"Perhaps we have lost faith in certification because of the entrepreneurship zeal of continuing educator promoters. Too often they offer certification in methods and treatments supported by cults of personality, public relations, and claims never documented in the literature.

Few of those selling their ideas and offering certificates have followed the common scientific practice of refinement through peer-reviewed publication, and fewer still have invested their rich rewards in efforts at examining their doctrines through research."

Jules Rothstein, Editor-In-Chief, Physical Therapy, November, 1995

The certification era
Imagine that you attend a course which I instructed. You like my teaching style. My content seems right to you. You believe that the information I share would be helpful to your patients. Plus you enjoy the hands-on subtleties of my treatment approach (let's call it "the Salzman Technique".)

At the end the course, you are delighted to hear that I will be offering a second tier CME course, one which builds on the first. It is natural for you to wish to attend the class, for I have met your standards. So far we have done nothing more than meet each others needs — for you, material which is pleasantly presented and dovetails with your treatment proclivities, for me, the gratification that others find my ideas helpful and of interest.

But, upon hearing that there a dozens, no hundreds, of providers who are interested in attending my courses, I take a step beyond offering courses which clarify the treatments I find useful. I offer you a certification in the Salzman Technique (which takes 4 consecutive CME courses to obtain).

What's wrong with that? I would argue nothing — as long as some stringent standards have been met. But the truth of the matter is that, for today's providers, there are an overabundance of certification programs which have failed to meet any of those standards.

Aquatic therapy-specific certification
As of 2007, one aquatic therapy certification does exist (see www.icatric.org for more information). Unfortunately, neither state statutes nor the National Commission for Certifying Agencies (NCCA) currently recognize the ICATRIC certification. In legal standing (although not in content or scope), aquatic therapy certification is comparable to certifications from other educational organizations, such as the Aquatic Exercise Association.

It is important that individuals understand that voluntary aquatic therapy certification is different from a national certification that is recognized by both the law (through state statute) and national accrediting agents (such as the National Commission of Certifying Agencies) as the "test of competence" for a profession.

There are no state or federal laws which require certification of individuals who practice aquatic therapy. A therapist may choose to sit for the aquatic therapy certification exam for his or her own satisfaction; however, these individuals should be aware that the certification will not be recognized by the law. In other words, state statutes do not recognize it as a credential which authorizes the holder to perform any act of healthcare (aquatic or otherwise).

Standards for assessing merit of certification programs
In 1996, Harris offered an excellent method for critiquing treatment alternatives for scientific merit.[1] Treatment approaches which do not meet these standards are not necessarily invalid treatment alternatives, just unproven ones. However, until these standards are met, providers should think carefully before throwing hard-earned dollars towards a "certification" in such an approach.

1) Theories underlying treatment are supported by valid anatomical and physiological evidence. There are two levels at which you may test the solidity of the claims of a certification course instructor. At the most basic level, the material taught in the course may not fly in the face of our understanding of the known universe. In other words, the proponents of this technique have not based any element of their treatment approach on something which could not be true. Note that this is different from "being true." This standards is less stringent. It doesn't demand that the technique has been shown to be valid; it demands instead that it can be. Some would argue that this is an unnecessary standard, for who would attend a course which is not built on a foundation of physiology, anatomy and physics? The answer, unfortunately, is "lots of people." The second level of testing for validity is more demanding: it asks for evidence that the technique not only can work, but does. This level of scrutiny is addressed in #4.

2) Treatment is specific to patient populations. When a CME flyer announces that a certain treatment approach is a panacea, watch out! The etiology of multiple sclerosis, fibromyalgia and mechanical spine pain are different. Is it not evident that the approaches used to treat these populations should be?

3) Potential side effects are discussed. There is no such thing as a treatment without side effects. Even water, over-consumed, is deadly. Additionally, side effects are not necessarily "negative." They are, instead, merely things which occur in tandem to the desired treatment effect. Failure of a CME certification course instructor to discuss potential side effects which may accompany application of their treatment approach should be a red flag to students.

4) Studies have validated the efficacy of the treatment. These studies are peer-reviewed, well-designed and either experimental (prospective, randomized, controlled) or single-subject experiments. As clinicians, it is important to base our therapeutic interventions on a solid foundation of compelling evidence. This is a cornerstone of our practices, not a creation of the current health care crisis.

As previously discussed, this is a much higher standard than #1. Not only must the treatment philosophy be founded on a solid base of science, but the approach itself should be verified in the world of clinical research. This standard, unfortunately, has not been met by many "tried and true" treatment approaches. Certainly, anyone paying extra CME dollars to obtain a certification in a treatment approach has the right to know if any of the approach has been validated in the testing ground of our profession: the experiment.

5) The proponents of the treatment are willing to discuss its limitations. A litmus test for examining a treatment technique — and the certification process which accompanies it — is the willingness of treatment supporters to discuss its limitations. Too often, questions about the validity of a technique are deflected by instructors. A posture of defensiveness by the instructor (when exposed to the thinking therapist) is a dead giveaway. Statements such as "I have seen it work for 20 years — we don't need to do studies" or "Patients love it" are proof by anecdote and thus no proof at all. It doesn't mean the approach is not effective, but it does mean more work needs to be done before clinicians pay money to become a "practitioner."

Conclusion
There are several methods of determining if individuals have aquatic therapy experience (transcripts, CME records, past jobs). Certainly, a certification may be a very good one. But (and here's the crux of the matter), no one should use an unvalidated certification as the litmus test to empower an individual to provide aquatic therapy. Each discipline is only permitted to provide and to bill for given interventions (known as their scope of practice). Individuals who question what services they can provide in the water should always return to the prevailing statutes and practice documents for their occupation.

Read More on this Topic
The above information was excerpted from the Aquatic Resources Network "Prove It! Justifiable Aquatic Therapy" and "Billing for Aquatic Physical Therapy: Tackling Aquatic Therapy Practice and Reimbursement Issues". To learn much more on this topic, order these valuable reference books online, send us an e-mail to obtain information on the Prove It! lecture series or call ARN at (715) 248-7258.

References
1. Harris SR. How should treatments be critiqued for scientific merit? Phys Ther. 1996; 76(2):175-181.

Disclaimer
The information presented in this article is meant to be a summary and educational in nature. It is not meant to serve as a substitute for legal advice.

Author Bio
Andrea Poteat Salzman, MS, PT is the owner of two businesses, the Aquatic Resources Network and Concepts in Physical Therapy. She has received both the prestiguous Aquatic Therapy Professional of the Year Award (Aquatic Therapy and Rehabilitation Institute) and the Tsunami Aquatic Therapy Award.

Salzman is well-regarded within the industry as:

• Editor-in-Chief of an aquatic therapy trade journal and newsletter;
• Author of over a dozen publications, including the soon-to-be-released Evidence-Based Aquatic Therapy textbook;
• Freelance author and columnist;
• Aquatic therapy seminar instructor;
• Adjunct faculty and research advisor, St. Catherine Physical Therapy Program, Minneapolis, MN;
• Immediate past manager of therapeutic aquatics, St. Paul Ramsey Medical Center, St. Paul, MN;
• Researcher and grant recipient examining aquatic exercise vs. land-based exercise.

She may be reached via e-mail at asalzman@aquaticnet.com