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.
Physical therapists are now actively implementing nutrition into practice and recognize it as an essential part of optimizing movement, physical function, mood, and improving health. Nutrition education and counseling is an important intervention to help people overcome chronic noncommunicable diseases, including many chronic pain syndromes.
Here are how physical therapists are using nutrition to help their patients cope with chronic disease, decrease pain and improve functional outcomes.
Evaluating and Addressing Metabolic Syndrome to Support Pain Relief
Each day I arrive at work in the outpatient physical therapy department, approximately 75% of my patients have a chronic disease; obesity, diabetes, depression, heart disease, or high blood pressure. Of course, all these patients have chronic pain.
We are in a global pandemic of chronic metabolic disease. In 2001, the UN Secretary-General declared that metabolic syndrome (MetS), type 2 diabetes, hypertension, dyslipidemia, heart disease and other non-communicable diseases, such as cancer and dementia, are a greater threat to developed and developing nations than is acute infectious diseases, including HIV. (1)
The rise in metabolic diseases has clearly followed the rise in the consumption of processed foods and added sugar. More than 60% of the American diet consists of highly processed foods. It is widely accepted that the most harmful additive is Sugar (glucose-fructose), which hides in 74% of all packaged foods- including those you think are healthy, like yogurt and granola bars. Fructose stimulates reactive oxygen species, inflammation, and insulin resistance, and it is metabolized in the liver, like that of alcohol. This causes 31% of adults and 13% of children in America to suffer from Non-Alcoholic Fatty Liver Disease (NAFLD). (2)
What can we do? We need to return to real foods and reduced added sugar intake. It seems simple, but we are surrounded by and are encouraged to eat rich, highly palatable processed foods, which are addicting, cheap and abundant. Physical therapist are in the perfect position to teach evidence-based nutrition to their patients. Patients need to know what healthy fats, proteins, and whole unprocessed carbohydrates are. Everyone can benefit from cooking, relaxing, and connecting mindfully.
It seems misleadingly simple, but physical therapists are in a perfect position to implement these changes. Together, we can affect and hopefully change the processed food culture which leads to metabolic syndrome and poor health.
Shannon Morris, MS, PT
Learn more about Shannon here.
Nutrition with Physical Therapy Improves Physical Function
Physical activity and function are key components of a healthy lifestyle, though it is estimated that only 1 in 5 Americans achieve the American Heart Association’s recommendation of 150 minutes per week of physical activity. Though reasons for decreased activity and decline in physical function vary widely, pain and inflammation are common drivers impacting physical function among patients treated by physical therapists. The impact of nutrition on drivers of physical function, including pain and inflammation, has been well researched.
Nutrition is a necessary and evidence-based approach for treating pain and improving physical function. The IDEA trial by Messier concluded that while both diet and exercise contribute to pain reduction, changes in diet and nutritional status were the biggest contributors (3). Another study concluded that a weight loss of just 10 pounds resulted in a 28% increase in physical function. Educating your patients about the significant impact of nutrition and diet on physical function can encourage and empower them to make dietary changes.
Moreso, inflammatory cytokines can act independently as pain mediators. The more active an inflammatory cytokine, the higher the perception of pain. For example, TNF-a (tumor necrosis factor) is commonly elevated in rheumatoid and osteoarthritic joints. It is, therefore, logical to address systemic inflammation through nutrition.
Arm yourself with the nutritional tools necessary to provide effective and impactful changes. Most patients have a rudimentary understanding of the most highly studied anti-inflammatory diet, The Mediterranean Diet, that can be expanded upon. Incorporating nutrition into your physical therapy practice can result in a profound impact on your patient’s physical function.
Heather Malecki, PT, DPT
Learn more about Heather here.
Optimizing Healthy Fats for Pain Relief
Fat, as a nutrient, is used in our body for myelinating nerves – this allows them to conduct faster. Fats are part of the building blocks of every single cell membrane. Depending on the type of fat, its metabolization can result in an elevated production of inflammatory markers – a process that leads to pain.
