By Meri Goehring, PhD, PT, Victoria Diefenderfer, SPT, Rebecca Feehan, SPT and Kacie Lambert, SPT

The Section on Aquatics of the American Physical Therapy Association (APTA) was developed for physical therapists with special interests in aquatics or who use aquatics on a regular basis to treat patients. Members of the section are in the process of compiling a research bibliography to determine the need for an APTA-sanctioned specialist certification for Aquatic Physical Therapy.1 At this time, the American Board of Physical Therapy Specialists does not offer specialization in aquatic physical therapy.

For those who are interested pursuing aquatic therapy certification, there are a number of available courses and classes to consider. Due to the diversity of offerings, it can be an overwhelming process to determine what type of aquatic certification is best for an individual's practice and career. This review of some of the available options may help you decide which type of aquatic certification suits your needs and interests.

In order to present the types of aquatic certifications in an organized manner, the various types will be listed using six different categories. These categories were first described by Lori Jake, a certified therapeutic recreational specialist.2 Each category presents reputable certification programs that may be of interest to physical therapists.

Please note that these categories are not mutually exclusive. Although some certifications may fit in more than one category, each is listed only once. The six categories are: 1) intervention-specific certifications, 2) population-specific certifications, 3) aquatic therapy and rehab industry certification, 4) aquatic fitness certification, 5) adapted aquatics and 6) basic aquatic certifications, including Water Safety Instructor and Lifesaving through the Red Cross.

As each type of aquatic certification is presented, additional information is provided as appropriate. This may include the program length, approximate costs, locations and continued education credits (CECs).

Category 1: Intervention-Specific Certifications

Halliwick Method

The Halliwick method is a neurotherapeutic facilitation rehabilitation technique that is used to teach patients to move independently in water with the goal of improving balance, posture, head control and general movement.3

As it was developed, four basic principles of instruction were established: mental adaptation, balance restoration, inhibition and facilitation. These principles are taught in a 10-point program that consists of mental adjustment, disengagement, transversal rotation control, saggittal rotation control, longitudinal rotation control, combined rotation control, up-thrust, balance in stillness, turbulent gliding, simple progression and basic swimming movement.3

The Halliwick method was designed for therapists who want to instruct patients of all ages with special needs to be as competent and independent as possible in the water. The Halliwick Association provides four-day courses in the United Kingdom, Mexico and Brazil as well as the United States. The prerequisite is attendance at the foundation course. For more information on the Halliwick method and the available training courses, go to www.halliwick.org.

Watsu

Watsu was created as a massage or wellness technique that supports and gently moves the body though warm water, promoting relaxation and excellent stretching. The patient is completely supported in the water, and the therapist stabilizes or moves one segment of the person's body though the water, stretching another body segment by the drag effect, or the resistance of the water. There are three different sequences or flows for Watsu: simple flow, for people who do not have adequate range of motion to complete normal Watsu positions; expanded flow and transition flow.3 For more information on classes, go to www.waba.edu.

Category 2: Population-Specific Certifications

Arthritis Foundation Aquatic Program

The Arthritis Foundation Aquatic Program was jointly developed by the National Arthritis Foundation and the Young Men's Christian Association (YMCA) of America. It offers an aquatic program with instructor/leader certification.4 This recreational program consists of 72 basic range-of-motion and strengthening exercises with optional endurance-building activities in a deep well, and is not designated to replace a prescribed regimen of therapeutic exercise. A deep well implies that the aquatic exercises are performed in a full-body submersion tank or pool, typically around six to seven feet in depth.

Despite the known benefits of exercise, people with arthritis tend to become sedentary as compared to those without arthritis.5 According to the American Journal of Health Behavior, it is common to both exercisers and non-exercisers to have the sense that arthritis has limited or changed their tolerance for physical activity.5Aquatic therapy is often used in the management of hip and knee osteoarthritis to improve the quality of life and activity level of the patient.

