Proper nutritional intake is a critical component in the prevention of lifestyle-based diseases and recovery from injury, pain, and illness. As such, it can be a very effective tool for physical therapists to understand and utilize. However, it can often be difficult to discern the relevance of nutritional information to a particular case or to decide whether certain nutrition-based treatment options are within the scope of physical therapists’ practice. This article summarizes the perspective of a 2021 manuscript published in the Physical Therapy and Rehabilitation Journal which explains the relevance of nutrition to physical therapy and encourages the integration of the two fields. 

How is nutrition related to physical therapy?

The majority of Americans consume a diet characterized by low-quality carbohydrates, high sugar consumption, and underconsumption of fruits and vegetables. Known as the Standard American Diet or Western Diet Pattern, this diet falls significantly short of established nutritional guidelines.^{1, 2} In fact, it is well-documented that the Standard American Diet is a leading risk factor in the development and aggravation of many chronic diseases including heart disease and diabetes.³ For this reason alone, nutrition is a vital component of health that impacts the same areas that physical therapists seek to improve. Additionally, many nutritional practices are analogous to those used by physical therapists. There are a multitude of nutritional guidelines that can be important to follow in different circumstances, including increasing the diversity of foods eaten, increasing vegetable consumption and hydration, and so on.^{4, 5} However, it is rarely effective to simply provide patients with information about dietary interventions. Rather, a personalized approach should be taken with each patient to develop a treatment plan that will work best for them. This places physical therapists in an excellent position to incorporate nutrition into their existing treatment options as this process is already integral to the success of their work. When developing a plan for a particular patient that includes physical activity or other lifestyle changes, physical therapists can easily include nutritional interventions that complement the rest of the treatment plan. 

Is nutrition really within the scope of physical therapy practice?

Although it can be difficult to establish the boundaries between physical therapy and nutrition, it is clear that nutrition is well within the scope of physical therapy practice. This is made apparent through multiple avenues. Firstly, under several sections of the Commission on Accreditation in Physical Therapy Education (CAPTE) Standards and Required Elements for Accreditation of Physical Therapist Education Programs support the role of nutrition in physical therapy.⁶ Most importantly, these sections dictate that physical therapists must receive significant education on nutrition and deliver treatment that is consistent with professional obligations and collaborations. Taken together it is clear that physical therapists have both the tools needed to incorporate nutrition into their daily practice and the authority to use them for their patients. It is recommended that different therapists take it upon themselves to determine when the nutritional needs of a given patient exceed their personal and professional expertise. In the event this is the case, it is always possible to either refer the patient to another professional or collaborate with another practice to develop the most effective solution.

Another aspect of the situation to consider is state-specific practice acts. It will always be important for physical therapists to review their own state’s laws to gain a better understanding of the scope of their practice. In most states, physical therapy practice acts make no mention of nutrition or diet.⁷ This indicates that physical therapists are free to address nutrition and diet with their patients. Certain states may have specific restrictions or further guidelines to follow (such as North Carolina which prohibits physical therapists from selling or prescribing vitamins and supplements), but ultimately state-specific laws agree that nutrition is within the scope of physical therapy.⁸ 

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Nutrition is a critically important piece of our health, and many physical therapists have recognized that it is also integral to recovery and rehabilitation processes. As such, therapists are increasingly interested in incorporating nutritional interventions into their practice. With so much information circulating on the internet and complicated practice laws, it can be difficult to discern whether physical therapists should use nutrition in their practices and if they are allowed to. However, with a thorough review of both the relationships between physical therapy and nutrition as well as the many legal aspects of physical therapy practice it is clear that the answer to both of those thoughts is a resounding yes. State-specific laws and regulations may limit the role of the physical therapist in some situations, but in general it is encouraged for therapists interested in utilizing nutrition to start incorporating it into their practices as soon as they feel comfortable. 

REFERENCES:

1. Murray CJ, Abraham J, Ali MK, et al. The state of US Health, 1990-2010. Burden of diseases, injuries, and risk factors. JAMA. 2013; 310:591-606.
2. Shan Z, Rehm CD, Rogers G, et al. Trends in dietary carbohydrate, protein, and fat intake and diet quality among US adults, 1999-2016. JAMA. 2019;322:1178-87.
3. Micha R, Peñalvo JL, Cudhea F, et al. Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States. JAMA. 2017;317:912-24.
4. Miyamoto K, Kawase F, Imai T, Sezaki A, Shimokata H. Dietary diversity and healthy life expectancy—an international comparative study. Eur J Clin Nutr. 2019;73:395-400. doi:10.1038/s41430-018-0270-3
5. Miller V, Mente A, Dehghan M, et al. Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study. Lancet. 2017;390:2037-2049. doi:10.1016/S0140-6736(17)32253-5