Much of the Standard American Diet includes food PRODUCTS- things that have a stable shelf life and designed taste good. About 60% of the foods consumed by Americans are processed foods. However, research has demonstrated that these types of fats found in packaged or fried foods (also known as hydrogenated) will increase inflammation in the body.
The “good fats”, such as omega3s and unsaturated fats from cold-water fish, grass-fed/pastured animal products, flax, walnuts, and pumpkin seeds have anti-inflammatory effects. Polyunsaturated and monounsaturated fats ( avocado, olives, macadamia, hazelnut) and the omega 3 fatty acids (ALA, DHA, EPA) have been found at a dosage of 3 g/day to reduce self-reported rates of join tenderness and decreased use of NSAIDs in people with rheumatoid arthritis (4).
How do you translate this to practice? Generally, if it is:
– An oil that comes from corn or “vegetable oil” or a “substitute” margarine/shortening
– Is hydrogenated to have a better shelf life (eg soy, safflower), or
– Compared to meat and poultry that was raised in a way not consistent with its biology (eats grain rather than grass and grubs),
…Then it is probably not the better option.
Alternatively, if it:
– Looks like the plant or animal it came from (cold water salmon, avocado, olives, nuts, seeds, coconut oil, palm oil, bacon fat)
– Doesn’t have a lot of chemical-sounding words in front of it,
…Then it’s probably a better option.
Make at least 2 g of the 35% of daily calories from omega 3s (or up to 4 g/day if you have an inflammatory condition like chronic pain, arthritis or CVD), and eat it with other vegetables and spices.
Ruth Will, PT, DPT
Learn more about Ruth here.
Low Glycemic Foods Stabilize Blood Sugar and Alleviate Pain
As physical therapists, we have the opportunity to educate our clients throughout our treatment sessions on important dietary choices. Everyone knows they should eat less sugar, however, we need to go a step further and explain what high and low glycemic foods are actually doing in the body.
Choosing to eat a diet with a lower glycemic index will decrease insulin spikes, support the body with more efficient regulation of blood sugar, and decrease the levels of triglycerides released from the liver. By choosing fruits and vegetables with a lower glycemic index, combined with protein and healthy fat, will actually slow the release of food from the stomach into the intestines. The combination of fiber from the plant-based foods will also decrease glycemic impact (5).
How many of our patients have been diagnosed with pre-diabetes or diabetes? What about heart disease? These co-morbidities have a direct relationship to chronic inflammation and thus, pain. It has been shown by regulating blood glucose, it will also decrease chronic pain throughout the body. Nutrition education is paramount to physical therapists, in order for us to treat the entire patient towards a pain-free quality of life.
Charlotte Walters, PT, DPT
Learn more about Charlotte here.
The Ketogenic Diet: A New Way to Treat Neuroinflammation?
Physical therapists treat many individuals with chronic health conditions, with chronic pain being near the top of that list, so it is quite apparent that nutritional counseling and education is neglected by our health care system. It is often said in passing, as a suggestion, that nutrition is important, but rarely is the appropriate amount of time allocated to addressing this issue. Nutrition education needs to be taken more seriously in health care, ideally in the prevention, but also in the management of chronic conditions and should be individualized, and evidence-based. The ketogenic diet is an example of an approach that can have countless positive effects on health and wellness when done correctly for the appropriate individual.
The Ketogenic Diet has received a lot of attention in recent years, and rightfully so. This approach to nutrition fundamentally shifts the fuel source that your body is acquiring its’ energy from, which is fascinating in it of itself! Rather than using glucose for energy (usually the case with a high carbohydrate diet), the ketogenic diet shifts your body into a state of ketosis where ketones (derived from fat) are used for energy, hence the name “ketogenic diet”.
Being in a state of ketosis has many potential advantages, including improved weight loss, improved cognitive function, and improvements with blood sugar control (6). Research suggests that our brains may function more effectively and efficiently when being fueled by ketones, as opposed to glucose. This has countless research teams investigating the use of the ketogenic diet to fight multiple cognitive and neurological conditions- and the current research is promising.
By teaching our bodies to run on ketones, we can use stored fat for energy- something that many people have a difficult time doing because the body normally using glucose for fuel.
