degree authorises the graduate, it does not police the field. What both systems require is the institutional coupling that links a standard of competence to a legal authority to practise and to a mechanism for withdrawing that authority when competence or conduct fails. Louisiana performs this coupling for one figure in one state, borrowing the ACSM signal and giving it the force of a licence. Ontario performs it for the whole profession, coupling the recognised degree to registration with the College and to the protected title. The lesson of the comparison is that the components, the signal and the authority, exist in both Italy and the United States, distributed differently and coupled in neither, distinguishing the certification that signals from the licensure that authorises, and the competence that a credential records from the accountability that only regulation enforces.

6. Reform Trajectories and Conclusions

6.1. Italy: From Legislative Recognition to Professional Sovereignty

The Italian reform trajectory has a clear logical sequence, even if its political realisation is anything but certain. The necessary next step is the establishment of the Ordine Nazionale dei Chinesiologi, a national professional order. The order is the institution that would convert the legislative recognition of Article 41 into operative regulation, because it would perform the functions the current framework leaves unperformed: maintaining the national register, controlling entry, setting and enforcing ethical standards, administering continuing professional development, and disciplining members who breach the boundary of competence or honesty. The order is not an optional ornament on the existing recognition. It is the missing institution without which the recognition remains a name in a statute.

The second element is the pursuit of healthcare-profession status for the LM-67 profile through the Article 6 pathway of Law No. 3/2018. Working at the clinical margin, with individuals in clinically controlled and stabilised conditions, the preventive and adapted kinesiologist is the profile for which the petition to the Ministero della Salute seeks to cross the boundary that the Lorenzin reform drew. Success on this pathway would not professionalise the whole field; it would recognise the most clinically engaged profile as a healthcare profession, with the integration into the National Health Service and the fiscal consequences that such recognition entails. Raiola and colleagues formulate the underlying hypothesis of a bifurcation, with the three-year figure oriented toward prevention and potentially configurable as a basic healthcare profession, and this bifurcation suggests that reform need not be all-or-nothing. It can proceed profile by profile, recognising the clinical profiles as healthcare professions while leaving the sporting and management profiles in the adjacent space.

Fiscal recognition is the third element, and it works as both an indicator and a lever. The Agenzia delle Entrate ruling in Risoluzione n. 9 of 2026 places the kinesiologist outside the healthcare perimeter for VAT purposes, and this fiscal exclusion is a marker of the profession’s incomplete status. Reform of the fiscal treatment would follow from, and would signal, the profession’s movement into the healthcare perimeter. The fiscal question is therefore not separate from the regulatory one. It is one of the institutional confirmations of the profession’s position, and its reform would register the profession’s changed status in the law of taxation as much as in the law of professions.

What overshadows all of this is the risk of stasis.

The State-Regions conference of July 2023 produced a political signal toward recognition, and political signals have accumulated alongside petitions and corrective decrees without producing the order, the register or the fiscal reform. The danger is that recognition continues to deepen rhetorically while the institutional structure remains unbuilt, so that the profession acquires ever more acknowledgement and no more security. The Italian reform requires the conversion of signal into statute, of recognition into institution, distinguishing the political will that the conferences express from the legal consequence that the legislation must enact.

A sequencing question accompanies the trajectory, and it is worth pausing here. The creation of the order and the pursuit of healthcare-profession status for the LM-67 profile are related but distinct objectives, and they need not advance together. The order would professionalise the whole field, conferring on all four profiles the institutional apparatus of self-government under state authority. The Article 6 pathway would reclassify a single profile as a healthcare profession, with the integration into the National Health Service that such reclassification entails. It seems reasonable to argue that the two objectives are complementary rather than alternative, the order securing the profession’s general institutional form, the healthcare recognition securing the clinical profile’s place within the health system. Pursued together they would address both the horizontal problem, the absence of an institution governing the whole profession, and the vertical problem, the exclusion of the clinical profile from the healthcare perimeter. Pursued separately, each would leave the other unresolved, distinguishing the institution that governs the profession from the recognition that places it within the health system.

6.2. The United States: From Voluntary Accreditation to Statutory Recognition

The American trajectory runs in the opposite direction, from a dense private infrastructure toward the statutory recognition that would give it legal force. Louisiana is the available template. It shows that a state can regulate the clinical exercise physiologist by statute, define the title and scope, and borrow the existing ACSM certification standard to fill the content of the licence. The constitutional structure permits this in every state; the obstacle is political and institutional. Expansion of the Louisiana model to other states is the clearest path by which the American system could acquire the legislative component it lacks, one jurisdiction at a time, building from the proof of concept that Louisiana provides.

The accreditation initiatives furnish the building blocks for a national accreditation floor beneath such expansion. The ACSM-CAAHEP requirement, adopted in 2020 with implementation scheduled for August 2027, and the NSCA-CASCE requirement, conditioning CSCS eligibility on accredited-programme graduation from 2030, together establish accredited education as the foundation of the principal credentials. These initiatives create, within the private system, the educational accreditation that statutory regulation would otherwise have to construct, so any future licensure regime could rest on an accreditation base already in place. The role of USREPS and CREP is complementary: the voluntary registry creates quasi-regulatory transparency, a searchable record of credentialled professionals that approximates the public register a regulated profession would maintain. These private institutions are not regulation. Even so, they assemble much of the material from which regulation could be built.

