Physical Therapy and Alcohol: A Good Mix?

By: Dr. Sean M. Wells, DPT, PT, OCS, ATC/L, CSCS, CNPT, NSCA-CPT, Cert DN

Many people kickback and enjoy a cold beer or nice glass of wine with a meal or just to relax. But does alcohol consumption pose a risk to our health and physical therapy patients? The answer can be difficult to find amongst the literature, especially due to industry influence. Let's take a look at the guidelines, some upcoming revisions to alcohol intake recommendations, and what all this means to PTs and physical therapy outcomes.

Old Guidelines

Alcohol intake guidance varies depending on where you live. In the United States, the Centers for Disease Control (CDC) and the Dietary Guidelines demonstrates that females should consume no more than 1 drink per day, while males can have 2 drinks per day. Most of this guidance is rooted in the fact that males usually have larger mass, and therefore, can physiologically "handle" more booze. Obviously all drinks are not created equal, so if a person takes the US guidelines from its face value it may promote overconsumption. For instance, a large can of beer may be seen as 1 drink when in fact it may actually be considered 2 drinks. A tall drink of vodka and soda may seem like 1 drink when in fact you actually poured 3 shots worth of vodka, making a total of 3 drinks. Understanding the amount of alcohol in each unit of alcohol is something the United Kingdom (UK) does well in its guidelines.

Physios in the UK may be familiar with their alcohol guidance as a recent campaign has pushed for more restraint with drinking. Instead of taking a daily approach like the US, the UK focuses on consumption across the week. The National Health Service (NHS) "advise limiting alcohol intake to 14 units a week for women and men. This is equivalent to drinking no more than 6 pints of average-strength beer (4% ABV) or 7 medium-sized glasses of wine (175ml, 12% ABV) a week." For many, calculating the units may seem tricky but I think the best part of the guidelines is the NHS advice to have "days off" of drinking and to focus on measuring your hard liquor, something the US guidelines currently fall short on.

Other countries have guidelines too. The European Union (EU) offer that people "limit alcohol intake. Intake should not exceed 10g per day for women and 20g per day for men. Alcohol consumption should not exceed 5 % of the energy intake in adults. Pregnant women, children and adolescents are recommended to abstain from alcohol." Interesting the EU guidelines offer physios insight into how much alcohol should be consumed based on total energy intake, while mimicking similar daily guidelines of the US CDC for men and women.

Upcoming Guideline Changes for the US

The US is about to roll out its 2020 Dietary Guidelines for Americans (DGA), which has been reported to urge Americans to drink less. Since the 1980s the DGAs has discourage heavy alcohol consumption, but has suggested moderate drinking may be good for heart health, amongst other issues (e.g. rheumatoid arthritis). A recent systematic review showed that the alcohol industry has and is capable of influence government guidelines. Supposedly the DGAs may be breaking away from such influence and guidance, as scientists have recently analyzed data to show that less alcohol is actually better. Many of the studies used in decision making the past were observational. Those drinking moderate daily wine perhaps were consuming a more plant-based diet, such as the Mediterranean or vegan diets. The effects seen may have been from the food, not the wine. Another issue with prior studies is the the "J" effect from sick quitters when plotting alcohol consumption relative to health issues. Those abstaining from alcohol altogether appear sicker than those consuming moderate amounts. This is due to the fact that a large number of those abstaining from alcohol altogether during the study had to in order to prevent further disease or issues from alcoholism. In summary, the data supporting drinking for positive health impacts is dwindling and less booze is better. As such, upcoming US alcohol consumption guidance will likely be reduced to 1 drink per day max for both men and women.

Alcohol and PT Practice

What does any of this mean for PTs? First, physios ought to be asking their patients about lifestyle and social factors like diet, regular foods, food patterns, hydration, and ALCOHOL consumption. Other doctoring professions like physicians, podiatrists, and nurse practitioners routinely ask these questions during their history and intake -- why should doctors of physical therapy do anything different?

More importantly the data for alcohol use and its impacts on PT practice is growing. A recent meta-analysis showed that excessive alcohol consumption was a major contributing factor to sarcopenia. Sarcopenia is an issue that physios deal with in many older adults. We use resistance training, power exercises, and nutrition to help these patients mitigate sarcopenia. PTs should also ask these patients to reduce their alcohol intake.

Osteoarthritis (OA) is another major issue that PTs address. Another review study has found that moderate alcohol consumption (1–7 drinks/week) was associated with 2-fold higher odds of erosive hand OA, which was statistically significant. For physios working with adolescents, it is important to see that early alcohol use may contribute to continued and possibly abusive alcohol consumption in adulthood. Such heavy alcohol consumption has been shown to produce aggressive OA degenerative changes in mouse models.

Other orthopedic issues we see in patients included rotator cuff tears and tendon pain. A recent study highlighted the following results:

Total alcohol consumption, wine consumption, and duration of alcohol intake were higher in both men and women with RCT than in both men and women in the control group. Excessive alcohol consumption was found to be a risk factor for the occurrence of RCT in both sexes (men: OR = 1.7, 95% CI: 1.2–3.9; women: OR = 1.9, 95% CI: 0.94–4.1). Massive tears were associated with a higher intake of alcohol (especially wine) than smaller lesions.

Several other cohort and case-controlled studies have shown a link between alcohol use and tendon ruptures. As such, PTs need to be aware of patients' alcohol consumption with rotator cuff, achilles, and other muscular tears.

As PTs we work with many patients that have had or are currently being treated for cancer. Preventing these cancers in the first place would be ideal, although many physios have not been trained to be proactively preventative. Consider this blog post a way to stimulate you and your colleagues to change your ways. Alcohol has been linked with oral and esophageal, liver, breast, and prostate cancers to name a few. Did you know that having cancer in the first place increases the risk of getting cancer again? As such, we should be educating cancer survivors that minimizing alcohol consumption would reduce their odds of cancer coming back. Such education requires no specialized training or degree -- merely engaging the patient in basic nutrition education and the science behind alcohol's cancer promoting effects is all you need!

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