Michael Murcko, PT, DPT, OCS
Learn more about Michael here.
PTs Can Use Nutrition and Lifestyle to Effectively Treat Multiple Sclerosis
Multiple Sclerosis (MS) is a progressive neurological condition with no known “cure”. The Western Medical approach is disease-modifying drugs and physical therapy. The available drugs are designed to manage symptoms and slow the progression of the disease. As outpatient physical therapists are taught, our roles are to help patients maintain ROM, strength, balance, endurance and functional mobility. Basically, to preserve current function and slow their decline.
In recent years, there has been more and more buzz about Functional Medicine and Functional Nutrition. From this newer perspective, MS is looked at through the lens of an autoimmune condition. For an autoimmune condition to develop, a person must have genetic risk factors, combined with intestinal permeability (“leaky gut”) and a trigger that activates the immune system. The vast majority of Americans are eating the SAD (Standard American Diet) diet which is highly inflammatory, deficient in nutrients and can contribute to, and perpetuate a leaky gut.
Physical therapists are well-positioned to counsel their patients on nutrition. A modified paleolithic diet combined with physical therapy and stress reduction techniques has been researched and showed positive outcomes including reduction of fatigue and improvements in quality of life (7). With the current understanding of autoimmune conditions and the role of functional nutrition, it’s time for us to do more than slow the rate of decline.
Let’s help these individuals with the combination of skilled PT and functional nutrition. Perhaps, we can help them reverse their symptoms and improve the trajectory of their health and life.
Lauren Bellows Bahr, PT, MSPT, HC, FNCP
Learn more about Lauren here.
Simple Ways to Decrease Sugar
Chronic disease continues to impact the lives of many Americans. With the SAD (Standard American Diet) recking havoc on our nation’s health, we must provide guidance and education to our patients. Physical therapists (PTs) are at the forefront, working with patients for extended periods of time, and building great relationships and rapport.
As PTs, we have the knowledge and time to discuss nutrition and lifestyle changes with our patients. It is imperative now, more than ever, to educate patients on the role nutrition plays in regards to gut health, inflammation, pain, and overall wellness. Dietary sugar is undoubtedly one of our greatest concerns when it comes to inflammatory processes. “Chronic low-grade inflammation is a key factor in the pathogenesis of cardiovascular disease, and is associated with diabetes, dementia, and depression, as well as a higher risk of mortality” (8).
Sugary drinks such as soda and juice are some of the greatest culprits. Due to the lack of fiber in juice drinks, sugar enters the bloodstream rapidly, spiking insulin and causing a ripple effect, and soda is even worse. Also, the number one purchased item in households utilizing food stamps is soda. Making simple dietary suggestions to patients such as decreasing their sugar intake and cutting out soda can assist by lowering overall systemic inflammation and facilitating the prevention of some chronic diseases.
Lauren Peters PT, DPT
Learn more about Lauren here.
Protein Needs Increase as Patients Begin to Exercise
When it comes to protein, there is much confusion on the type, quality, and the amount we should be eating. Amino acids, the building blocks of proteins, are involved in immune function, healing, muscle mass, and neurotransmitter production. Incomplete proteins are those that consist of insufficient amount of amino acids, such as plant sources (i.e beans, legumes, nuts). For this reason, a larger serving is required to obtain an equal amount of protein per serving as compared to animal sources, which are complete proteins. As a key macronutrient and major fuel source, we should not be sacrificing the quality we are putting into our bodies. When possible choose organic, grass-fed, pasture-raised, hormone and antibiotic-free proteins.
Adequate protein intake is important in building muscle mass and strength. The Recommended Dietary Allowance (RDA) for protein is 0.8g per kg of body weight, regardless of age and activity level. Factors that alter protein utilization include age, inflammation, impaired digestion and absorption. With that said, the RDA is not sufficient for the population we treat as physical therapists. An increased protein intake of 1-2g per kg of body weight is recommended for this population, especially the post-surgical population. Individuals that present with severe fatigue, muscle loss, poor wound healing, and hair loss may have inadequate protein intake (9).