The political lever for statutory expansion is the consumer protection argument. The claim that the public cannot distinguish a clinical exercise physiologist from an uncertified trainer, and that vulnerable individuals are thereby exposed, is the argument most likely to move state legislatures, because it frames regulation as protection of the public rather than protection of the profession. Shepherd and Saynor (2022) reinforce this argument from the clinical side, contending that the clinical exercise professional possesses an expertise warranting recognition in its own right, and the British and Australian precedents show that such recognition is achievable. The American trajectory therefore requires the conversion of private infrastructure into public regulation, using the Louisiana template, the accreditation floor and the consumer protection argument together, distinguishing voluntary accreditation from statutory recognition, market transparency from legal authority, and certification from licensure.

6.3. Conclusions

Both systems have moved, in their own way, toward professional recognition. Italy has legislated the kinesiologist into the law of the state and defined its profiles. The United States has built an elaborate private architecture of accreditation, certification and registration, and has, in one state, crossed into statutory licensure. These movements are real, and the analysis does not dismiss them. The profession is more recognised, more credentialled and more institutionally elaborated in 2026 than it was a decade earlier, in both countries.

Neither system, though, has resolved the core tension. The formal acknowledgement of the profession coexists, in both, with institutional fragmentation that undermines the profession’s practical autonomy, its public recognition and its integration into healthcare delivery. In Italy the fragmentation is the gap between the legislative title and the missing order, between the four-tier degree structure and the absent register, between the political signals and the withheld legal consequences. In the United States the same gap between naming and governing reappears in a different costume: between the private credential and the public statute, between the proliferating certifications and the unprotected title, between the accreditation floor and the legislative recognition that would rest upon it. The fragmentation differs in form and converges in effect.

The vulnerable subject remains exposed in both. The patient referred to adapted physical activity, the athlete entrusted to a self-described preparer, the casual fitness participant who joins a gym: each operates in a market where credentials are multiple, titles are unprotected and professional accountability is diffuse. This is the operative harm. It is not the abstract untidiness of an incomplete regulatory scheme. It is the concrete exposure of the person who cannot distinguish competence from its imitation and who has no legally guaranteed signal to rely upon. The available evidence, from the curricular fragmentation that D’Elia et al. (2024) document to the terminological conflation that Bartlett et al. (2024) measure, indicates that this exposure is systemic rather than incidental.

Structural reform is therefore required.

The requirement does not arise because kinesiologists lack knowledge, competence or professional identity. They possess all three. The disciplinary base is mature, the practitioners are trained, and the professional communities are organised and articulate. The requirement arises because the regulatory apparatus has failed to translate that identity into enforceable, coherent, publicly legible status. The failure is institutional, not intellectual. It is a failure of the state, in Italy, to build the order that its own legislation implies, and a failure of the states, in the United States, to recognise the profession that its own private institutions have so thoroughly prepared.

The comparison also yields a more general lesson about the relationship between recognition and regulation, and it is a lesson that travels well beyond the kinesiologist. Recognition is the cheaper act. It costs a legislature a clause and a name; it costs a market the adoption of a credential. Regulation is the dearer act, since it requires an institution, a register, a disciplinary apparatus and the sustained administrative capacity to maintain them. The temptation, in both systems, has been to perform the cheaper act and to present it as if it were the dearer one. Italy has named the profession and allowed the naming to stand in for the order. The United States has certified the practitioner and allowed the certification to stand in for the licence. In each case the substitution is plausible enough to satisfy the immediate demand for acknowledgement and inadequate to deliver the protection that acknowledgement promises. The legitimacy deficit is, at bottom, the same gap between naming and governing, the cheaper act that has been performed and the dearer act that has not.

This gap is not closed by further recognition. A second statute naming the Italian profession more emphatically would not build the order; a fifth American certification more rigorous than the others would not create the licence. The gap is closed only by the institutional act that each system has avoided: in Italy the creation of the order and the register, in the United States the enactment of statutory recognition state by state on the Louisiana model. The obstacle, the analysis indicates, is no longer conceptual. The model is known, the components are available, and the precedents, Ontario, the United Kingdom, Australia and Louisiana, are visible. What remains is the political and institutional will to perform the dearer act, distinguishing the recognition that has been granted from the regulation that has been withheld.

The architecture of reform must distinguish, in both systems, between the components that each has confused or omitted. It must distinguish title protection from scope-of-practice regulation, because reserving a name is not the same as defining a practice. It must distinguish certification from licensure, because a market signal of competence is not a legal authority to practise. And it must distinguish professional recognition from professional sovereignty, because naming a profession is not the same as empowering it to govern itself under the authority of the state. Italy has the recognition and lacks the sovereignty. The United States has, in its private institutions, the apparatus of self-government and lacks the recognition that would make it sovereign. The defence of the kinesiologist as a profession depends, in both countries, on completing the recognition-regulation gap that each has left open. Without that completion the profession remains what it is today in Italy and in the United States alike: acknowledged but unsecured, credentialled but unprotected, recognised but not yet sovereign.