Welcome back to the Healing Pain Podcast with Nolan Peacock, PT, DPT’

Cardiovascular disease is the number one killer of both men and women in the United States. Despite its severity, it is still a preventable and reversible condition. Nolan Peacock, PT, DPT of St. John’s Health joins Dr. Joe Tatta to discuss how primary care can better treat heart diseases through physical therapy. She explains why PTs must go beyond being movement experts and start providing lifestyle interventions to heart disease patients. Dr. Nolan discusses how this setup can help promote physical activity to the aging population and empower patients to actively improve their quality of life, all while keeping the impact of cardiovascular disease at bay.

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Addressing Cardiovascular Disease With Lifestyle Medicine Physical Therapy With Nolan Peacock, PT, DPT

In this episode, we’re learning how to address cardiovascular disease from a lifestyle medicine physical therapy approach. Heart disease is the number one killer of both men and women. This is a preventable condition. This is also a reversible condition. As primary care physical therapists and other health professionals, it’s our responsibility to screen as well as intervene in everyday practice. As physical therapists, we are movement experts, but we are no longer just movement experts. We are also lifestyle behavior change experts. That’s a good thing because we’re not only treating one condition, such as arthritis. We’re treating comorbid conditions or conditions that occur together, such as arthritis and obesity or low back pain and diabetes.

My guest is Dr. Nola Peacock. She’s an outpatient physical therapist and the lifestyle medicine clinical coordinator at St. John’s Health in Jackson, Wyoming. In her clinical practice, she specializes in the treatment and prevention of chronic lifestyle conditions such as cardiovascular disease using a combination of physical therapy, lifestyle tools, and health behavior change interventions.

In this episode, we discuss primary care prevention, health and wellness, evaluation treatment, and management of cardiovascular disease in physical therapy practice. Dr. Peacock did write the section on cardiovascular disease in the textbook Integrative and Lifestyle Medicine in Physical Therapy. You can find that now on Amazon or by going directly to the publisher at OPTP.com. Without further ado, let’s begin and meet Dr. Nola Peacock and learn about a lifestyle approach to treating cardiovascular disease.

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Nola, welcome to the show. It’s great to have you here.

Thanks, Joe. It’s a pleasure to be here with you.

I’m excited to speak with the integrative physical therapist and learn about all the work that you’re doing and practice and how you’ve been able to weave in all these interventions together to help people with cardiovascular disease and help our older populations live a more active life. The work you’re doing as a physical therapist is a great model for younger physical therapists and maybe physical therapists interested in changing a little bit of what they do in practice. Tell us where you are in your practice and how you got started in the work that you’re doing.

I presently practice in a small community hospital in a rural town in Wyoming. I have the opportunity to work in an outpatient setting. The predominant work I do is with patients with all kinds of cardiovascular diseases. I do a little bit of other work that has to do with the aging adult. Most of my days are spent in the trenches working with people trying to prevent and treat cardiovascular disease.

In addition to my Doctorate in Physical Therapy, I have my board certification in geriatric physical therapy, which has been a super great help to the work that I do day in and day out. I’m also a national board-certified health coach, which I lean on every single day in every conversation with every patient to help improve the care I deliver. On top of that, I’m a board-certified diplomat of the American College of Lifestyle Medicine, which blends in nicely with what I do as well.

As a physical therapist, as you start talking about cardiovascular disease, a lot of PTs probably are thinking about maybe a more traditional model where they’re embedded within a cardiopulmonary rehabilitation setting and helping people recover from things like coronary bypass surgeries and things like that. It sounds like what you’re doing is different because you’re in more of an outpatient setting. There’s a bit more of a preventative as well as an intervention based on what you do.

I would say that half of my time is spent in a more traditional cardiopulmonary rehab. It might appear like a traditional cardiac rehab program phase two in the outpatient setting. The second half of my day is indeed focused almost entirely on primary prevention. We started a new program at my hospital called lifestyle medicine. The intention of that program is for primary care providers, cardiologists, or whomever to refer to the program patients that they are concerned are headed down the road of developing cardiovascular disease. That’s the point in which I intervene and talk about all of the different ways that integrative and lifestyle medicine can help them prevent ending up on my schedule in the formal rehab program. I do both, which is wonderful. I love it.

