Not a single week goes by without media outlets advertising the newest drug or medical procedure to treat pain. Pharmaceuticals and invasive interventions are effective first-line choices to treat acute pain. However, most don’t provide long term relief.
The biomedical model focuses on treating symptoms without addressing the root cause, such as poor nutrition, sedentary behaviours and other lifestyle factors. This is often the reason why many of the modern chronic diseases are poorly treated and never resolve. Chronic pain is a stellar example.
Now that the impact of diet on chronic (or “lifestyle”) diseases is widely accepted, and patients’ concerns about the limited efficacy and potential risks of prescription drugs continue to grow, practitioners are encouraged to look more closely at factors such as exercise, the maintenance of a healthy weight, stress reduction, and diet.
This change is driven by consumer demand as well as strong evidence that common biomedical “fixes” such as NSAIDs have been shown to kill more than 16,500 patients per year(1).
Patients are increasingly looking for safe and more natural, long-term answers for managing and preventing pain and non-communicable disease.
And they expect their health care practitioners to be on a similar page.
Physical therapists are well positioned to address both physical activity and nutrition. Both are safer solution to treat chronic pain than invasive procedures and prescription meds.
As physical therapists, we are presented with a real opportunity here.
I have discussed research which demonstrates that physical therapists can play an active role in lifestyle-related interventions such as nutrition. Providing information on nutrition will put you ahead of the curve and improve patient outcomes.
Diet and nutrition are key components of many conditions treated by physical therapists. And nutrition directly affects recovery and function while an individual is under a physical therapist’s care. It makes sense, then, for physical therapists to be concerned with and address nutritional intake and eating patterns of their patients and clients. Although not always addressed in practice, nutrition is part of the professional scope of practice for physical therapists.
Physical therapists are well positioned to address both physical activity and nutrition. Both are safer solution to treat chronic pain than invasive procedures and prescription meds. As physical therapists, we are presented with a real… Click To Tweet
Poor Nutrition, Pain and Chronic Inflammation
Research continues to support an association between the food we eat and chronic pain. Inflammation is a contributing factor to the persistence of pain.
Energy is obtained by oxidation (burning) of nutrients within cells. When calorie (nutrient) intake surpasses calorie demand, some cell types (eg hepatic, adipose, and muscle cells) can store excess nutrients as lipids or glycogen for later use. However, with increased availability of nutrients oxidative reactions also increase, and excess by-products of these reactions -reactive oxygen species (ROS) and reactive nitrogen species (RNS)- are produced, overwhelming the cells’ antioxidant defenses. Excess ROS and RNS lead to oxidative and nitrosative stress, which modifies and damages proteins, lipids, and DNA with potentially serious consequences (6).
“A lot of chronic pain is the result of chronic inflammation, and the evidence is quite strong that your diet can contribute to increase systemic inflammation,” said Dr. Fred Tabung, PhD, MSPH, a researcher with the Department of Nutrition at Harvard’s T.H. Chan School of Public Health. “But, your diet is also one of the best ways to reduce it.”
To learn more about diet-related inflammatory mechanisms check out my blog: PRESCRIBING OPTIMAL NUTRITION AND PHYSICAL ACTIVITY FOR LOW-GRADE CHRONIC INFLAMMATION AND PAIN
3 Ways Physical Therapists Can Start Integrating Nutrition
Although physical therapists are aware of the importance of healthy eating they rarely provide specific nutrition advice due to insufficient knowledge and/or lack of confidence (7).
We learn some basics in PT school, but there is still no requirement to teach nutrition in doctoral physical therapy programs in the United States. Globally the majority of PT programs have left nutrition out of the curriculum.
Assessing your patients nutritional status and understanding the specifics of different diets is critical to provide effective nutrition education, guidance and counseling. Lastly, it is important to track patients’ progress, to reinforce engagement and adjust recommendations.
Here are 5 ways you can begin to implement nutrition into your physical therapy practice.
1- Screen for Poor Nutrition
Nutritional screening tools can be easily implemented in the physical therapy setting to identify a patient’s nutritional needs, adverse food-related practices, and disease risk factors. Results can be used to empower the individual to make positive dietary changes, alert them to risk factors, and determine the need for referral to a registered dietitian or physician (for example, upon suspicion of diabetes) (8).
