What is aquatic therapy and who can perform it? What qualifications must one must have to consider themselves able to practice aquatic therapy? Does one need to have a degree in physical therapy? Or is there a specific aquatic rehabilitation program of study that leads to a degree and/or certificate that would suffice?
In the future, each state attorney general may be asked to render an opinion about this matter (much as they have done with joint manipulation). There may even eventually be state legislation which restricts the use of the term "aquatic therapy" or "aquatic therapist". But for now, in the absence of a prevailing legal authority on this matter, confusion reigns. So let's work through the question logically.
Point #1. To determine who can perform aquatic therapy, we must define what "aquatic therapy" is.
|Definition of Aquatic Therapy: A therapeutic procedure which attempts to improve function through the application of aquatic therapeutic exercises. These procedures require constant attendance of a therapist educated in performing aquatic therapeutic exercises. [1, 2] Common synonyms: Aquatic Rehabilitation, Aqua Therapy, Pool Therapy, Water Therapy, Hydrotherapy (outside the USA).
First, notice that aquatic therapy is considered a therapeutic procedure, not a modality. There are many technical and practical distinctions between the practice of aquatic therapy and the application of therapeutic modalities.
Definition of Therapeutic Modality: Any physical agent applied to produce therapeutic changes to biologic tissue; including but not limited to, thermal, acoustic, light, mechanical, or electrical energy. Whirlpool for wound care, or hydrotherapy, is considered a modality by the American Medical Association (AMA). 
Definition of Therapeutic Procedure: A manner of effecting change through the application of clinical skills and/or services that attempt to improve function. The physician or therapist is required to have direct (one-on-one) patient contact. A procedure typically requires patient participation. 
It undeniable that water has been used throughout our history as a modality to elicit the passive transmission of heat, cold, chemicals, friction, pressure or a combination of the same by immersing the body or body part. It is, however, an important distinction to describe the difference between the use of water as a passive modality and the use of water for an active procedure. The term aquatic therapy should be reserved for the latter as is evident by the manner in which the AMA has chosen to define it. [1, 2]
Second, note that it is necessary to distinguish the term "aquatic therapy" from the terms "adapted aquatics" and "aquatic fitness".
Definition of Adapted Aquatics: A learn-to-swim program for individuals with disabilities. 
Definition of Aquatic Fitness: A mode of aquatic exercise that is distinctively not swimming and not therapeutic exercise, but which is performed in a face-out, vertical position in various depths of water with the intent to improve physical and/or mental health. [4, 5].
Neither adapted aquatics nor aquatic fitness are considered therapeutic procedures (or modalities) by the American Medical Association.
Third, note that aquatic therapy, as defined by the AMA, is not "tied" to a single profession. It can arguably be performed by several legally-regulated healthcare providers who have scopes of practice which permit them to perform such services (see point #2) and who are permitted to use the AMA's Current Procedural Codes (CPT).
However, all healthcare providers who can legally perform aquatic therapy are not permitted to perform every intervention which is included under the umbrella term "aquatic therapy". In other words, providers must operate under same limitations to scope of practice as they operate under on land. By entering the pool, all scopes of practice do not become equal.
Example: Physical therapists' scopes of practice do not include breath control for speech enunciation, so when/if a physical therapist works in the water, his practice of aquatic therapy cannot include the practice of speech therapy even if such an act seems a natural extension of his work.
Example: Massage therapists' scopes of practice are comprised of massage/bodywork and some adjunctive modalities, so when/if a massage therapist works in the water, his practice of aquatic therapy can be comprised of those services (the exact definition of what these acts entail is left to the definition found in each state's practice act). His scope of practice does not permit him to perform aquatic therapeutic exercise or joint mobilization or other interventions which are not included as part and parcel of his practice. This remains true even if the massage therapist has received continuing educational training in which he has learned to perform such acts.
Example: Kinesiotherapists' scopes of practice are comprised of therapeutic exercise and education, so when/if a kinesiotherapist works in the water, his practice of aquatic therapy can be comprised of therapeutic exercise and education. He cannot perform acts or services not covered by his scope of practice, such as massage or other manual therapies.
Lastly, it is important to note that not all professions are legally permitted to work with all patients at all times. In some states, massage therapists are restricted to working with "apparently healthy" individuals and cannot see clients for "therapeutic" interventions.
According to the American Kinesiotherapy Association, kinesiotherapists may only work with medically stable individuals in post-acute rehab settings.
Clinical exercise physiologists (in Louisiana, the one state which recognizes them) can only "formulate, develop and implement exercise protocols and programs, administer graded exercise tests, and provide education regarding such exercise programs and tests in a cardiopulmonary rehabilitation program [under the direction, approval and supervision of a licensed physician]....".
In some states, athletic trainers cannot work with individuals who are not team athletes (as traditionally defined). Whatever limitations each healthcare provider has on land must be upheld once he enters the pool.