That’s a really nice use of our healthcare system before people get way down that pathway on sick care. There’s no surgery in this case, or maybe persistent pharmaceutical interventions. It’s how we can intervene and prevent delay or oftentimes reverse what has happened to some due to poor lifestyle choices or lifestyle habits.

One of my favorite conversations that I love to have was with a patient, a 50-year-old man who was having breathing difficulties following COVID and had some diagnostics done for his lungs. In doing that workup, it was discovered that he had significant coronary artery calcification. He and his own words said, “COVID saved my life,” because he would never have known about this had he not been following up on COVID care. He is so perfect. He is motivated to make some lifestyle changes to decrease his risk for cardiovascular disease. I said to him, “This approach can manage, treat, and sometimes even reverse heart disease.” He was pretty excited to hear about that.

The word reverse is not one word we use too frequently in healthcare in general. In physical therapy, I don’t think we use that word. We should use it more to help people imagine what the possibilities are. So often, people are told, “You’re going to have to manage this condition,” which we know there is an aspect of chronic disease management that we have to help people with. The idea of reversing a condition is something that’s new. The lifestyle and health-promoting benefits that we‘re talking about fit into that model. As providers, we have those skills, interventions, and the time to work with people where, oftentimes, maybe a primary care physician doesn’t necessarily have that time.

That word reversal is so powerful. It does get patients’ attention. They want to know more. I would say that the two circumstances in which I use that most commonly are cardiovascular disease and, in particular, heart disease and diabetes. It is such a nice thing to be able to say to patients, “We can help you treat this, manage it, and live with it, but if you really want to commit to making some changes that are not always easy, but they’re simple, you can indeed reverse the beginnings of heart disease.” It’s the thing that gets me excited about what I do every day.

Physical therapists are working more and more in primary care practice settings. They’re using more integrative interventions and lifestyle-based interventions. In the book that you contributed to, which is called Integrative and Lifestyle Medicine in Physical Therapy, which everyone can check out on the OPTP website, Nola wrote a portion of the chapter on obesity, diabetes, and cardiovascular disease, specifically cardiovascular disease portion. I know you lectured at CSM and did a great workshop there. If you’re talking to a physical therapist and have the opportunity to work in a primary care practice setting, what advice do you have for them with regard to screening, examining, and intervening when it comes to cardiovascular disease specifically?

This question brings up a good point. Heart disease is the number one killer of men and women of all Americans. It’s a big deal. I don’t know if that always gets the attention that it should potentially get. What that says to me as a clinician is that for every person that walks through my door, I need to be screening. At the bare minimum, doing blood pressure, getting a family history, and easy basic questions and screening tools that don’t take a lot of time.

For example, if I see a patient for osteoporosis, I’m screening for cardiovascular disease. I believe that my role in bridging physical therapy into the primary care arena is that we need to assume that these people presented to us might have some risk factors for heart disease. It’s a critical point. Thank you for bringing that up. I think about that all the time. For every one that walks in my door, it’s my responsibility to screen for that.

Let’s take an example. As a physical therapist, do you screen for factors related to metabolic syndrome?

I do. I take a thorough history of family history but personal history and other comorbidities, like diabetes, hypertension, and all these things that can partner in the development of heart disease. We can’t miss any of these. It’s amazing how many patients will say this to me. I’ll ask them perhaps, “What was your last A1C?” and they don’t know. There’s an opportunity for us to educate about, “Your blood sugar management is important for the prevention of heart disease and all other cardiovascular diseases.” It’s an important part of what we do. It doesn’t take a lot of time. Sometimes it pushes us as physical therapists maybe a little bit out of what we’re doing if we’re working in an orthopedic setting or a women’s help setting. It may not be the first thing that comes to our minds, but it ought to be one of the top priorities that were covering.