Overweight/obesity: can be easily screened by measuring BMI and waist circumference. This allows for the classification of patients as underweight, normal weight, overweight, or obese. Obesity is associated with many metabolic conditions, osteoarthritis and chronic pain syndromes.
Poor nutrition: while prevalent among all weight ranges, is less commonly assessed during physical therapy examinations. The Mini-Nutritional Assessment and the DETERMINE Your Nutritional Health Questionnaire are brief, simple, and reliable screening tools aimed at older adults. They are easy to implement in the physical therapy practice (9). Caution is advised when interpreting these results because not all persons with scores indicating risk may be truly undernourished. Nonetheless, these tests are valid and reliable tools for identifying potential risk and the need for a more in-depth assessment by a physician and/or registered dietitian.
2- Understand the Pros & Cons of Different Eating Patterns
We are frequently bombarded with information about diet, nutrition and food. Given the strong connection between food and pain it is important to educate both patients and the general public through nutrition education, wellness and health promotion. It can be confusing for patients to navigate through information. Below I list below several diets, some of them best suited to specific situations, with proven benefits in reducing pain and alleviating common health conditions.
For expert insights on nutrition for pain, listen to my podcast NUTRITION FACTS AND FICTION ABOUT PAIN WITH DR. ALAN CHRISTIANSON, NMD
Dietary Approaches to Stop Hypertension (DASH) diet
The DASH diet comes from a landmark study demonstrating the plan’s efficacy in reducing hypertension risk and lowering high blood pressure (11). It emphasizes fruits, vegetables, and low-fat dairy foods and is low in saturated fat, total fat, and cholesterol. The DASH diet also encourages the consumption of whole grains, poultry, fish, and nuts while discouraging red meats, sweets, and sugary beverages. Patient guidance for personalizing the diet can be found here.
The ketogenic diet includes high-fat (~75%), low-carbohydrate (~5%), moderate protein (~20%) diet that was shown to offer many health benefits (12). It is probably most known for the treatment of epilepsy and difficult-to-control seizures in children, but current evidence shows that this diet can help with weight loss and diabetes (13). A 2019 study in the International Journal of MS Care, conducted by physical therapists, found that people with mild-to-moderate multiple sclerosis (MS) attained better ambulation, daily function, and quality of life when they followed a ketogenic-like diet (14). The ketogenic diet can produce marked and rapid health effects, and common benefits include:
- Increasing energy and normalizing hunger
- Weight loss
- Balancing blood pressure, and improving triglyceride and cholesterol levels
- Reducing the risk of insulin resistance and type 2 diabetes
- Attenuating inflammation
The ketogenic diet can be a vast departure from the way many people are used to eating, and it is more difficult to adhere to. Attention needs to be paid to unwanted effects (“keto flu” symptoms), among which are nausea, fatigue, headache, and dry mouth (15).
To learn more about the keto diet, listen to my podcast ANTI-INFLAMMATORY AND KETOGENIC NUTRITION WITH LEANNE ELY
The Mediterranean diet is a collection of dietary habits that are common to people residing in countries that border the Mediterranean Sea. There is no one single Mediterranean diet, but the many versions share some common characteristics: a high consumption of fresh fruits, vegetables, legumes, whole grains, nuts, seeds and olive oil; a moderate intake of fish and poultry; a lower consumption of red meat, dairy and saturated fatty acids; and a low-moderate alcohol consumption (16). Adherence to this diet has shown to reduce overall mortality (9%) and mortality from cardiovascular disease (9%), cancer incidence (6%) and incidence of Parkinson’s and Alzheimer’s diseases (13%) (17). Its main benefits include:
- Protecting heart and gastrointestinal health, and improving cognitive function
- Regulating blood sugar and preventing diabetes
- Reducing circulating inflammatory markers
A recent clinical trial showed that following a Mediterranean diet decreased the risk of frailty, functional disability, and sarcopenia in the elderly (18). Another study that followed over 10,000 women in their 50s and 60s found that those who followed a Mediterranean-style diet were 40% more likely to live to 70 years old without chronic illness, including physical and psychological disabilities, than those with less healthy diets (19).
