Welcome to Orthostatic,
a podcast brought to you by
the Academy of Orthopedic
Physical Therapy.
Patrick Berner is on the show today.
Patrick, welcome to the program.
I appreciate it.
Thanks for having me.
You're no stranger to
talking about the topics
we're going to get into
today because you have,
and I remember the first
time we met in person,
you have an interesting background.
How do you explain to our
audience or how would you
explain to people you've
got this sort of cool
mashup of backgrounds?
Help people understand that.
Yeah, so, you know,
it probably originally
stems from me being born
and raised in New Orleans
and being surrounded by
people living with, you know,
systemic chronic disease.
So a food around passion started up,
right?
So that's where my
professional journey started,
was looking at what people
ate and how it impacted
their health and outcomes.
But I started to learn that
there was a movement
component to people's outcomes.
And that's what led me to
the profession of physical therapy.
But then I realized that most PTs,
and especially your orthopedic PTs,
only look at the movement component,
only look at the pain or
functional deficit.
And it was frustrating.
So I actually went back and
did an internship and sat for boards.
So I was able to become a
registered dietician in
addition to being a physical therapist.
That's great.
And you get to look at, you know,
we talk about this clinical
toolbox a lot.
And there is a cliche that
says when all you have is a hammer,
the world is full of nails, right?
So maybe just always only
looking at movement and not
considering some of the
other things like nutrition
or sleep or mental health or stress.
Hey,
we might be missing some of those things.
So this episode is really...
Just a reminder,
and you're going to give us
some tactical information
of maybe if I don't have
the background of Patrick,
how do I begin to sort of
ask some of those questions
and why it's important?
So how important is
nutrition in orthopedic
physical therapy outcomes?
Where would we start there?
Yeah, I think, you know, the thing, Jimmy,
is I'm super biased,
but it's extremely important.
You know, if you look at those outcomes,
whether you're an
orthopedic therapist trying
to facilitate improvements
in strength or you're
trying to facilitate wound
healing versus some type of surgery,
you know,
you're thinking all your post-op patients,
joint replacements, ACL repairs,
et cetera.
If you're trying to
facilitate the system to recover, well,
you've got to fuel the
system appropriately in order to do so.
Thank you.
That's where nutrition comes into play.
You know,
it really helps support the
interventions that that
therapist is implementing
in their plan of care to
get the person where they
need to be more efficiently.
And I think really set the
patient up for other
success as well in their
overall health outcomes.
All right.
So let's ask this next
question a couple different ways.
First,
what specific nutritional advice can
PTs provide to patients with,
we'll call it musculoskeletal issues,
bread and butter, orthopedic issues?
So what nutritional advice
can PTs provide to their patients?
Yeah, so, you know, Jimmy,
that's a good question.
And what happens is, though,
is there's nuance across
the country because of
practice acts and what a
physical therapist can do.
So for most of us across the country,
if you keep that
information and that
education relatively broad,
you're in a good spot.
So you're looking at general
healthy intake, you know,
an adequate consumption of
fruits and vegetables, good whole grains,
things that facilitate, you know,
a reduction in systemic inflammation.
And with that reduction in
systemic inflammation,
you're gonna see healthier
tissue function, right?
You're gonna see irritation
to tendons and ligaments
kind of come down a little bit.
You're gonna see performance
increase when there's
adequate supply of nutrients.
I think also within an orthopedic setting,
if you're thinking of your
post-op patients,
protein is one of the
biggest conversations we
need to be having because
if you wanna facilitate healthy muscle,
And that healthy muscle
turning into improved
strength and function, well,
you got to fuel it with an
adequate amount of protein.
So it sounds as if the safe
route or the appropriate route,
depending on your state practice act,
right?
And there's more than a few
of those in the country.
It seems like staying on the
education side keeps people
safe in terms of liability,
but also accurate in terms of scope.
Is there a resource that you'd recommend?
I could see a PT saying, well,
according to this organization,
this is what they would
recommend for someone who
is living with your condition.
Yeah, so, you know,
you think of the national organization,
the Academy of Nutrition and Dietetics.
So their consumer-facing
website is eatright.org.
So that's going to be one source to go to.
And that's, again,
it's very similar to like the APTA,
right?
But it's for the dietetics
and nutrition professional.