As physical therapists, taking blood pressure, heart rate, and respiratory rate, we’re comfortable with that. People would identify those fitting squarely in our scope of practice. I mentioned the word metabolic syndrome, and you mentioned blood sugar. Looking at testing blood sugar and A1C are things that we learn about in school, but oftentimes, those habits are not necessarily carried over into practice unless you wind up in a specialty practice. Maybe like yours, which is specializing in cardiovascular disease. Those skills and principles can be carried over to any aspect of PT practice.

This brings up the point that perhaps my focus is on cardiovascular disease and that sequela. I also screened for musculoskeletal issues. For example, urinary continence, as I would screen for mental health issues. I cannot just look at a person with a heart. It’s everything altogether. We love specialties. They’re great, and they do wonderful things, but we can’t miss the fact that we are treating the entire person and the environment in which they exist and their socioeconomic status. We have to have respect for all of these things in addition to screening for things that aren’t exactly what the person is seeing us for.

You mentioned in your practice that you are working with patients with a cardiovascular disease history, but you’re also seeing other orthopedic-type conditions and injuries that might be more typical of PT practice. When I look at what you do and your work, it starts to bridge a gap between primary care and physical therapy, looking for cardiovascular disease and looking at older and aging populations and how we can help promote physical activity and other wellness types of interventions in that aging population which sometimes people feel like, “As I get older, I should be less active. I should have pain. I’m just going to develop thin bones.” You hear these things all the time. How does your work start to connect those two together?

Where the dots connect in my practice is that I see what I’m doing as promoting active aging. My definition of active aging is being able to optimize and maximize the things that all of us want to do, whether it’s social, recreational, occupational, or physical. All of these things play into our experience of aging in an active way. We keep doing the things that are important to us and the priorities that are meaningful to us. Whether that means addressing cardiovascular disease as a primary diagnosis or a secondary diagnosis is critical, along with other musculoskeletal concerns and fall prevention. Those things that support the experience of active aging is where my practice comes all together.

It’s taking all the pieces of these different areas and addressing them so that the aging adult can live the fullest life. I’m really lucky. I get to practice in a setting where people are very physically active into their later years. They sometimes demand some pretty amazing things of their bodies into their 80s. I’ve seen patients out skiing on the hill or out hiking on the trails and are in their late 80s. They just expect that. To me, that’s the active aging piece that pulls all the pieces together that you were asking about.

You work and live in a ski town. People grew up skiing.

Absolutely. That’s the culture in which I practice. There is an expectation that, “When I turn 60, I’m not done skiing.” People expect to keep doing these things like climbing, mountaineering, and backpacking. I love that because that, to me, is part of the definition of active aging.

It’s interesting because there’s a social aspect there. In that town, there’s this social mindset that, “Just because I’m getting older and moving along in my years doesn’t mean that I won’t be skiing or hiking.”

Exactly. That leads to a lot of the work that I do. I do a lot of outreach into the community about education, presentations, speeches, talks, and things. A lot of it is geared toward how we keep people doing what they love to do. That can be physical, like hiking, skiing, climbing, and all those good things. The social aspect is massive. Everybody wants to be with their friends, loved ones, or community doing things that they enjoy and that make them feel they’re doing important things to them. That is a point not to be missed. The physical functioning that we focus on as physical therapists have such an important social peace and equality of life peace, without a doubt.

That’s well said. It’s the physical aspect of what we promote. People look at physical therapists being movement experts, but moving your body extends beyond the clinical setting. Being able to move your body means you can now move throughout your life and engage with things you want to engage with.

You can look at this on two sides of the same coin. As physical therapists, we are rehabilitating people to be able to do the things they want. I’m doing that, but I’m also coming from the other side and preventing these problems from happening in the first place so they can continue to do what they want to do with a focus on cardiovascular disease but also musculoskeletal issues, maintaining good body weight, exercising a range of motion, and strengthening. All those things support that same principle.