The Arthritis Foundation's Aquatic Program offers several benefits. First, they strive for accessibility for the general public through physician recommendations and marketing strategies. Second, this program offers functional weight-bearing and progressive exercises with emphasis on quality of movement.5

A disadvantage of the program, as with some other aquatic programs, is that a skilled therapist does not necessarily provide aquatic exercise instruction. Therefore, instructors have the potential to lack insight for maintaining neutral spine/posture and proper body mechanics throughout the exercises despite prerequisite training.6

The facilities must be sanctioned by and adhere to specific Arthritis Foundation Association (AFA) criteria, including accessibility and temperature requirements, among others. The trainee must show current CPR, First Aid and Basic Water Rescue training. After the course is completed, applicants must pass a practical demonstration of water exercises as well as a written exam. They must then teach an aquatic program twice a week for six weeks to earn certification.

Credit hours are given by the AFA and people seeking CECs must appeal or apply for credit through their professional association. Application for recertification is made every three years and in order to maintain certification, all classes must be held in the pre-approved sanctioned facility. Contact information for certification can be made through the local chapter of the AFA, which can be found at www.arthritis.org.

Category 3: Aquatic Therapy & Rehab Industry Certification

The Aquatic Therapy & Rehab Industry (ATRIC) is a non-profit educational organization that promotes the development of healthcare professionals involved with aquatic therapy. They offer continuing education courses at conferences and workshops to enhance the skills of aquatic therapists.7

This organization provides many certifications including, but not limited to, International Council for Aquatic Therapy & Rehabilitation Industry Certification (ICATRIC), Ai Chi, aquatic therapy for athletes, arthritis, Bad Ragaz, Watsu, Halliwick, aquatic gait training and aquatic orthopedics. Classes are held throughout the year across the continental United States. To become ICATRIC-certified, the prerequisites include current training in cardiopulmonary resuscitation (CPR) and first aid, basic water skills, and 30 documented hours of training in aquatic therapy and rehabilitation. Certification also requires one of the following: an undergraduate or graduate degree in related fields, an unrelated degree and three years of experience, or five years of experience in the field.7

An advantage of this program is that this is a well-known and established organization that offers instruction in many different techniques. A disadvantage is the substantial amount of mandatory prerequisites. For more information, visit www.atri.org or call 866-GO2-ATRI (462-2874) or 906-482-7097.

Category 4: Aquatic Fitness Certifications

Aquatic Exercise Association

The Aquatic Exercise Association (AEA) offers certification as an aquatic fitness professional, and also a deep module certification.8 In order to be certified, one may or may not choose to become a member of AEA (members pay discounted rates), and must pass a written examination. A minimum of six months of practical teaching experience in aquatic exercise with six to eight weeks of advance study must be performed prior to taking the examination. This training must incorporate information in the current AEA aquatic fitness manual and specific study objectives must be met. There is also an optional Aquatic Fitness Professional Review course to prepare you for the exam.

The Deep Module Certification is available to current aquatic fitness instructors and professionals. An additional six months of teaching experience and six to eight weeks of study of the fitness professional manual are required. A Deep Module Review course is optional and prepares you for the exam. To recertify every two years, a minimum of 15 CECs per certification period is required, as well as a current CPR card and a $50 fee.8

AEA offers several CEC courses after certification. These include Older Adults and Aquatic Exercise, Aquatic Warm Ups and Cool Downs, Aquatic Circuits and Intervals, Cardio and Strength Training Programs, Deep Water Techniques, Aquatic Kick Boxing, Aqua for Kids, and Aquatic Sport, Function and Performance.8 Go to www.aeawave.com for more information.

Canadian Aquafitness Leaders Alliance, Inc.

The Canadian Aquafitness Leaders Alliance, Inc. (CALA) specializes in certification for aquatic fitness, but is also an excellent resource for physical therapists seeking a population-based aquatic therapy certification. CALA's foundation course, Part I: Aquatic Leadership Training and Certification, is a 20-hour course taken over one weekend. Part I, the foundation course, is mandatory for the certification; Part II, however, is optional for those who are "a highly experienced and/or certified fitness leader with an excellent working knowledge of applied anatomy, applied physiology, components of fitness principles of training, use of music as well as exercise and class design."9 Part II is an additional 20 hours.

