ENHANCE YOURPHYSICAL THERAPY PRACTICEWITH NUTRITION IMPROVE PATIENT OUTCOMES BY EMPHASIZING AN OFTEN-OVERLOOKED ELEMENT OF RECOVERY: NUTRITION.

03

Restoring function and reducing pain are primary goals of physical therapy. You have many tools to help your patients accomplish these goals, but there’s one tactic for faster healing that you may not be maximizing: nutrition. Diet can affect how clients experience pain. How your patients eat and drink might even be the difference between a speedy recovery and an extended rehab period.

says Graeme Lauriston, doctor of physical therapy and vice president of EXOS Physical Therapy and Sports Medicine. “That includes people with acute or chronic inflammation, chronic pain, post-surgical patients, professional athletes, and the general population who might be coming in for low back or knee pain. Even the proactive health and wellness client who doesn’t have injuries but wants to improve mobility or performance can benefit from it.”

A physical therapist’s scope of practice varies by state. In many states, it includes nutrition. (You can check your state’s practice act to see for yourself.) Even if it does, the knowledge you need — and the time required to effectively implement the right nutritional plan during therapy — may fall short of what your patients need. Adding a dietitian to your team can enhance your treatments and fast-track business growth.

EVERY PERSON OR SITUATION THAT YOU SEE IN THE PHYSICAL THERAPY CLINIC CAN BENEFIT FROM NUTRITION GUIDANCE,”

03

AT EXOS, NUTRITION IS ONE OF THE FOUR PILLARS OF PERFORMANCE, ALONG WITH MINDSET, MOVEMENT, AND RECOVERY. It’s part of the foundation of a healthy lifestyle and should be included in training and therapy. This guide will help you build your knowledge about nutrition as it relates to healing, and help you integrate more nutrition education — if not an actual dietitian — into your practice.

PART 1

WHY INVEST IN NUTRITION? We all know how important lifestyle habits, especially diet, are to improving health and lowering the risk of a variety of diseases. Nutrition is key to boosting patient performance. It’s no different when it comes to physical therapy, whether a patient is recovering from surgery, an injury, or dealing with the side effects of a chronic condition. “If your patients aren’t treating what they’re putting in their bodies with any importance, it will slow the healing process,” says Paige Crawford, M.S., R.D., C.S.S.D., senior project coordinator for EXOS’ performance innovation team. “When patients have injuries, those needs change — and it’s not just about calories.” (See “The best foods for recovery,” page 7.)

Here’s how some common conditions treated in the physical therapy clinic can benefit from an increased focus on diet.

INJURY OR POST-SURGERY. Whether treating an injured athlete or someone who tripped on the sidewalk, your goal is to restore function and

return your patient to his or her prior level of performance — or better. “Dietary goals during this time include ensuring energy needs are being met but not exceeded, preserving muscle mass while preventing body fat increases, supporting protein synthesis, and managing inflammation,” says Bob Calvin, M.S., R.D., C.S.S.D., director of performance nutrition for EXOS.

Muscle starts to atrophy quickly with disuse or immobilization, often within 36 hours. As muscle mass declines so does strength and the ability to work hard to recover. Maintaining protein intake is crucial for preserving muscle, even during periods when total calories consumed has decreased. In addition, during long periods of inactivity, muscles become less sensitive to insulin, increasing blood sugar.

Injuries and surgery also trigger an inflammatory response, a natural part of the healing process. The more severe the injury, the greater the inflammation. Underlying inflammation, such as the kind found in the chronic conditions mentioned below or caused by a poor diet, can alter the immune response to injuries and trauma. New research is even

showing that dietary interventions to reduce inflammation may be useful for treating traumatic brain injuries.

And with recovery comes increased energy demands, often by up to 50 percent, according to a 2015 literature review published in the journal Sports Medicine. While overall energy expenditure may drop, restricting intake too much hampers healing. Finding the right dietary balance during recovery isn’t easy. Simply being in pain may make somebody eat more. It’s even common to see dietary deficiencies among elite athletes. So imagine what non-athletes, who may be eating fast and processed foods on a regular basis, are experiencing.

CHRONIC CONDITIONS. Diabetes, obesity, and autoimmune conditions can all contribute to pain and alter how pain is perceived. Studies have shown that dietary interventions can impact the risk and severity of diabetes and weight gain. Diet shifts, such as eliminating certain foods that might inflame the gastrointestinal tract, can also impact autoimmune conditions. As diet changes and these problems improve, the patient feels better, moves better, and heals better.

03

DEALING WITHINSURANCE

PART 2

HOW TO BRING NUTRITION INTO YOUR PRACTICEThe ultimate goal in adding nutrition to your practice is to improve outcomes for the patient. Better outcomes ultimately translate to more referrals, increased business, and happier patients. While a physical therapist may provide dietary counseling, his or her nutritional knowledge is likely to be far less comprehensive than a dietitian’s.