If a patient came into your clinic and said, “Dr. Smith diagnosed me with heart disease. He said I don’t need surgery yet, but if I start to change some things in my life, I should be able to prevent this. I’ve also noticed that I have started to slow down a little bit. I don’t walk as fast, and I’m not as strong on these ski slopes. What can I do about it?” What would be the lifestyle interventions that you recommend to a patient who comes in with those questions and expectations that they like to overcome?

The first thing I try to do is to get a sense of where that person is. Are they feeling motivated? Are they fearful? Are they filled with dread? Where are they at? Where are they in the processing of this information? I think that sometimes fear is the motivator, but it’s not always the motivator that I prefer to work with. I want to work with somebody who wraps their head around what’s going on. They feel like what they do can make a difference. Once I know that a person is there or I help them get there by saying that, “This isn’t just happening to you. You can exert some effort and make a change on this,” then that patient feels like, “I’m in the driver’s seat, and I can make some changes.”

I spent a lot of time talking with these patients that there are non-modifiable risk factors for heart disease. We don’t pay attention to them because there’s nothing we can do. Fortunately, there’s this huge category of modifiable risk factors. That’s where I turn my attention to with that new patient that comes to see me, saying, “I’ve got this new diagnosis. What do I do?” I then walk through everything that they have in their arsenal. I’ll talk a lot about nutrition within the scope of my training. There are some powerful pieces of information there that people often don’t know about. I spend a lot of time talking about stress and stress mitigation rather than stress reduction.

Stress is a part of life, but what can we do to mitigate that stress and the effects of it? I talk a lot about other comorbidities we mentioned, like diabetes. I look at their labs and go over the labs with them so that they understand how those pieces play into it. I talk about other controllable risk factors like hypertension. Once I laid that foundation, as a physical therapist, I spend the bulk of my time talking about, “What kind of exercise program can we tailor together that will help you improve your strength, make you feel more confident in what you’re doing, improve your endurance, and all those things? How can we angle that towards treatment prevention and reversal of the disease?”

It sounds like there’s a lot of educating that you’re doing. We know that there’s a lot of education that we help people with regard to their care. Have you arrived at the point yet in your practice where you spend an entire session working on things? Some people say education, and some people say counseling. I like the word counseling better. They’re very similar. To me, they’re almost the same thing. Therefore, they really are the same thing. Are you there yet where you’re like, “I’m going to spend a whole session counseling on this thing?” We can pick a topic because lifestyle medicine is broad. There are a lot of physical therapists that think, “If I don’t do manual therapy and therapeutic exercise during the session, either I didn’t do my job, or I’m in some weird in-between point. I don’t know who I am as a professional.” Where have you arrived at in your practice?

I would add to your list patient education, patient counseling, and coaching. I spend a huge portion of my time with patient coaching. It’s a blending of counseling, education, and coaching. There are sessions where the majority of what I’m doing is providing tools, training, knowledge, and education counseling for the patient so they can take what they’ve learned and do it themselves. Maybe my little trick with this is that I may not be doing manual therapy or other hands-on things, but I can certainly get a patient on a treadmill or a stationary bike, or we can be working on balance things where they’re working on something physical, and I’m talking away and giving them the information that I feel like they need. I know multitasking isn’t supposed to be healthy for us, but I pretty much do it all day long. I would say that the value that I provide for my patients is the training, education, counseling, and coaching that I can do for them.

That’s the most valuable piece that we can offer people.

If twenty years ago, had you asked me that, I don’t think I would have said that. I would have felt like I needed to do something for the patient, and now I’m comfortable providing information that they can go and do this. It’s a shift in roles for us as physical therapists.

It’s a shift in mindset. I look at it as the doing and fixing as a physical therapist versus the counseling and coaching.

What it does for us, too, is that it decreases our potential for burnout. When I am fixing people or if what I did didn’t help them and it’s my fault, that’s a major recipe for burnout. When I’m providing them with what they need, it’s evidence-based. Everything I teach my patients is evidence-based. I can back it up. They get sick of me talking about studies. When we shift our role from the fixer to the supporter, coach, trainer, or educator, it changes our work tremendously. I love it.

