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Assessing Aquatic Merit

"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

 Byline: Andrea Salzman, MS, PT


Imagine that you attend a course that 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 other's needs—for you, material that 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 are dozens—no, hundreds—of PTs who are interested in attending my courses, I take a step beyond offering courses that clarify the treatments I find useful. I offer you a certification in the Salzman Technique (which takes four 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 PT, there is an overabundance of certification programs that have failed to meet any of those standards.


Assessing Merit of Certification Programs

In 1996, Harris offered an excellent method for critiquing treatment alternatives for scientific merit. [1] Treatment approaches that do not meet these standards are not necessarily invalid treatment alternatives, just unproven ones. However, until these standards are met, PTs should think carefully before throwing hard-earned dollars toward 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 standard is less stringent. It doesn't demand that the technique has been shown to be valid; it demands instead that it is merely possible 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 a lot of people. The second level of testing for validity is more demanding: it asks for evidence that the technique not only can work, but actually 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 all different. Is it not evident that the approaches used to treat these populations should be as well?


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 that occur in tandem with the desired treatment effect. Failure of a CME certification course instructor to discuss potential side effects that 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 should be peer-reviewed, well-designed and either experimental (i.e., 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.


Physical therapy as a profession is young. In 1988, Sievers et al examined the PT scientific foundation in their retrospective study, which compiled evidence found in literature that demonstrated effectiveness of physiotherapy for musculoskeletal disorders. [2] The results were grim.


Since then, PTs have begun to hold themselves to a much higher standard than before (for example, observe the "Hooked on Evidence" project at www.apta.org). Certainly, anyone paying extra CME dollars to obtain a certification in a treatment approach has the right to know if any aspect 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 that 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 PT) 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 PTs pay money to become a "practitioner."


Conclusion

For some reason, I occasionally have an urge to string letters after my name that, upon close inspection, add nothing to my credibility. If I am a physical therapist, the letters after my name are my credibility.


All the rest? Unless they meet the standards addressed above, they're all just window dressing.



References

1. Harris, S. (1996). How should treatments be critiqued for scientific merit? Physical Therapy, 76(2), 175-181.


2. Sievers, K., Klaukka, T., & Saloheimo, E. (1988). Is physical therapy effective for musculoskeletal disorders? Scandanavian Journal of Rheumatology, 67(Suppl), 90-92.



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