CAN A PHYSICAL THERAPIST GIVE NUTRITION ADVICE? WHAT THE LAW SAYS ABOUT A PT COUNSELING ON NUTRITION

Home
Blog
CAN A PHYSICAL THERAPIST GIVE NUTRITION ADVICE? WHAT THE LAW SAYS ABOUT A PT COUNSELING ON NUTRITION

Public health recommendations for lifestyle interventions, including diet, nutrition advice, and physical activity, have been widely publicized for the treatment and prevention of diseases, including chronic pain (1).

One vital component of lifestyle, functional, and integrative medicine is nutrition. Nutrition education and counseling have steadily worked its way into the scope of practice of many licensed health professionals.

But does nutrition fall within the scope of practice for physical therapists?

The short answer is YES… but read on for the whole story.

nutrition advice - Can a PT give nutrition advice?

With obesity, diabetes, and other non-communicable diseases at an all-time high, the need for nutrition education is paramount. The evidence for all licensed health professionals to include nutrition in practice, including physical therapists/physiotherapists, has been building for over two decades. A 2014 study in the American Journal of Clinical Nutrition noted:

“Understanding and applying nutrition knowledge and skills to all aspects of healthcare are extremely important, and all health care professions need basic training to effectively assess dietary intake and provide appropriate guidance, counseling, and treatment to their patients.”

“Physicians, physician assistants, nurses, nurse practitioners, pharmacists, dentists, dental hygienists, occupational therapists, physical therapists, speech and language pathologists, and others can positively affect patient care by synchronizing and reinforcing the importance of nutrition across all specialty areas.”

“Nutrition is also an important component of education, training, practice, and research for PAs, physical therapists (PTs), occupational therapists (OTs), and speech and language pathologists (SLPs). These graduates are ideally positioned to serve as health coaches promoting lifestyle modifications, especially during the rehabilitative continuum.”

With sufficient evidence regarding both the positive and negative influences of diet and nutrition on health, more and more licensed practitioners are implementing nutrition into the care plan.

Physical therapists are now actively implementing nutrition into practice and recognize it as an essential part of optimizing movement, physical function, and improving health. Nutrition advice is an important intervention to help people overcome chronic noncommunicable diseases, including many chronic pain syndromes.

What is the Link Between Nutrition and Pain?

Practitioners are using nutrition as an evidence-based intervention to improve physical function and quality of life (3). Optimizing nutrition has a positive influence on recovery while an individual is under a physical therapist’s care; therefore, it follows that physical therapists would be concerned with and address diet and nutrition in practice (4).

In the profession of physical therapy, the treatment of chronic pain is a hot topic.

Fueled by the APTA’s #ChoosePT campaign, patients are looking to physical therapists for:

A non-invasive way to alleviate pain.
The non-pharmacologic treatment of pain.
A trusted and licensed practitioner to counsel and provide information.

Optimizing nutrition is a game-changer for those with non-communicable diseases and pain (5).

For example, osteoarthritis is a painful condition that affects millions of Americans (6). Studies have demonstrated a positive relationship between nutrition and pain management in patients with OA (7). Nutrition advice combined with physical activity is a proven way to help patients with OA and other chronic pain syndromes including fibromyalgia, autoimmune diseases, pre-diabetes, diabetes, complex regional pain syndrome, neuropathy, and spinal pain (8,9).

There are 5 ways diet influences pain and pain perception:

A healthy diet is associated with a normal BMI and the alleviation of chronic pain (10).
Certain foods and food components have proven antinociceptive, analgesic, and anti-inflammatory functions (1 1).
A poor diet leads to significant negative changes in the gut microbiome, shifting the human organism toward a chronic proinflammatory state. This is associated with many chronic diseases, including chronic pain syndromes (12).
Proper nutrition prevents both intestinal permeability as well as the permeability of the blood-brain barrier—both of which influence peripheral and central sensitization (13).
Proper nutrition positively influences mood disorders such as anxiety and depression common comorbidities in ~50% of those with pain (1 4).