What you were talking about with regard to cardiovascular disease especially is there’s a strong aspect of health behavior change which is the underlying aim in everything you’re doing as a physical therapist, whether you’re working with some with cardiovascular disease and orthopedic injury or just an orthopedic injury.

I strongly feel that those of my colleagues who practice in this mindset of integrative lifestyle medicine is that we have shifted from the expert that just knows it all, does it all, prescribes it, mandated, and enforced to this role of supportive and figuring out where the patient is, what they want, what’s important to them, and how to get there with evidence-based practices. It takes us a little bit off the driver’s seat. We’re now more the copilot. I firmly believe, and research will back me up, that this approach of work has longer-lasting changes. We are behavior modification experts, not just movement experts. I’m both together.

I love that. One of the reasons why I love that is because if you go to the APTA website, to this day, it still says that physical therapists are movement experts. There’s a lot of the work I do through my show and other resources I have out there, and now people like you are joining this movement and saying, “APTA, let’s have a conversation.” We are concerned about movement. Movement and physical activity is well within what we do, but ultimately, we’re after changing someone’s health.

It’s for the long run. That’s where the power of what we do comes in. It’s clearly a cost-saving. It improves the quality of life, but it also empowers the patient to feel like they can do something. When we started our conversation, I gave you the example of the man that was referred to me that had calcification of his coronary arteries. There was nothing that he could do. When he heard even a little bit of a glimmer of, “Maybe if I do something in a particular way, I can help myself to improve and get better,” he’s sold on this for life. He’ll always do it because he feels empowered to do so in the long run.

In the chapter that you wrote in the book Integrative and Lifestyle Medicine in Physical Therapy, you have two other co-authors with you, Rupal Patel, who did the part on diabetes management, and Ericka Merriwether, who did the part on obesity care. What would you like to see happen with this? This is a textbook for PT education and practice. It’s going to be utilized in PT schools and PT private practice. How would you like to see your chapter utilized by the profession broadly? When we talk about the profession, we could talk about education, clinical practice, and research. How would you like to see the profession pick up this chapter and say, “Lifestyle medicine for cardiovascular disease?” How should they run with that material?

What I love about the chapter that we authored is it blends three important coexisting morbidities that play with each other not always nicely and lead to heart disease. It is a small little isolated example of what physical therapy can be that we are not just treating diabetes in a silo. We are not treating osteoarthritis in a silo. It is comprehensive, holistic, and the whole person. This is where lifestyle medicine comes in beautifully.

Lifestyle medicine is not just physical. It is, but it’s also stress-related. It’s positive social connections. It’s avoiding risky substances. There’s more to it than one isolated diagnosis. I don’t think we can treat patients appropriately when retreating just the diagnosis that comes with the referral or the first thing that comes out of their mouth in our evaluation. I love this chapter because it brings three important pieces together and shows beautifully how the three can come together to support improvements and benefit each of the areas.

There are overlaps in those three diagnoses that we mentioned, obesity, cardiovascular disease, and diabetes. Oftentimes people look at targeting disease in practice. As you mentioned, you don’t just target one thing. If you’re sending a patient to me for cardiovascular disease, the tools, principles, and skills that I have, when I apply them, will help someone overcome and reverse their cardiovascular disease, but it’s also going to broadly apply to diabetes and are helping them maintain a healthy weight, help their physical function, and maybe even help with their mental well-being.

A great example of that is if someone’s referred to me and says they’ve had some falls or their primary care provider is concerned about their fall risk. When they come through the door, the first thing on my mind is fall risk assessment and fall reduction. It then spirals to all the other things. What is going on here? Is there a chronic pain issue? Is there a strength deficit? Is there something else going on that’s not the obvious thing that’s leading to this problem? That is where physical therapy becomes fun because we get to investigate the whole picture and not just target it on that one diagnosis we think we’re treating. We should be, in my opinion, treating the whole person.

If there’s a PT who doesn’t want to jump right in and convert their whole practice into a cardiovascular disease rehabilitation center but wants to start addressing those, what recommendations do you have for them?