Conclusion: The term "aquatic therapy" is an umbrella term; it is used as a convenience to describe many 1:1 therapeutic procedures which occur in the water. However, the exact nature of those acts and services differ for each profession which takes its patients into an aquatic setting. All things do not "become equal" once in water. All therapeutic interventions do not become fair game to all providers.
Point #2. With few exceptions, healthcare acts and services regulated by the state may only be performed by individuals who have been granted legal permission, through state statutes commonly known as "practice acts", to perform those acts and services.
In order to determine who can provide healthcare in the USA, we must examine the legal codes or practice acts. Practice acts are typically exclusive in other words, they reserve the right to perform healthcare functions for professions with a legal scope of practice.
Practice acts typically describe the therapeutic interventions (e.g. therapeutic exercise, neuromuscular reeducation, gait training, manual therapies, ADL training, massage, etc.) which can only be performed by individuals which meet certain educational, training, testing and title requirements. This remains true whether the intervention is provided on land or in an aquatic environment.
In other words, once a state "maps out" the territory of a healthcare profession (using PT as an example), only licensed/registered/certified PTs/PTAs (or individuals practicing under the direction of a PT/PTA) may perform those acts or imply they are performing those acts.
There are a few legal exceptions to this standards: students-in-training; other healthcare professions with a legally regulated overlapping scope of practice; and/or healthcare professionals who hold exemptions from the law.
An example of an exempted provider would be a kinesiotherapist who performs therapeutic exercise and education services within the Veteran's Administration system. Although, these interventions are considered within the "scope of practice" of other state-regulated healthcare providers, federal regulations, such as those crafted by the US Department of Veteran's Affairs, supersede state law. Thus, kinesiotherapists are permitted to practice within the VA system even though states do not currently regulate them through a practice act.
Conclusion: Individuals who wish to perform any state-regulated acts or services by their state must meet the educational, training, testing and/or title requirements outlined within a state practice act (such as the Physical Therapy Practice Act) or be exempted from the same. Individuals who do not meet these standards are not permitted to perform such acts or services or imply they are performing such acts or services whether on land or in the water.
Point #3. To determine if a certification process can authorize an individual to practice, we must first examine the legal standing of that certification.
In some cases, a national certification exam not a licensure exam serves as the permit-to-practice process. In these cases, individual states have determined that a certification satisfies the testing prerequisites necessary to practice a healthcare profession in that state. It is important to note that such certifications achieved this status by meeting rigorous accreditation standards of a federally recognized agent, such as the National Organization for Competency Assurance's (NOCA) National Commission for Certifying Agencies. Certifications which have not been so accredited may not be perceived as valuable by the state government, employers, peers and the public. For a complete listing of the certifications currently accredited by NOCA, log onto www.noca.org.
Example: Some states permit massage therapists to practice based on their ability to successfully pass the National Certification Board for Therapeutic Massage and Body Work (NCBTMB)'s certification. This certification is accredited by the National Organization for Competency Assurance (NOCA)'s National Commission for Certifying Agencies.
Example: Some states permit athletic trainers to practice based on their ability to successfully pass the National Athletic Trainer's Association Board of Certification (NATABOC)'s certification. This certification process is accredited by NOCA's National Commission for Certifying Agencies.
Example: Some states permit therapeutic recreation specialists to practice based on their ability to successfully pass the National Council for Therapeutic Recreation Certification (NCTRC)'s certification. This certification process is accredited by NOCA's National Commission for Certifying Agencies.
Example: Some states permit occupational therapists to practice based on their ability to successfully pass the National Board for Certification in Occupational Therapy (NBCOT)'s certification. This certification is federally recognized.
Other than the above "permit to practice"-type certifications, there are currently no known certifications which affect the legal ability to practice aquatic therapy. Until and unless state governments establish a given aquatic certification as a "gateway" or prerequisite to practice, aquatic therapy and aquatic fitness certification should be seen as strictly educational in nature and not a means to "validate" their practice.
As of 2000, there is only one organization certifying aquatic therapy providers, the Aquatic Therapy &Rehabilitation Institute.
|The ATRI Certification: In 1999, the Aquatic Therapy and Rehabilitation Institute (ATRI) (Chassell, Michigan) began to offer the "aquatic therapy and rehabilitation industry (ATRI) practitioner" certification. The ATRI certification process, which is open to healthcare providers and lay persons with life experience, does not extend legal authorization or protection to practice aquatic therapy. According to ATRI, individuals who were not permitted to practice aquatic therapy before taking this certification should not believe that they will become "certified aquatic therapists" capable of practicing after sitting for this certification. To date, the ATRI certification has not received accreditation from the National Organization for Competency Assurance's (NOCA) National Commission for Certifying Agencies. For more information on the ATRI certification process, contact ATRI at phone (906) 482-9500, fax (906) 482-4388, or online at www.atri.org.
Since such a certification cannot currently "open the legal gate" to practice aquatic therapy, the need for and authenticity of a broad-baseline or "big tent" certification is currently hotly debated. Certification implies that the individual is now qualified to practice in a field.  And therein lies the weakness of a "big tent" certification.