FODMAPs is an acronym for Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols. These are poorly absorbed, short-chain fermentable carbohydrates that are naturally present in many foods, including garlic, wheat, legumes, dairy products, apples, and stone fruits, to name a few. Restricting consumption of these carbs helps prevent intestinal gas and bloating, promoting gastrointestinal health.Marked improvement was seen in patients suffering from IBD (Inflammatory Bowel Disease, which includes Crohn’s Disease and Ulcerative Colitis), Irritable Bowel Syndrome (IBS), and Fibromyalgia (20). This diet is not recommended for long-term therapy, requires monitoring for adequate calcium and fiber, and dietary counseling by a health professional is recommended for proper follow-up.
It has been suggested that the advent of farming and food factories following the Industrial Revolution brought changes in our diet that were too abrupt for our genome to adjust; hence, our bodies are ill-equipped to handle highly processed, artificial foods. Advocates of the Paleo Diet (sometimes referred to as the Paleolithic Diet, Primal Diet, or Ancestral Diet) suggests foods that were regularly consumed by our human ancestors during the Paleolithic time period (approximately 2.6 million-10,000 years ago) may be beneficial for the prevention and treatment of some of our modern day chronic diseases. The Paleolithic food groups include meat, fish, shellfish, fresh fruits and vegetables, roots, tubers, eggs and nuts. Excluded from this diet are highly refined grain products, processed sugars, industrial seed oils, and dairy products. Some controversy exists regarding this diet, as it excludes whole grains and legumes, which are good sources of fiber, vitamins and other nutrients.
Intervention studies demonstrate favorable changes in disease risk factors, particularly in cardiovascular and diabetic risks, after the adoption of a Paleo diet (21, 22). Positive effects were seen regarding:
- Blood pressure, lipid profiles, and glycated hemoglobin (HbA1c)
- Glucose tolerance, insulin sensitivity, and weight
- C-reactive protein level (a marker of inflammation)
Because it reduced inflammatory factors, the Paleo diet has been touted as a good dietary approach to autoimmune disease.
The Autoimmune Protocol (AIP)
The AIP is a much stricter version of the Paleo diet, developed from clinical observation. Foods on the AIP comprise healthy meats, including organ meats, seafood, vegetables (except nightshades), fruits, fats, and fermented foods. The AIP does not allow eggs, nuts, seeds, nightshade vegetables (tomatoes, potatoes, eggplant, peppers), as well as non-nutritive sweeteners (including stevia). The AIP should be used as an elimination diet, with the reintroduction of some of the excluded foods after a given period of time. It can be somewhat difficult to implement, and guidance from a health professional is suggested.
A 2014 study conducted by Dr. Terry Wahls, who reversed her MS symptoms with her version of the Autoimmune Protocol called the Wahls Protocol, found that a multimodal intervention that included an AIP diet significantly improved fatigue in MS patients (23). Beneficial effects of the AIP have also been described in patients with IBD (24), while anecdotal and peer-reviewed evidence support relief from autoimmune conditions such as thyroiditis (Hashimoto’s disease), Sjögren’s syndrome, and rheumatoid arthritis.
For first-hand insight into how the AIP and Paleo diets can help treating autoimmune disease, listen to my podcast: MODERN PALEO NUTRITION TO TREAT AUTOIMMUNE CONDITIONS WITH DR. TERRY WAHLS
The plant-based diet has gained much popularity based on proven health benefits ranging from improved heart function, better weight management and glycemic control, and reduced inflammation (25). The Plant-based diet is centered around whole, unrefined (or minimally refined) plants. Meat products (beef, poultry, seafood), as well as dairy and eggs, are consumed only occasionally. Highly refined products such as bleached flours, sugars, and oils are not allowed. While not necessarily vegan (no animal products consumed), this diet is mainly based on whole plant foods. Though percentages vary, plants can make up 70-80% of the diet.
People who eat primarily plant-based diets often exhibit:
- Lower incidence of heart disease, stroke and cancer
- Increased serum levels of antioxidant micronutrients (alpha- and beta-carotenes, lycopenes, lutein, vitamin C and vitamin E)
- Reduced arachidonic acid formation, from which pro-inflammatory agents (prostaglandins and leukotrienes) are created within cells
Accordingly, evidence shows that a whole-foods, plant-based diet significantly improves measures of functional status, and reduces pain among patients suffering from osteoarthritis, rheumatoid arthritis, fibromyalgia, diabetic neuropathies, Crohn’s disease, and migraine (26–31).