Outside of that, you know,
choosemyplate.gov is a good
option as well because it's
got a lot of helpful resources
handouts and resources for patients,
you know,
how to add more fruits and
vegetables to your day,
how to get more whole grains,
what are your protein sources,
how to add more protein to your day.
They have some of those nice,
easy resources to provide to patients.
So that's been the first
place that I would look for
those two major websites.
And as an orthopedic physical therapist,
you might not necessarily
need to go to the lengths
that Patrick did,
which is to become a
registered dietitian.
These organizations are vetted.
They're, you know, you mentioned a.gov,
which is usually we can
assume of higher quality.
They've done sort of the work.
And now by suggesting those,
you sort of stay on the
side of education and not prescription,
correct?
Yeah,
because all you're really doing is
you are bringing the
awareness to the patient
that these things exist.
You know,
they could certainly access them
on their own,
but you're just creating
that awareness in that
you're not trying to build
out a meal plan or dive into the
the nitty gritty of what
specifically they need to eat,
but you're creating
awareness to what healthier
intake looks like.
And it's that healthier
intake that's going to
drive improved recovery.
Right.
So generic and so big picture, which is,
hey,
you should maybe consider eating a
little healthier.
We kind of know that, right?
Now you want to go from
strategy to tactics.
And it sounds as if the
resources you suggested
have those opportunities to get tactical.
But again,
you're not prescribing those
particular things you're
educating and suggesting.
Yeah.
And you know, that's again, Jim,
where the state nuance comes into play.
Because realistically, if possible,
as an orthopedic physical therapist,
you want to find that
opportunity to dive in deeper if able.
Because you can educate
people to your blue in the
face that they should eat
more fruits and vegetables.
Most people know that.
It's really trying to get
into the conversation into
finding out why that person doesn't eat X,
Y,
and Z. And that takes a little bit more
skill and a little more
knowledge to do so.
But it also involves a
conversation around the
environment that that person lives in.
But again,
the nuance and what you can do
and what rabbit hole you
can dive into is state-dependent.
Yep.
How does, you know,
you mentioned wound healing,
you mentioned, you know, building muscle.
Obviously,
there's a nutrition component to
those things.
How else does nutrition
interact with other forms
of physical therapy, treatment,
or rehabilitation?
Yeah.
So, you know,
we talked about that systemic
inflammation component.
You think of the prevalence
of diabetes within this
country and how that has an impact on a
you know,
nerve conduction and general healing.
There's a good bit of
research out there that
looks at those suffering
from neurological conditions as well.
And so if you're in that
outpatient orthopedic
clinic that you so happen
to have that patient who
has a history of a stroke
or MS or something,
there's evidence out there that points to,
well,
if that person was to consume a
healthier eating pattern, you know,
there's severity of their symptoms.
would come down a little bit.
I think the other big one to mention too,
that's related to the
systemic inflammation
component is people living
with osteoarthritis or
rheumatoid arthritis.
There's a lot of evidence
out there that looks again,
if you were to consume more
of an anti-inflammatory eating pattern,
the symptomology comes down.
seems as if it's a multifactorial approach,
right?
Where we're not discounting movement,
obviously,
as two physical therapists
talking on this podcast,
which is brought to you by
the Academy of Orthopedic
Physical Therapy.
It's not saying that we're
removing one of the components,
but looking at this human
from a couple of different
aspects or a couple of different sides of
that human's life and paying attention to,
well, is it just movement?
Is it just what I'm going to
do with my patient,
with my PT background?
Or could I be one more touch
point for a tactic?
And Hey, have we considered this?
Can I help you?
Can I educate you on this?
Yeah, a hundred percent.
And it's looking, you know,
it's beyond nutrition as well.
Like you mentioned earlier,
it's things like sleep or
stress and having a greater
recognition for where that
person lives and
and the environmental
influence that they endure,
how that has an impact on
what you're working towards.
You've been a physical
therapist who looks through
this lens of also looking
at nutrition for a while now.
You know,
is there a story where you've
seen nutritional changes
impact someone's rehabilitation,
like something that, you know,
someone can picture?
Yeah.
So I think one of the most
impactful stories I've come
across as looking at
And this has happened with a
couple of patients, you know,
that come out of surgery.
I think they were both the
ones I'm thinking of were
drum replacement.
Maybe one was a traumatic
fall and ended up having to
have a nailing or something done.
But they were having a
pretty difficult time with
their recovery because the
wound wasn't healing.