All are important to the practice of physical therapy and the effective treatment of pain.

Why are Physical Therapists Implementing Nutrition Into Practice?

Physical therapists are experts in the non-pharmacologic treatment of pain. They understand the research regarding the treatment of chronic pain and are translating evidence to practice. A multimodal approach to pain manag ement is the most effective way to manage pain.

As the link between nutrition, disease, and overall health becomes much harder to ignore, physical therapists have been seeking freedom to incorporate nutrition into their practice. Counseling on exercise and providing manual therapy, may not be enough to help people cope with pain and improve quality of life. Nutrition is often the missing link to reverse pain.

The many advantages of nutrition delivered by a physical therapist include:

Accessibility and convenience for the patient.
Allows DPTs to practice at the highest level in a primary care capacity.
Enhances the therapeutic relationship between provider and patient.
The efficient use of time with one provider focused on the entire plan of care.
The ability to track complete biopsychosocial outcomes in one episode of care.
Cost-effective care, eliminating multiple providers, copayments, and other costs.

Physical therapists realize nutrition, combined with other treatments, can help people return to function. But are you ready and know enough about nutrition to begin screening for and providing information? There are many factors to consider, but your personal scope may be the first place to begin.

Nutrition and Your Personal Scope of Practice as a Physical Therapist

Nutrition advice plus physical therapy has become such a hot topic that it spawned an entire debate at a 2018 APTA conference; however, at the end of the debate, most nearly everyone agreed that physical therapists are qualified to give nutritional advice (1 5).

Nutrition education is included as a required element in the curricula of doctoral physical therapy programs established by the Commission on Accreditation in Physical Therapy Education (CAPTE), the official accrediting agency for entry-level physical therapists and physical therapist assistants.

C APTE standards 7A, 7C, 7D16, 7D24, 7D28, and 7D34 all apply to nutrition education.

Graduate-level doctor of physical therapy programs now include one, often two, and sometimes three classes on health and wellness promotion. Foundational nutrition is often covered in these courses. The education of a physical therapist prepares them with the skills to screen for and provide nutrition education and counseling.

Some physical therapist assistant (PTA) programs also include nutrition, and a PTA may be required to follow through on a plan of care that includes nutrition education.

Finally, the research and evidence clearly support a physical therapist’s ability to counsel with regard to lifestyle medicine including physical activity, nutrition, weight loss, stress management, cognitive-behavioral interventions, and even smoking cessation.

A 2012 systematic review in the Journal of Physiotherapy Theory and Practice asked the question: Can physical therapists counsel patients with lifestyle-related health conditions effectively? A systematic review and implications. The study concluded by stating that “physical therapists can effectively counsel patients with respect to lifestyle behavior change, at least in the short term. They can be effective health counselors individually or within an interprofessional team.”

A 2 016 study found that physiotherapists are confident and consider the incorporation of dietary counseling very important and of high priority in their daily clinical work.

Just as you would with dry needling, manual therapy or pain science education, further training in nutrition may improve a professional’s confidence and competence.

As a physical therapist, you may pursue further continuing education to sharpen this skill.

We each have our own personal scope of practice based on university training, affiliations, continuing education, and life experience. Your personal scope is important to reflect upon in addition to your state practice act before incorporating nutrition into your practice.

Now that you have an overview of the evidence, does the American Physical Therapy Association support the inclusion of nutrition as part of the physical therapy scope of practice?

The American Physical Therapy Association’s Position on Nutrition

The professional scope of practice for physical therapists is ever-evolving. The good news is that APTA has officially released a position statement supporting the inclusion of nutrition as part of the scope of practice for physical therapists (House of Delegates P06-15-22-17).

P er the APTA website:

“Diet and nutrition are key components of many conditions managed by physical therapists. What’s more, nutrition can directly affect 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. Nutrition is part of the professional scope of practice for physical therapists.

APTA’s position is that it is “the role of the physical therapist to screen for and provide information on diet and nutritional issues to patients, clients, and the community within the scope of physical therapist practice.”