Accordingly, evidence shows that a whole-foods, plant-based diet significantly improves measures of functional status, and reduces pain among patients suffering from osteoarthritis, rheumatoid arthritis, fibromyalgia, diabetic neuropathies,… Click To Tweet
3- Measure and Share Patient Progress
If your nutrition intervention is specifically designed for weight loss, you will track one or more evidence-based and objective measures of patient progress (32). Regular, accurate assessment and consistent follow-up will increase patient engagement and potentiate health benefits. Moreover, the assessment of body mass index (BMI) as a primary measure of obesity is a quality measure for the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) (recently rolled over into the Merit-based Incentive Payment System, MIPS), by which physical therapists can receive incentive payments from CMS for measuring and reporting BMI.
Addressing Behavior Change and Nutrition
Long-term habits, including those that cause harm to us, can be hard to break. Fortunately there are several psychological approaches that physical therapists can learn to lead their clients and patients towards healthy changes in nutrition and physical activity. These include behavioral/cognitive therapies, such as CBT and ACT, that I reviewed extensively in the Pain Science Institute’s blogs.
5 Tips for Nutrition Education in Physical Therapy Practice
Working with patients suffering from many different conditions, I’m often impressed at how optimal nutrition becomes the needle-mover to alleviate pain. Because everybody’s different, assessing your patients attitudes toward food and eating habits is crucial to provide effective nutritional advice. So how can a PT incorporate these considerations into practice? Here are a few simple tactics you can use right now:
Tip #1 – Ask nutrition-related questions during the PT evaluation
Simple things like “do you take a multivitamin” or “about how many vegetable servings do you eat a week” can help lead to gradual dietary tweaks that yield impressive results.
Tip #2 – Have your patients keep a 24-hour food diary
Beyond establishing adherence and accountability, asking patients to write down everything they eat for 24 hours provides insight to their daily eating habits. Once you have this information, you can help them gradually improve and address behaviour change related to diet and nutrition.
Tip #3 – Provide nutrition education as part of the PT treatment plan
Rather than impose a major dietary overhaul, ask patients to do things that don’t seem so overwhelming. Not every patient needs to be placed on a restrictive elimination diet to realize health benefits or reverse pain. For example, increase their water intake, or eliminate processed foods and sugar. The average American has 10 added teaspoons to their diet. An elimination of sugar is a great place to begin!
Tip #4 – Create simple, attainable goals
Begin by allowing your patients to experience success in some way. You might ask a patient to lose 5 pounds over 3 weeks, or provide information about incorporating more omega-3 fats into their diet combined with their exercise program. These goals are doable, and they can provide your patient with the confidence to take on more challenging targets.
Tip #5 – Offer patients resources for better nutrition
Providing your patients with collateral sources of information—a helpful blog post, or an engaging book on nutrition—helps to reinforce the idea that the benefits of what they’re doing are well-established, and that they’re not alone in their journey toward healthier living. During a subsequent visit, ask patients if they got anything out of what you shared. The more reliable, readable information they receive, the better the chances that they’ll begin to become genuinely interested in the topic themselves, and for the long run. Over time, I’ve even had a few patients recommend books and blogs to me. Refer patients to nutrition and dietary professionals when their needs exceed the professional scope and your personal scope of practice.
Reversing Pain Using Functional Nutrition
According to the National Institutes of Health, educating patients about the effects of nutrition on health and coaching them to make positive dietary changes is “one of the most useful tools doctors have to improve overall health outcomes in their patients and specifically reduce inflammation”—yet physical therapy schools often do not prepare most practitioners.
Chronic pain is a complex condition, and quite often difficult to reverse with conventional medicine. The good news is, chronic pain is usually preventable and can be reduced or eliminated with simple yet powerful lifestyle changes.
Functional Nutrition is nutrition-based care that is focused on building health by restoring proper physiological functioning of the body. When you have multiple symptoms they are clues to the ways in which your body is not functioning the way it should be.
Integrating functional nutrition into the treatment of pain helps successfully treat more complex pain syndromes, improves your outcomes and completely transform your practice.
Here at the Integrative Pain Science Institute, we work with physical therapists every day to ensure they have the tools to more fully treat chronic pain. Physical therapy plus functional nutrition is an evidence-based intervention for chronic disease and chronic pain.
Click here to learn how integrating functional nutrition for pain can transform your practice by treating your most complex patients.
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