Aquatic Therapy: Procedure or Profession? (Part 2 of 2)

Part 1 defined aquatic therapy as a procedure. Part 2 looks at the laws and certifications that decide who may perform it.

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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.

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.

For education only; not a substitute for individual clinical judgment.