The addition of nutrition to the scope of practice for physical therapists was a positive step by the APTA. As primary care providers of neuromusculoskeletal care, this makes sense.

Last, let’s look at what PT state practice acts say.

What Does My State PT Practice Act Say About Nutrition Advice?

As a physical therapist, your state PT practice act regulates your scope of practice.

Even though the APTA has officially added nutrition to our scope of practice, there is no “rule” that state PT boards are required to adopt APTA recommendations. States have the option to officially adopt the guidelines, modify or ignore them.

State practice acts should now adopt this terminology. This will require PTs to organize, galvanize, and contact their state boards urging them to take action.

But it may not be necessary…

Per the APTA, physical therapy services to promote health, wellness and fitness are considered within the scope of practice for physical therapy whether or not the state in which you are providing or plan to provide services is included below. However, applying state law to specific programs or services varies based on a number of factors including the specific legal language describing physical therapy services in your state licensing law, specific inclusions or exclusions, additional formal interpretations made by your state Board of PT, and the existence and level of direct access.

Currently, not one PT state practice act prevents a physical therapist from educating and counseling on nutrition. This is excellent news!

The majority of state PT practice acts include “health and wellness promotion,” which is defined as promoting and advocating for healthy lifestyles to reduce the burden of disease and disability on individuals and society (see your state practice act below) (16).

For example, the PT practice act of North Carolina clearly addresses health and wellness promotion, stating that part of the scope of practice of physical therapy includes “preventing injury, impairment, functional limitation, and disability, including the promotion and maintenance of fitness, health, and quality of life in all age populations.”

On the opposite end of the spectrum, the state of West Virginia PT practice act includes no language with regard to nutrition or health and wellness promotion.

Most states PT practice acts fall somewhere in the middle, citing health and wellness promotion, but are silent about nutrition or nutritional supplements.

What If My State PT Practice Act is Silent?

A silent state practice act means your state has no official ruling.

A silent state practice act is void of any language or terminology on a particular topic.

In this case, you would refer to:

1) your personal scope of practice, and
2) your state nutrition laws.

State Nutrition Laws—What Do They Say About Physical Therapists Using the Term “Nutritionist” and “Dietician”?

Nutrition laws vary from state to state. The terms “registered/licensed dietician” and/or “nutritionist” are governed by state nutrition laws. You can only use this term if you meet the requirements set forth by your state nutrition law.

Some states do not allow any person to give nutrition advice other than a registered dietitian. Others allow any person to give nutrition advice.

In some states, you may be able to call yourself a “nutritionist” but the use of the term “registered” or “licensed nutritionist” may require a certain degree and/or examination. PTs should check their state’s laws on nutrition for confirmation.

Since nutrition is part of the scope of practice for physical therapists it is not necessary to call yourself a nutritionist or go back to school for another degree. There is plenty you can do within your scope of practice to educate and counsel patients about diet and nutrition. As a physical therapist, you should not advertise your services as medical nutrition therapy.

What About Nutritional Supplements and Physical Therapy?

Most state practice acts are silent on the topic of nutritional supplements, with one exception. Currently, the only state that limits a physical therapist from selling nutritional supplements in North Carolina. PTs in the State of North Carolina are currently taking action to overturn this.

The PT practice act of North Carolina specifically mentions nutritional supplements, stating that “promoting an unnecessary device, treatment intervention, nutritional supplement, product, or service for the financial gain of the practitioner or of a third party as determined by the investigative committee.”

There are evidence-based supplements that provide a clinically meaningful treatment effect on pain and function, as well as associated symptoms such as anxiety and sleep (17).

As we move away from pharmaceuticals and invasive procedures for the treatment of chronic pain, diet along with evidence-based nutritional supplementation will be an important part of pain care and one that physical therapists can incorporate into practice (18).

FREE Download: The 5 Pillars of Pain Care
Dr. Tatta’s simple and effective pain assessment tools. Quickly and easily assess pain so you can develop actionable solutions in less time.

Download