As physical therapists, we have the opportunity to educate them on implementing dietary changes in order to optimize their function. When building an exercise program for those with possible protein deficiency, exercise should be increased gradually. A good nutrition and exercise program will help our patients with achieving long-term health benefits.
Liat Avital, PT, DPT
Learn more about Liat here.
Using Nutrition and Lifestyle to Effectively Treat Osteoarthritis
Osteoarthritis is a degenerative disease of synovial joints and it is one of the top five diseases that causes pain and disability worldwide. Recent studies relate the chronic low-grade systemic inflammation with metabolic syndrome as a linking, worsening factor. The risk factors for OA – gender, aging, diet, stress and metabolic syndrome- are the same as for dysbiosis. This suggests there may be a new metabolic OA or an OA phenotype. The gut-joint axis could explain the good results of enhancing gut microbiome in the immune and clinical response of OA patients (10).
In relation to diet, it has been demonstrated that functional nutrition patient education is a powerful tool. Based on their metanalysis results, Liu et al. published a useful “traffic light recommendation” for supplements. It includes the quality of evidence along with effectiveness on clinical outcomes (11).
Manipulating the intestinal microbiota by switching our patients to a healthy lifestyle based on regular exercise, good sleep habits and enriched diet can positively impact their life quality.
Giuliana Lunecke, DDS
Giulianna is a dentist who works with orofacial pain and has an interest in diet and nutrition.
Learn more about Giuliana here.
Training the Next Generation of Physical Therapy Students to Use Nutrition
“Transforming society by optimizing movement to improve the human experience.” (12) This has been the American Physical Therapy Association’s (APTA) vision statement since 2013. Moving into a new decade, we need to expand our horizons to ensure that our sole focus is not just on addressing impairments of the body function and structure, but to consider the role that lifestyle behaviors play in disease, optimizing movement and improving the human experience (13, 14).
One lifestyle behavior, improper nutrition, accounts for up to 2/3 of the risk for multiple chronic non-communicable diseases like obesity, diabetes, cardiovascular disease, musculoskeletal problems and persistent pain (15, 16). Proper nutrition is essential for energy, physical and mental health, recovery from injury as well as prevention and management of chronic diseases.
Consistent with their vision, the APTA now promotes education, research and practice between physical therapists and registered dietitians to promote the health and well-being of society. They also consider it within the professional scope of practice to screen for and provide information on diet and nutritional issues.
This is a call to action to encourage not only physical therapists but physical therapy educators to align entry-to-practice education to embrace a lifestyle approach to patient education and management which includes nutrition to maximize health and reduce disease risk.
“Let food be thy medicine and thy medicine be thy food”
– Hippocrates 460 B.C.
Holly Jonely, PT, DPT
Learn more about Holly here.
Building Awareness Around Food Sensitivities and Chronic Pain
More people are visiting doctor after doctor in search of answers and diagnosis for systemic and chronic symptoms that impact their daily lives. These symptoms often include muscle and joint pain, stomach pain, constipation, diarrhea, anxiety and depression, fatigue, congestion, headaches, weight gain or weight loss resistance (17).
The common practice in our healthcare system is for physicians to order expensive tests, prescribe multiple medications and often treat the symptoms without ever getting to the root cause of the problem. The above-listed symptoms are signs of chronic inflammation that are often associated with food sensitivities- which differ from food allergies and intolerance that have immediate reactions- making it easy to identify the food causing the response. Food sensitivities, on the other hand, are often missed because the immune response is delayed for hours or even days, making it very difficult to correlate the suspected food with the symptom(s) (18).
For this reason, people continue to eat foods that cause irritation and inflammation. This leads to leaky gut, gut dysbiosis and chronic inflammation, which is the root cause of the symptoms that they are seeking answers and relief from (19).
While food sensitives are different from person to person, the most common are sugar, gluten, dairy, GMOs (especially soy and corn) and eggs- all a part of the Standard American Diet (SAD). The best way to determine the culprit is by doing an elimination diet for at least 3 weeks, then evaluate if the symptoms improve. After the elimination period and resolution of symptoms, the person begins to slowly add back in all the foods, except sugar, one at a time over 3 day periods. This helps evaluate the reoccurrence of symptoms to identify which particular food is causing the symptoms. Food is medicine!