Each of the certifications discussed above (massage therapy, athletic training, therapeutic recreation, occupational therapy) are currently accepted as a test of competence by state governments are limited to individuals of a single discipline or field.
However, since aquatic therapy is composed of unique (and sometimes mutually exclusive) interventions for each healthcare profession, there can be no one unified "field" of aquatic therapy. Since no two disciplines share an identical scope of practice, any aquatic therapy exam could not cover information which was not legally within the scopes of practice of all who are permitted to sit and test. Instead it would become necessary to remove all elements of the exam which dealt with non-overlapping scopes.
Such an exam, limited to aquatic topics which were not scope-specific (fluid mechanics, handling principles, safety and risk management), would become something wholly different from an aquatic therapy exam. It would become a hybrid of an adapted aquatics, aquatic fitness and pool operator exam (for which there are already numerous testing certifications).
But, it grows even more complex. Add to the mix of healthcare providers allowed to sit for the exam, individuals who have experience working in the water, but no legal scope of practice. How can a single test (which is open to all these individuals) certify competence in "aquatic therapy" when some who sit for the exam are legally barred from performing therapeutic interventions which are considered within the scope of practice of regulated professions (e.g. gait training, massage, therapeutic exercise, ADL training, mobilization/ manipulation, and so on)?
Whereas it does not seem to be appropriate for the above mix of persons to sit for an aquatic therapy certification, it does seem permissable for such a mix to sit for an aquatic fitness exam. Why? What is the distinction? Aquatic fitness (and fitness and wellness services in general) are not regulated services, whereas it appears that aquatic therapy is. In states which regulate their healthcare providers, therapeutic services such as therapeutic exercise, manual therapy and neuromuscular reeducation can only be performed by providers whose state codes permit their practice. This applies whether the environment is aquatic or land-based. (Note the above few exceptions to this).
In aquatic therapy, the potential for harm to the consumer is relatively high, whereas, in aquatic fitness, the potential for harm to the consumer is relatively low. In aquatic fitness, the cost to benefit ratio is weighed more heavily on the side of benefit. Thus, aquatic fitness certifying bodies can have a lower threshold of accountability; fitness instructors can be taught more absolutes (red flags, precautions/contraindication, exercise technique execution) in lieu of assessment and evaluation skills. Instructors are working towards the group's interest, not designing a program for a single individual's impairments, functional limitations and disabilities, and thus do not have to demonstrate the same level of critical decision-making skills as if they were performing therapy. In contrast, in aquatic therapy, the "essential" is often in the "invisible".
The diagnostic, prognostic and treatment choices which are made by a therapist are based on a more in-depth understanding of an individual's body. Thus, there is a valid reason why an aquatic fitness certification can be appropriately offered to multiple disciplines (and even to lay persons) and why an aquatic therapy certification probably should not.
Conclusion: If an organization were to develop voluntary baseline standards for aquatic therapy, the therapy community would probably be able to agree on some core elements common to each profession. Aquatic therapy providers need standards which are different from land-based therapy providers. The messy part comes when we move beyond standards and into a single certification which proports to vouch for the safe practice of aquatic therapy. Instead, each distinct discipline should work to provide its members, at a minimum, baseline standards. Note: the common argument that "waiting for such individualized action will take too long (and that, in the meanwhile, something is better than nothing)" is an invalid argument. Something which is improper is rarely better than nothing.
No one discipline "owns" the water. Different therapeutic disciplines and wellness/fitness instructors have unique (and sometimes mutually exclusive) things to offer the public. Some overlap, some do not. But each profession must remain true to the standards established by its respective scope of practice and legal practice act. Because of these limitations, it seems implausible that a single multidisciplinary certification will ever be able to serve as a legal standard or prerequisite for practicing the therapeutic procedure aquatic therapy.
Learn More on this Topic
Individuals interested in reading more on certifications and on the legal aspects of billing and reimbursement for aquatic therapy should order Billing for Aquatic Physical Therapy by phone (715) 248-7258, fax (715) 248-3065 or online.
1. American Medical Association. Current Procedural Terminology (CPT), 4th ed. American Medical Association; Chicago, IL; 1999: 415-416.
2. CPT Information Services. Personal communication clarifying CPT definition of aquatic therapy. American Medical Association: Chicago, IL; April 8, 1999.
3. American Alliance for Health, Physical Education, Recreation and Dance, Association for Active Lifestyles and Fitness, Aquatic Council. Adapted Aquatics Instructional Credentialing Program. American Alliance for Health, Physical Education, Recreation and Dance: Reston, VA; 1999.
4. Elder T, Campbell K. Aquatic Fitness Everyone, 2nd ed. Winston-Salem, NC: Hunter Textbooks Inc; 1997.
5. Aquatic Exercise Association. What is aquatic fitness? Water Well. 1999; Vol. 6.
6. Definition of "certification": A document certifying (authenticating or vouching in writing) that one has fulfilled the requirements of and may practice in a field. Black HC. Black's Law Dictionary, 6th ed. Publisher's Editorial Staff: St. Paul, MN; 1990.
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.
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 firstname.lastname@example.org