And they were kind of
entering into a state of malnourishment.
where they weren't getting enough of X, Y,
and Z. So the body wasn't responding,
the wound wasn't healing.
So they weren't able to
progress in therapy,
weren't able to get back on
their feet as quickly as they wanted to.
So what we did is when we
started intervening and
recognizing that there was
some malnourishment going
on and started having
conversations with other
providers and the need for
protein supplementation,
Once that protein
supplementation kicked in,
which is gonna include a
variety of other nutrients
as well to support wound healing,
once the nutrition regimen
changed and that addition was added,
the wound started healing as it should.
And then once that wound started healing,
we were able to get back to
more targeted functional
activity with improved
strength and mobility and
really just progressing
that patient where they needed to be.
Nutritional changes and
changes in movement and exercise,
these things take time.
It's less of I did this
thing and I immediately saw results.
So a lot of this, I imagine,
has to go with things we've
already talked about, education,
motivational interviewing,
which also comes with a
component of listening and
building trust.
to help someone understand this concept of,
Hey, you know,
we've heard you are what you eat.
And I think people can understand that,
but what you eat or don't
eat can affect this thing
of movement or pain or
rehabilitation or building muscle.
And both of these things take time.
Yeah, they do.
And that's,
I think probably a challenging
thing for many orthopedic
physical therapists out there to
to grasp is that it does take time.
It's not going to be,
they start eating more
protein this week and the
next week they're going to be stronger.
You know,
it's going to take time for the
body to respond to that, you know,
for that, that muscle health to improve,
to have carry over to
improvements in functional strength.
So it's not going to be immediate.
And if you are looking at
going down that road,
that route of motivational
interviewing and behavior
change to get that person to
to start eating better,
that's going to take a lot
of time to be successful.
And so that it's long lasting.
You could be looking at
something that takes three
to six months to change
your behavior if you're
trying to get a person to
consume more fruits and
vegetables or consume more protein.
Yeah,
I heard a great mentor in a clinic
explain it to a patient
that was sort of eavesdropping.
And they very plainly said, listen,
How long do you think it
took your behaviors to get
us to this point with your knee?
And they said, well,
probably a couple years.
They said, well,
do you think you're ready
to devote a couple months
to a few changes to see
some improvement to start
to work our way out of this?
And I think when it was framed that way,
not just do this and it
will get better in this
indefinite amount of time.
If I don't see results quickly,
I sort of check out as well.
And framing it that way, listen,
we're going to do some
things in terms of movement.
We're asking about sleep and nutrition.
We're asking about stress
and mental health.
And this is sort of the 360 to a human.
When it was put that way,
it was almost a very
educational light bulb
moment for that patient saying,
it did take me a long time
to get to here.
So yes,
I don't think a quick fix is
actually possible.
So I'm willing to invest and
commit to that.
Yeah, everything takes time.
And, you know,
I think the other thing to consider, too,
that takes time from a
physical therapist
perspective is it takes
time for you to learn how
to start implementing it into practice.
You know,
what does that conversation look like?
How do you start screening people?
How do you provide education information?
You know, what's your flow?
of how you integrate, that takes time.
It's not gonna be you do it
well next week.
It takes time for you to
start being able to
practice more holistically.
And what's it look like for
you to do it compared to
another therapist?
Well,
you've educated clinicians on this
previously in different facets,
presenting it at various conferences.
At what touch point in the
patient life cycle does this come in?
Is this something they fill
out before they come to the clinic?
Is this something you ask in
initial evaluation?
Is this something you ask on
follow-up visits?
Where are the opportunities
to bring this into practice?
Yeah, so it's a good it's a good question.
And sometimes it's a large it depends.
But I think there's two ways
you can go about it.
And it may depend on the
patient that's in front of you.
You know,
if you've got someone that's
coming into the clinic for
their initial evaluation
and they're coming to you
with a condition or their post-op and,
you know, right out the gate,
nutrition is going to
impact their recovery.
I'm likely going to start
screening initially, right,
with that initial eval.
I'm going to use some type
of food frequency
questionnaire or just ask
simple questions in terms
of what their eating pattern looks like.
Are they getting enough of X, Y,
and Z to support it?
So I might do that out the gate.
But if I'm dealing with a
patient where after a couple visits,
maybe it's something
related to chronic pain or
some other type of inflammatory condition,
they got a nagging tendon
that's not recovering, I might start to
early on, you know,
work on building my
relationship and start
educating that patient on
how nutrition is applicable
and important potentially
to what's going on.