The certification exam must be completed within one year of taking the course(s), and is composed of theory and practical components. One must be a member to complete the CALA certification. To maintain a certification, one must maintain membership, have a minimum of eight CECs per certification period, and pay an annual recertification fee.9

The CALA offers specialty courses that range in number of hours, and many courses can be taken. There is an open book exam with a theory and case format and practical component (for some). The specialty courses are: Arthritis/Joint Rehab, Back Splash (spinal injuries), Breast Cancer, Cardiac Rehab, Multiple Sclerosis and Sports Injuries. All classes except Arthritis also require an eight-hour course, "The Healing Power of Aquatic Exercise and the Principles of Immersion," in addition to the rehab prep course. To re-certify, one must maintain current CALA membership, have a minimum of eight CECs, conduct a certain number of post aquatic therapy sessions per year, and pay an annual re-certification fee. Visit www.calainc.org for more information.9

Category 5: Adapted Aquatics Instructor training

The American Association for Physical Activity & Recreation (AAPAR) is a subdivision of the American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD).10 This is a leading organization that provides a national credentialing workshop for instructor training in adaptive aquatics.

The purpose is to train professionals how to teach swimming and water-safety skills to individuals with disabilities. The course instructors are Master Teachers. The credential of a Master Teacher is available to current adapted aquatic instructors in which the applicant's resume and teaching is reviewed.

Once accepted, the adapted aquatics instructor must successfully complete the four-hour Master Teacher workshop that is offered on a limited basis and usually in conjunction with district or national conferences.10

Material covered in the program includes significant training in the various disabilities, classroom time and an examination process. Discounts for course and textbook are available for AAHPERD members. Workshops are held at various facilities throughout the U.S. and at AAHPERD national conventions. To host a credentialing workshop, an application can be downloaded at: www.aahperd.org/aapar.

Prerequisites for the "Teacher of Adapted Aquatics" include: being over 18 years old, current in CPR (in adult, child and infant), current in First Aid, current in automatic external defibrillator (AED) certification, current instructor certification in instructional swim agency such as the YMCA or American Red Cross, sufficient strength to assist in lifts up to 125 pounds, and experience in working with individuals with disabilities in the water.10

Continuing education credits are pending for this course and may specifically fulfill requirements for recreation therapists or physical educators through the Aquatic Exercise Association (AEA). More information may be attained on-site. All applicants must attain a minimum of 80 percent on a 75-question multiple-choice exam and through a practical demonstration of water skills. Visit www.AAHPERD.org for more information. Contact information is through Barb Zipperer at bzipperer@mtrymca.org.

Physical therapists who work with the pediatric population in school settings may benefit from this agency for further aquatic credentialing. However, due to its specificity, it is not universally pertinent or applicable for many physical therapists interested in aquatic therapy.

Category 6: Basic Aquatic Certifications

Basic aquatic certifications include Water Safety Instructor (WSI) and Lifesaving through the Red Cross. Information for these programs as well as CPR and lifeguarding courses can be obtained through contacting your local YMCA, park district or community college.

Basic aquatic certifications are excellent for providing foundational knowledge for therapists interested in working in a water environment. WSI and Lifesaving will provide a therapist with the tools to react in an emergency when in and around the water, and offer basic knowledge about water safety and swim principles.

A basic aquatic certification is sometimes required to obtain a more advanced certification in aquatic exercise or therapy. If a therapist has a basic aquatic certification but not a certification in aquatic exercise or therapy, he may still be able to use land-based therapeutic techniques and adapt them to an aquatic environment, while still having the basic knowledge needed to ensure a safe intervention for the client or patient.

However, basic aquatic certifications will not provide knowledge and skills to offer interventions that are specific to the aquatic environment, and therefore may limit the interventions a therapist can provide in the water.

As the field of physical therapy moves toward specialized practice, certifications will allow therapists to develop professionally and enhance the foundations for treatment intervention and plan of care. Aquatic certification programs are available to therapists who want to build their aquatic physical therapy practice.

Although most aquatic certifications are not therapy-specific, they can empower therapists with the knowledge to build on skills to provide aquatic interventions that enhance the quality of care for patients. Aquatic certification courses will also teach therapists how to determine which patients would benefit from an aquatic environment.

When searching for a certification course to enhance their practice, physical therapists must weigh the advantages and disadvantages of the course, and also take the time to learn the qualifications of the instructors and determine whether the intervention is evidence-based.

For more information, contact the Section on Aquatics of the APTA.