According to the American Physical Therapy Association, “A physical therapist should refer out when the required education [for the patient] is beyond general information that can be found in the public domain, or involves information that is outside of dietary guidelines. Clients who require extensive meal planning, [or] specific values for any macro- or micronutrients should be referred out, as should patients with specific disease processes or who are on specific medications that are directly affected by dietary manipulations.”

To make nutrition a truly strong pillar of your practice, it’s best to seek the expertise of a dietitian. Not every physical therapy clinic is able to staff a full-time dietitian, but there are other options if you want to make nutrition a priority.

FULL INTEGRATION. EXOS facilities have a dedicated dietitian on staff who’s integrated into the team.

Every client who comes in receives nutrition counseling. “Having someone on-site is usually the best option,” Calvin says. “A large part of a dietitian’s role is to make food and nutrition come to life, and this doesn’t happen as readily when it’s not in person. When I work with clients in person, I’m able to make a connection faster, the results are accelerated, and the client’s continued compliance is higher than when I’ve worked with someone over the phone or computer.”

Full integration denotes that, in addition to an initial consultation when therapy begins, there are periodic nutritional follow-ups to ensure the patient is on track. “Once the initial interaction (assessment) has taken place,” Calvin says, “the dietitian must continue to serve the client, providing education and coaching through each phase of their therapy journey. We upgrade habits in pursuit of upgrading performance outcomes.

While many physical therapists bill insurance for therapy, reimbursement for nutrition services can be more challenging. Always check with the third-party payer (insurance company) about the current procedural terminology codes they reimburse for and who can use them. Dietitians can typically bill for medical nutrition therapy, nutrition counseling, or weight-loss counseling. Physical therapists may be able to bill for nutrition under “patient education.” State licensing and health care laws will determine this and may affect how you establish your systems (unless you’re a cash-based practice). Understanding these rules up front will help you maximize your dietitian-therapist relationship.

04

TO MAKE NUTRITION A TRULY STRONG PILLAR OF YOUR PRACTICE, IT’S BEST TO SEEK THE EXPERTISE OF A DIETITIAN.

05

HOW TO SUPPLEMENTFOR INJURIESWhile most dietitians agree it’s best to obtain vitamins, minerals, and other nutrients from whole food, supplements can help fill gaps in a patient’s diet, especially a patient whose health is compromised. Consider supplements for patients recovering from an injury or surgery. (Supplements should always be personalized to the patient and based on his or her stage of recovery, health, and nutritional status.)

OMEGA-3S: These fatty acids can be helpful in fighting excess

inflammation. They also assist in cellular repair of the joints, organs, and

skin. Omega-3s are found in cold-water fish (sardines, mackerel, and

salmon) as well as in flax, chia seeds, and walnuts.

SPECIALIZED PRO-RESOLVING MEDIATORS: These are a

component of omega-3s that target inflammation and help mediate

immune response. A healthy intake of omega-3s will help maximize

production of specialized pro-resolving mediators, but many people need

the extra boost.

MULTIVITAMIN: These are an insurance policy against general

nutrient insufficiencies. A diverse, plant-based diet of whole foods should

provide enough vitamins, minerals, fiber, and other nutrients.

GLUTAMINE: This amino acid helps boost gut health. Why is this

important? The gut contains much of the immune system, which can

be bolstered by improving gut health. Additionally, antibiotics that a

patient may be on can interfere with gut health. Glutamine supplements

can also be important during times of stress. Glutamine is also found in

nuts, beans, leafy greens, and animal products (seafood, beef, dairy, and

eggs).

COLLAGEN PEPTIDES: The protein collagen is an important

component of skin, bones, and joints, so naturally it’s vital for healing.

Calvin recommends that you advise patients to take collagen with

vitamin C to help boost connective tissue structure and function.

Collagen peptides are found in bone broth and gelatin. Additionally, foods

rich in vitamin C (leafy greens, berries) help with collagen production.

PART-TIME CONSULTANT. If a full-time role isn’t an option, consider bringing a dietitian in on a contract or part-time basis to meet with clients you feel could benefit the most, says Lauriston. You can also offer nutrition counseling as a stand-alone service.

OFF-SITE REFERRALS. By making referrals to a dietitian whose approach complements yours, you can emphasize nutrition even without a dietitian on-site (see “Making integration work”, page 6). You could bring a dietitian into your clinic for special nutrition events, open houses, or workshops. A nutritional specialist may also be able to provide educational materials for distributing to patients.

When looking for a nutritionist, seek someone with the registered dietitian credential, says Crawford. “There are a variety of nutrition degrees and certifications out there, and they’re not similar,” she explains. Dietitians have a bachelor’s or master’s degree from an accredited program and have supervised practice in many settings. They also have to pass a national exam and maintain continuing education, much like what a physical therapist goes through. If you’re working in an athletic environment, look for someone who has specialized credentials, such as a C.S.S.D. (certified specialist in sports dietetics) certification.