Sara Lazenby Lester, PT, DPT
Using Curcumin as a Safe Alternative to Manage Chronic Pain
Pain and inflammation impact function and quality of life of many individuals living with joint arthritis and various other conditions. Turning to NSAIDs for symptom relief is common within this population, but these are known to have consequences and negative health effects when used long-term.
Research has sought out to find solutions that may naturally produce the benefits that people hope to gain from NSAIDs, but without the side effects. For example, turmeric, a common spice and seasoning in some regions, has demonstrated promising anti-inflammatory properties. Curcumin is one turmeric’s bioactive compounds (20).
This was the source of a recent systematic review and meta-analysis investigating its impact on symptoms in joint arthritis. Studies compared subjects taking curcumin extracts to control groups of ibuprofen, diclofenac, and placebo. The conclusion was made that 8-12 weeks of turmeric extract supplementation can reduce pain and inflammation at levels similar to NSAIDs without any notable adverse effects. The dosage of these supplements was roughly 1000mg a day.
Additionally, studies have found that curcumin supplementation can significantly decrease inflammatory biomarkers. This information is very valuable for patients, and, in conjunction with a well-rounded treatment plan, can help improve daily function. As noted above, turmeric is a spice, and many common herbs and spices demonstrate great anti-oxidant and anti-inflammatory properties. Adding these to meals can not only add flavor but can further promote an anti-inflammatory diet.
In conclusion, turmeric and its component, curcumin, have been proven safe and effective on symptoms of pain and inflammation in individuals with joint arthritis.
David Lerman, PT, DPT
Learn more about David here.
Foods to Include in Healthy Diets
Negativity and fear are tactics used in many parts of our lives. Whether it is childrearing, politics or nutritional advice, everybody has their opinion on what NOT to do. This negative approach doesn’t sit well with me. I am an eternal optimist; always drinking from the 1/2 full cup of green tea. I would argue that, especially in the realm of nutrition, you are better off looking at ways to include the greatest amount of foods in your diet then worrying about foods to avoid. Variety is the spice of life, and this goes for your food intake too. Seek out a food you have never had before or even a different color. Purple cauliflower anyone?
The internet is full of easily accessible recipes on how to prepare these novel foods. This variety will help you take in a myriad of nutrients and phytochemicals. Also, tasting new foods helps you stay mindful and present about what you are putting into your mouth. If every day you are eating the same things for breakfast, lunch or dinner you may not actually be tasting what you are eating. Taste, savor and smile as you eat.
I recommend embracing and enjoying as many whole foods as your body tolerates. If you limit anything, cut out Highly Processed Foods (HPF) from your diet. According to Dr. Joe Tatta of the Integrative Pain Science Institute, HPF’s are ”foods may be processed by baking, frying, or deep-frying. Many also have non-food chemical additives, flavor enhancers, and preservatives. Highly processed foods have a strong tendency to trigger the brain’s reward centers and alter the taste buds, making consumers come to prefer them…Many find that when they completely avoid these foods, their appetite becomes much more manageable and their health improves.”
So, look for ways to add new whole foods to your plate and limit or eliminate those convenience foods which are packaged and processed for convenience, but offer little nutritional value.
Christine Robenalt, MSPT
Learn more about Christine here.
Physical Therapy with Nutrition is Safe, Effective and Evidence-based Pain Care
Physical therapists are using nutrition as an evidence-based intervention to improve physical function and quality of life. 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.
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 the safe and effective treatment of pain, including:
- The non-pharmacologic treatment of pain.
- A non-invasive way to alleviate pain.
- A trusted and licensed practitioner to counsel and provide information.
Optimizing nutrition is a game-changer for those with non-communicable diseases and many chronic pain syndromes.
How are you implementing nutrition into your PT practice?
Joe Tatta, PT, DPT
Ready to implement evidence-based nutrition into your practice?
Sign-up for the Functional Nutrition for Chronic Pain Practitioner Certification Program waitlist!
