Nutrition: To Collaborate or Not?

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

Can you recall a recent treatment session or patient case where you connected with another fellow physical therapist (PT), occupational therapist (OT), or speech therapist (ST)? Overall the treatment session or case probably went well, right? Both you and the other provider worked together, solved several problems, and/or potentially identified major issues that changed the course of rehabilitation.

In this example it is easy for us in rehabilitation to see how easy it is to collaborate with other rehab professionals -- but what about dieticians? My team and I have long argued that PTs ought to work more collaboratively with these healthcare providers. Let me delve into several reasons why and examples of how nutrition collaboration benefits all.

Dietitians' Education

Dietitians are educated and clinically trained to work with many challenging populations. Their 4 year college education and clinical training prepares them to work with the sickest of clients and also the most healthy. Many dieticians are licensed and/or are registered, hence the RD credential. They can specialize in certain populations and/or conditions, similar to PTs or MDs. As such, dieticians can help our patients while we are helping them move better.

A great example of this would be a client of mine with Parkinson’s. She began working with me to improve her transfers, gait, and balance. Unfortunately she began to have digestive problems and, due to medication, developed high serum potassium. As such, she needed a lower potassium diet but one with adequate fiber and water to help her GI motility. I collaborated with an awesome registered dietician who helped guide our client to modifying her diet. The dietician worked specifically with older adults and had much exposure to low-potassium diets when she was in clinical internship. With the dietary changes, I noticeably saw our client’s energy levels improve and she also had fewer complaints of abdominal pain during PT. It was a win-win!

Prevention

Preventing other health conditions is slowly being adopted in PT practice. Our model of care delivery was stuck in the biomedical, fix-it-later model, which is evolving to a more client-centered, bio-psycho-social model rapidly. Inpatient rehabilitation often involves patients with multiple comorbidities, polypharmacy, and a list of functional deficits. Nutrition is often interconnected with each of these issues. Consider this:

A patient’s diet may be related to significant weight gain, heart disease, and diabetes.
Hypertension and hypercholesterolemia are most often associated with a diet high in salt, fat, and processed foods; such conditions often warrant the use of multiple drugs to reduce blood pressure, cholesterol, or serum glucose.

Functional declines are intertwined with biomedical changes, medications, and nutritional factors. Preventing functional declines involves pragmatic and repeated movement, as well as good wellness characteristics, including diet.

A great example of this would be a recent patient I had who had been diagnosed with thoracic outlet syndrome. He was a young male training to be in the United States Navy. After a thorough PT examination I had uncovered he had fractured the clavicle on his involved side, which may have contributed to structural restrictions around his upper quarter. I provided him with my best interventions and we moved forward thinking we were making progress...until he started developing symptoms in his other hand the following week. My next visit was a detailed re-evaluation with a more thorough history and discussion about diet. I asked about “social factors” such as tobacco use, sleep quality and quantity, and alcohol consumption. I also detailed a 24 hour dietary recall, which proved to be very helpful. My client was using large amounts of alcohol every night to go to sleep. The next day he would wake and go for a workout or run and his symptoms would be back. I advised him and his primary physician of his alcohol abuse pattern and recommended he connect with a local dietician to help with the change and his post-workout recovery.

Both his physician and dietician advised him to slowly taper down on his alcohol use. As a team we advocated for alternative forms to help with sleep like meditation, teas, and sleep hygiene. As his alcohol use declined so did his symptoms! After 1 month of no alcohol his symptoms were completely gone. He now regularly uses me for PT as aches and pains pop-up in preparation for Navy boot camp.

Consider how another client could also reap prevention and healing benefits from changing their diet? A patient with burns needs additional protein, calories, and nutrients to help heal. Meniere’s syndrome can be related to a person’s dietary salt intake, necessitating a lower sodium diet. Older adults in nursing homes with cognitive declines are at risk of malnutrition: PTs can identify this risk and act by consulting dieticians. Lastly, many chronic conditions are diet-related: a referral to a dietician may help them change their way for the long haul.

Response to Rehabilitation Interventions

The human body responds to stimuli both inside (food) and out (exercise). One mainstay rehabilitation treatments is active exercise. We often load patients to challenge their neuromotor systems in hopes to improve function, performance, or quality of life. Our treatments may span therapeutic exercise, resistance training, functional training, and balance work to name a few. Most of these treatments have interplay with dietary factors.

Most sports PTs, strength coaches, and athletic trainers will highlight the importance of calorie and protein intake in their athletes. Sufficiently timed protein after exercise has been shown to optimize muscle protein synthesis and prevent catabolism. The literature also demonstrates that certain foods naturally rich in nitrates may boost running and sprinting performance. In essence, food can help athletes recover from exercise as well as boost performance. As such, a dietician can help these athletes meal plan and dose their food accordingly -- another win-win!

Neuro and geriatrics PTs often see clients with balance deficits. Falls can create major disability and even death, so improving a client’s balance is vitally important. Resistance training, balance work, and patient education can improve a client’s balance -- but so can food! Several studies have highlighted the positive effects of berries on cognition, parallel processing, and balance. Most authors suggest it is the natural food color, which is a strong antioxidant, that helps to boost blood flow to the brain and improve balance. PTs can easily ask clients to add berries to their daily menu with minimal downside; alternatively you may wish to have the client seek out a dietician trained in neurological conditions.

I can think of many cases in my practice where I knew my client could benefit from changes in nutrition. In simple cases nutritional counseling was easy; however, in most cases, clients need comprehensive nutritional care. Dieticians are a great resource for this. As PTs have earned their Doctorates it is still difficult to balance all facets of every client’s needs. Having an RD to collaborate with can be very helpful.

In the end, PTs are constantly learning more, especially in regards to wellness and nutrition. Some clients may benefit from a collaborative treatment from both PT and dietician. I encourage you to seek out several dieticians to have in your armory of care. Some may handle certain clinical specialities or populations better (e.g. sports vs inpatient older adults), so having a few to rely on would be wise. Lastly, be open to the referral and co-treatment of a client: it will ultimately help the client the most!

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