06

PART 3

MAKING INTEGRATION WORK Once you’ve started working with a dietitian — whether on-site or via referral — there are a number of ways to go about making the interaction seamless for patients.

ESTABLISH SYSTEMS. “First and foremost, training, therapy, and nutrition should work together,” says Calvin. “That happens when therapists and dietitians understand each other’s worlds.” Make sure the dietitian understands exactly what you’re doing with each client and why. Explain the assessments you use, the specific healing process, and the recovery milestones you look for.

TALK THE SAME TALK. Using similar language when working with patients helps reinforce concepts in both nutrition and physical therapy. Understanding your frames of reference and how you each approach the patient minimizes confusion and conflicting messages.

COMMUNICATE REGULARLY. Schedule periodic meetings to review patients and raise any concerns about the process. Use these meetings to spot opportunities for better integration or patient education. “You have to communicate to truly understand what each other does,” Calvin says.

LOOK FOR OTHEROPPORTUNITIES TO BRING NUTRITION TO LIFE. “Some of the most impactful interactions I have with clients occur on the weight room floor or in the café during meals,” says Calvin. “These are organic, informal interactions that can’t occur remotely.” These conversations often happen naturally when you have a full-time, on-site dietitian. You can achieve the same kind of interaction in other ways, including taste tests, cooking demonstrations, workshops, grocery shopping trips, and more.

USE NUTRITION AS AMARKETING TOOL. “Nutrition hasn’t been well integrated into most rehabilitation practices, from elite sports medicine clinics to smaller practices,” says Lauriston. Take advantage of this shortfall and use your focus on nutrition as a selling point for your practice. People want to get better and heal faster, especially athletes. When marketing your business, emphasize nutrition as well as success stories.

FIRST AND FOREMOST, TRAINING, THERAPY, AND NUTRITION SHOULD WORK TOGETHER.”

7

THE BEST FOODS nutrient delivery, and waste removal — all related to recovery and wound healing. He recommends drinking three liters of water per day for the average-size patient. Older patients may have a harder time monitoring hydration and, as a result, may easily become dehydrated without knowing it.

HEALTHY FATS: Fat in the diet boosts cellular repair in the joints while protecting against inflammation. Fat also improves satiety by helping a person feel full for longer. Nuts, seeds, avocado, and fatty fish contain beneficial monounsaturated and polyunsaturated fats.

VEGETABLES AND FRUIT: These are often rich in vitamins, minerals, and phytochemicals, including antioxidants that combat oxidative stress, which can contribute to tissue injury. “Our need for micronutrients increases with stress and injury,” Calvin says. These include vitamins C, A, D, magnesium, copper, iron, and zinc. Any time clients can increase their vegetable and fruit intake, it’s a win. If they have a choice, suggest they reach for brightly hued options — think kale, sweet potatoes, blueberries, and raspberries — all of which tend to be rich in antioxidants.

Inadequate nutrition can slow healing and exacerbate pain. That’s why EXOS emphasizes foods that build (protein), prevent (veggies and fruit), and protect (fats) in the first two months after a traumatic injury or surgery. Energy intake, especially carbohydrates (fuel), should be adjusted to match a patient’s activity level, which is usually low in the beginning. As activity and physical therapy increases, portion sizes can grow to provide adequate nutrition for recovery. To speed healing, make sure your patients’ diets include:

PROTEIN: Protein, ideally from plant-based sources, is key in building muscle and supporting the immune system. Without protein, muscles and ligaments deteriorate, and wound healing and the immune response may become compromised. A literature review in the journal Sports Medicine found that while energy intake is often reduced during rehabilitation from an injury (due to low activity levels), it’s important to maintain the same protein intake as before injury, as long as that intake was adequate.

HYDRATION: Dehydration can impact a variety of metabolic factors, says Calvin, including blood volume,

A good rule is to suggest that, come mealtime, clients fill half their plates with veggies. “We recommend having at least three colors on every plate,” Calvin says.

Papaya and pineapple contain enzymes that help digestion. Tart cherry juice may help with inflammation and muscle soreness. A 2018 review published in the journal Nutrients concluded that cherries decreased markers for oxidative stress, inflammation, loss of strength, and muscle soreness, among other beneficial effects.

FERMENTED FOODS: These provide an excellent probiotic source for the gut. Since so much of the immune system resides in the gastrointestinal tract, the beneficial microorganisms of probiotics may boost healing and kill bad microorganisms. Foods like kimchi (fermented cabbage), kefir, miso soup, and kombucha contain beneficial bacteria.

SPICES: Turmeric, cinnamon, ginger, and hot peppers are packed with antioxidants and anti-inflammatory compounds, and some may even have prebiotic power (feeding good bacteria) as well, says Calvin.

03

T H E R A P Y D E V E L O P M E N T @ T E A M E X O S . C O M