REFERENCES:
1. United Nations General Assembly. Prevention and control of non-communicable disease. UN General Assembly. New York, 2010.
2. Lustig, Robert. Fructose: It’s “Alcohol Without the Buzz”. American Society for Nutrition. Adv. Nutri. 4:226-236, 2013.
3. Messier JAMA.2013:310(12):1263-1273 Christensen R et al., Osteoarthritis Cartilage, 2005;13:20-7.
4. Young-Ho Lee, Sang-Cheol Bae, Gwan-Gyu Songa. Omega-3 Polyunsaturated Fatty Acids and the Treatment of Rheumatoid Arthritis: A Meta-analysis. Archives of Medical Research 43(2012) 356-362.
5. Mäntyselkä, P., Miettola, J., Niskanen, L., & Kumpusalo, E. (2008). Glucose regulation and chronic pain at multiple sites. Rheumatology (Oxford). doi: 10.1093/rheumatology/ken220
6. Ruskin DN, Masino SA. The nervous system and metabolic dysregulation: emerging evidence converges on ketogenic diet therapy. Front Neurosci. 2012;6:33. Published 2012 Mar 26. doi:10.3389/fnins.2012.00033
7. Bisht B1, Darling WG, Grossmann RE, Shivapour ET, Lutgendorf SK, Snetselaar LG, Hall MJ, Zimmerman MB, Wahls TL. (2014). A multimodal intervention for patients with secondary progressive multiple sclerosis: feasibility and effect on fatigue. J Altern Complement Med. doi: 10.1089/acm.2013.0188
8. Della Corte K, Perrar I, Penczynski K, Schwingshackl L, Herder C, and Buyken A. (2018). Effect of Dietary Sugar Intake on Biomarkers of Subclinical Inflammation: A Systematic Review and Meta-Analysis of Intervention Studies. Nutrients. doi: 10.3390/nu10050606
9. Lonnie, M., Hooker, E., Brunstrom, J., Corfe, B.M., Green, M.A., Watson, A.W., . . . Johnstone, A.M.(2018) Protein for Life: Review of Optimal Protein Intake, Sustainable Dietary Sources and the Effect on Appetite in Ageing Adults. Nutrients, 10(360), 1-18.doi:10.3390/nu10030360.
10. Liu, X., Eyles, J., McLachlan, A. J., & Mobasheri, A. Which supplements can I recommend to my osteoarthritis patients?[published online March 1, 2018]. Rheumatology (Oxford).
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12. APTA. Vision Statement for the Physical Therapy Profession and Guiding Principles to Achieve the Vision. http://www.apta.org/Vision/. Updated September 25, 2019. Accessed January 17, 2020.
13. Dean E et al. Raising the Priority of Lifestyle—Related Noncommunicable Diseases in Physical Therapy Curricula. Physical Therapy. 2016, 96(7):940-948.
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15. Egger G et al. Beyond obesity and lifestyle: a review of 21st century chronic disease determinants. Biomed Res Int. 2014.
16. APTA. The Role of the Physical Therapist and the American Physical Therapy Association in Diet and Nutrition. http://www.apta.org/…/Practice/RolePTDietNutrition.pdf. Updated September 20, 2019. Accessed January 17, 2020.
17. Ontiveros N, Hardy M.Y., Cabrera-Chavez F. (2015). Assessing of Celiac Disease and Nonceliac Gluten Sensitivity. Gastroenterol Res Pract. doi: 10.1155/2015/723954
18. Hvatum M, Kanerud L, Hällgren R, Brandtzaeg P. (2006). The gut–joint axis: cross reactive food antibodies in rheumatoid arthritis. Gut. doi: 10.1136/gut.2005.076901
19. Tatta, Joe. 2017. Heal your pain now: The revolutionary program to reset your brain and body for a pain-free life. Boston, MA:Da Capo Press.
20. Daily, James W., et al. “Efficacy of Turmeric Extracts and Curcumin for Alleviating the Symptoms of Joint Arthritis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.” Journal of Medicinal Food, vol. 19, no. 8, 2016, pp. 717–729., doi:10.1089/jmf.2016.3705.