References

1. Morris, D. (2000). Specialist certification and/or credentialed residency programs in aquatic physical therapy. Journal of Aquatic Physical Therapy, 8(1), 13-16.

2. Jake, L. (2006). Aquatic Therapy Certification. Therapeutic Recreation Directory. Available atwww.recreationtherapy.com/articles/aquaticstherapy.htm.

3. Ruoti, R., Morris, D., & Cole, A. (1997). Aquatic Rehabilitation. Philadelphia: Lippincott.

4. Arthritis Foundation.(2006). Available at www.arthritisfoundation.org.

5. Abbott, J., Der Ananian, A., Vrazel, J., et al. (2006). The exercise experience in adults with arthritis: A qualitative approach. American Journal of Health Behavior, 30, 731-745.

6. Day, A., Heywood, S., & Hinman, R. (2007). Aquatic physical therapy for hip and knee osteoarthritis: Results of a single blind randomized control trial. Physical Therapy, 87, 32-35.

7. Aquatic Therapy and Rehab Industry. (2006). Available at www.atri.org.

8. Aquatic Exercise Association. (2006). Available at www.aeawave.com.

9. Canadian Aquafitness Leaders Alliance, Inc. (2006). Available at www.calainc.org.

10. American Alliance for Health, Physical Education, Recreation and Dance. (2006). Available atwww.AAHPERD.org.

The methods used to gather information for this article were approved by Northern Illinois University Institutional Review Board.

Meri Goehring is assistant professor at the Northern Illinois University College of Health and Human Sciences School of Allied Health Professions Physical Therapy Program, DeKalb, IL. Victoria Diefenderfer, Rebecca Feehan and Kacie Lambert are all students of physical therapy in the program.

Looking It Up: Bibliography of Evidence Supporting Aquatics

Halliwick and Watsu

Sterba, J., Safar-Riessen, D., & Deforest, M. (2004). Effect of aquatic therapy on gross motor function measure in children with cerebral palsy. Developmental Medicine and Child Neurology, 46, 47-48.

Arthritis

Melton-Rogers, S., Hunter, G., Walter, J., & Harrison, P. (1996). Cardiorespiratory responses of patients with rheumatoid arthritis during bicycle riding and running in water. Physical Therapy, 76(10), 1058.

Hinman, R., Heywood, S., & Day, A. (2007). Aquatic physical therapy for hip and knee osteoarthritis: Results of a single blind randomized controlled trial. Physical Therapy, 87(1), 32-43.

Multiple Sclerosis

Pariser, G., Madras, D., & Weiss, E. (2006). Outcomes of an aquatic exercise program including aerobic capacity, lactate threshold, and fatigue in two individuals with multiple sclerosis. Journal of Neurologic Physical Therapy, 30(2), 82-90.

Roehrs, T., & Karst, G. (2004). Effects of an aquatics exercise program on quality of life measures for individuals with progressive multiple sclerosis. Journal of Neurologic Physical Therapy, 28(2), 63-71.

Broach, E., & Dattilo, J. (2003). The effect of aquatic therapy on strength of adults with multiple sclerosis.Therapeutic Recreational Journal, 37(3), 224.

Back Pain

Konlian, C. (1999). Aquatic therapy: Making a wave in the treatment of low-back injuries. Orthopedic Nursing, 18(1), 11-20.

General Exercise and Strength

Tsourlou, T., Benik, A., Dipla, K., Zafeiridis, A., & Kellis, S. (2006). The effects of a 24-week aquatic training program on muscular strength performance in healthy elderly women. Journal of Strength and Conditioning Research, 20(4), 811-818.

Darby, L., & Yaekle, B. (2000). Physiological responses during two types of exercise performed on land and in the water. Journal of Sports Medicine and Physical Fitness, 40(4), 303-311.

Sports

Levin, S. (1991). Aquatic therapy. The Physician and Sports Medicine, 19(10), 119-123.

Breast Cancer

Tidhar, D., Shimony, A., & Drouin, J. (2004). Aqua lymphatic therapy for postsurgical breast cancer lymphedema. Rehabilitation Oncology, 22(3), 6-14.

Obstetrics

Smith, S. (2006). A pilot study on the effects aquatic exercises on discomforts of pregnancy. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35(3), 315-323.