And then once that
relationship is established
and there's trust,
because that patient's
likely going to be more of
a behavior change, right?
If I'm dealing with chronic
pain or tendinopathy that
won't get better,
that I want to establish
that relationship and trust,
then I'm going to start
screening and asking questions,
maybe several visits down the road,
because the responses I get
are going to be very
different from if I did it on day one,
you know, post-op patients,
totally different.
They know that their life is going to be,
you know, um,
different after coming out of surgery,
they know that they're
going to have to make some changes,
whether it's weight-bearing
restrictions or modifying activity.
It's, I think, easier early on to bring in,
hey, you need to get more protein,
you need to stay hydrated, et cetera.
But the ones with the chronic,
I'd build a relationship
first because you're likely
going to go down a road of
behavior change.
And in order for that person
to buy into it,
they've got to trust in
where you're coming from.
Good use of slipping in.
It depends as well on a
physical therapist.
Yeah,
it would not be a complete episode
unless you did that.
Any other resources?
You mentioned some good ones
early in the episode.
Is there a book out there
that if someone was saying, yeah,
I want to get a little more educated,
is there something that
someone has written that
you might suggest for a
physical therapist who just
wants to get a little bit
more knowledgeable about nutrition,
even for themselves or their patients?
Um, you know, there's,
there's a lot of nutrition
texts out there.
I do think some of them are,
or sometimes one sided, you know,
where there'll be more of
an emphasis in a plant
focused diet versus a carnivore.
So some of that stuff gets kind of,
I think, segregated.
Uh, you know,
we had two PTJ manuscripts
that we published a few
years back that kind of
tried to help lay the
foundation of what nutrition looks like,
uh,
within our profession and how to
implement it into practice.
Uh,
we've got a textbook chapter coming out,
uh, within the primary care, uh, text,
the boys are not text.
The fourth edition has a
whole chapter on nutrition, uh,
where we try and educate again,
the foundation and give the
tools and resources to, uh, to implement,
uh, into practice.
But I'm always hesitant in
recommending texts because
texts are typically always one-sided.
Mm-hmm.
And I'm not a fan of just
honing in on that one thing
because there's so much
nuance to what a person eats.
And there's so much impact
to an individual,
whether personal or environmental,
that influences their decision making.
In this situation,
one book does not fit all.
It doesn't.
No,
because that's one thing I do caution
in looking at those type of
books is it's always going
to try and direct you down one path.
But that one path might not
be suitable for you.
And we know that.
The more we learn through
research in nutrition and
sleep and movement is if
two people were to do the
same diet and the same
exercise routine and get the same sleep,
they still, because of genetics,
would get different results
and environment.
Those things are still variable.
So this is where a skilled
clinician comes in and says,
these are the things I need
to tease out to figure out
why we're not getting the
results that something else
with a similar situation might.
All right.
Segment on the show we call
The Final Thought.
Anything you'd want to leave
with the audience that's
listening and still
listening after 15 minutes and saying,
okay,
I now know a little bit more what I
might want to learn about
in terms of nutrition and
bringing them into my practice.
What would you want to leave
with the audience?
Just start having the conversation.
I mean, that's really it.
Just start having that
conversation and start to
get comfortable with having
that conversation.
you know, the first few patients,
it's going to seem very awkward.
Yeah.
And you might get pushback where it's like,
why are you talking about
what I'm eating when I'm
here because of my knee pain?
So it might take, you know,
empowering or not empowering.
It may take you digging into
some of the why, you know,
what's the connection
between nutrition and so
that you can then empower
the patient as to why it is
important and give that information.
But it really starts with,
you just got to start
having the conversation.
And no matter what way,
whether it's a standardized
screener or you just ask them, hey,
how often are you eating
fruits and vegetables?
What are your protein sources?
How much water do you drink
throughout the day?
Just start the conversation
is really the biggest thing.
Because you don't know if
you have to go down the
next path of education and
resources unless you start
having that conversation.
And it starts with you.
The conversation for
nutrition does not make its
way into your patient interaction,
most likely,
unless you bring it in there.
Patrick Berner,
thanks for bringing some
nutrition into the lives of
orthopedic physical
therapists and just having
this very introductory conversation.
Yeah, I appreciate you.
Thanks for having me.