6. Commission on Accreditation of Physical Therapy Education. Standards and Required Elements for Accreditation of Physical Therapist Education Programs. http://www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources/Accreditation_Handbook/CAPTE_PTStandardsEvidence.pdf Accessed March 25, 2021
7. American Physical Therapy Association, Jurisdictional (Legal) Scope of Physical Therapist Practice. http://www.apta.org/ScopeOfPractice/Jurisdictional/. Accessed March 25, 2021.
8. Position Statement –NC Board of Physical Therapy Board of Examiners. Vitamins, Nutritional Supplements, Over-the-Counter (OTC) Medications. https://www.ncptboard.org/PositionStatements/d24c7f05. Accessed March 26, 2021. 

Additional References on this topic:

Berner P, Bezner JR, Morris D, Lein DH Jr. Nutrition in Physical Therapist Practice: Setting the Stage for Taking Action. Physical Therapy. 2021;(pzab062). doi:10.1093/ptj/pzab062

Dean E. Physical therapy in the 21st century (Part I): toward practice informed by epidemiology and the crisis of lifestyle conditions. Physiother Theory Pract. 2009;25(5-6):330-353. doi:10.1080/09593980802668027

Dean E, Al-Obaidi S, De Andrade AD, et al. The First Physical Therapy Summit on Global Health: implications and recommendations for the 21st century. Physiother Theory Pract. 2011;27(8):531-547. doi:10.3109/09593985.2010.544052

Dean E, de Andrade AD, O’Donoghue G, et al. The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases. Physiother Theory Pract. 2014;30(4):261-275. doi:10.3109/09593985.2013.856977

Dean E. Physical therapy in the 21st century (Part II): evidence-based practice within the context of evidence-informed practice. Physiother Theory Pract. 2009;25(5-6):354-368. doi:10.1080/09593980902813416

Dean E, Skinner M, Myezwa H, et al. Health Competency Standards in Physical Therapist Practice. Phys Ther. 2019;99(9):1242-1254. doi:10.1093/ptj/pzz087

Abaraogu UO, Ogaga MO, Dean E. Practices of Nigerian physiotherapists with respect to lifestyle risk factor assessment and intervention: A national cross-sectional survey. Physiother Theory Pract. 2017;33(6):497-507. doi:10.1080/09593985.2017.1318421

Magnusson DM, Rethorn ZD, Bradford EH, et al. Population Health, Prevention, Health Promotion, and Wellness Competencies in Physical Therapist Professional Education: Results of a Modified Delphi Study. Phys Ther. 2020;100(9):1645-1658. doi:10.1093/ptj/pzaa056

Bezner JR. Promoting Health and Wellness: Implications for Physical Therapist Practice. Physical Therapy. 2015;95(10):1433-1444. doi:10.2522/ptj.20140271

Standards and  Required Elements for Accreditation of Physical Therapist Education Programs.  http://www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources/Accred  itation_Handbook/CAPTE_PTStandardsEvidence.pdf Accessed March 25, 2020.

BSc WF, BSc EK, Johannes Peter van de Leur BA P MS, Elizabeth Dean DipPT P BA, MS. Can physical therapists counsel patients with lifestyle-related health conditions effectively? A systematic review and implications. Physiotherapy Theory and Practice. 2012;28(8):571-587. doi:10.3109/09593985.2011.654179

Dean E, Gormsen Hansen R. Prescribing optimal nutrition and physical activity as “first-line” interventions for best practice management of chronic low-grade inflammation associated with osteoarthritis: evidence synthesis. Arthritis. 2012;2012:560634. doi:10.1155/2012/560634

American Nutrition Association. State Regulation of Nutrition Practice. https://theana.org/advocate.

Berner P, Bezner JR, Morris D, Lein DH Jr. Nutrition in Physical Therapist Practice: Tools and Strategies to Act Now. Physical Therapy. 2021;(pzab061). doi:10.1093/ptj/pzab061

DiMaria-Ghalili RA, Mirtallo JM, Tobin BW, Hark L, Van Horn L, Palmer CA. Challenges and opportunities for nutrition education and training in the health care professions: intraprofessional and interprofessional call to action. Am J Clin Nutr. 2014;99(5 Suppl):1184S-93S. doi:10.3945/ajcn.113.073536

Van Horn L, Lenders CM, Pratt CA, et al. Advancing Nutrition Education, Training, and Research for Medical Students, Residents, Fellows, Attending Physicians, and Other Clinicians: Building Competencies and Interdisciplinary Coordination. Advances in Nutrition. 2019;10(6):1181-1200. doi:10.1093/advances/nmz083