An important point that can be made here is that every patient that you see, your patient with Parkinson’s or a spinal cord injury, when you are doing your screening as a physical therapist and looking at some key indicators, like respiratory rate, pulse, and blood pressure, if you find something that’s out of the accepted norm for that demographic, follow up on it. Don’t just say, “Their blood pressure is 130/90,” and move on. Take a few moments. Follow up on that with the patient, family member, caregiver, or whomever.

I personally think that it should be followed up with the referral source. If it’s self-referral, that’s a little different. It needs to be follow-up on. Make a connection with the primary care provider or the specialist that sent that person to you. Don’t just let it be, “I screened for this.” Proper screening and good physical therapy care are to screen documents but do something with it. That’s an easy way to dip your toes in, extending beyond the silo of care that you provide and branching it out to, for example, cardiovascular disease. It’s a super easy way to do it. Frankly, it’s what we should do.

If a patient comes in with chronic lower back pain and you screen and find they also have hypertension and their blood sugar’s a little high, maybe it’s 100, are you referring them back to their primary care? Are you opening up the conversation and saying, “Are you aware you have these risk factors?” and they might say maybe yes, and refer them to a cardiologist or a cardiac specialist?

It can be a lot of different approaches. I always turn it back on the patient and say, “Are you aware of this? Do you understand this? Tell me more about what you know.” I’m quiet for a minute and try to hear what they have to say about their understanding. If it seems like they got a plan in place, “Yes, I found out about this. I’m working with my doctor on this,” that’s great. More often than not, I will reach out to the primary care provider or whomever the referral source was and make that phone call. One of the beauties of an electronic health record is that I can look at their chart and say, “Nobody has ever talked with them about their elevated blood sugars.” I will take that extra step, and I understand that it takes time and a little bit more effort, but that, to me, is the practice of good holistic care.

The take-home message there is, let’s say someone has access to electronic health records in a big medical system or maybe someone brings in their lab results, and just because they’ve seen a physician that’s identified high blood sugar or hypertension, it doesn’t mean they’ve received effective counseling on that.

This goes back to what we were talking about earlier. If we want to dip our toes into primary practice, we better get comfortable with looking at labs, asking follow-up questions, getting that information, and then deciding what’s proper to do with it. I absolutely agree with you definitely.

Nola, it’s been great to speak with you. I know everyone’s going to love reading the chapter that you wrote on cardiovascular disease in the book Lifestyle Medicine in Physical Therapy. You can all find that on the OPTP website. If people want to follow you and your work, how can they learn more about you?

The best way to find me is at StJohns.health. In a tab that pops up, you’ll see a Lifestyle Medicine tab. Click on that, and you’ll learn a little more about the health coaching we’re offering and the lifestyle medicine I’m doing. You can follow up with me there.

I ask at the end of every show to share this information with your friends and colleagues interested in cardiovascular disease, active aging, integrative medicine, and lifestyle medicine, to share it on your Facebook, LinkedIn, and Twitter. If you’re on Instagram, take a screenshot of this show and tag me in it. I’ll make sure to tag you back. It’s been a pleasure being here with you. I’ll see you next episode.

Important Links

• Integrative and Lifestyle Medicine in Physical Therapy
• OPTP.com
• APTA
• StJohns.health
• Lifestyle Medicine
• https://integrativepainscienceinstitute.com/integrative-and-lifestyle-medicine-in-physical-therapy/

About Nola Peacock

Dr. Nola Peacock is an outpatient physical therapist and the Lifestyle Medicine Clinical Coordinator at St. John’s Health in Jackson, Wyoming. Nola is a board-certified clinical specialist in geriatric physical therapy, a national board-certified health and wellness coach, and is board-certified by the American College of Lifestyle Medicine. She serves on the steering committee of the American Physical Therapy Association’s Council on Health Promotion and Wellness. In her clinical practice Dr. Peacock specializes in the treatment and prevention of chronic, lifestyle-related conditions with physical therapy intervention and health coaching.