Some may argue that nutritional counselling is not part of physiotherapy, but nutrition plays a crucial role in the musculoskeletal healing process. So, should physiotherapists give nutritional advice to optimise their patients’ recovery?

Sports and Exercise Physiotherapist Andrew Wynd says it’s nearly impossible to separate diet when it directly relates to common conditions treated at a physiotherapy clinic.

“I believe some physiotherapists should provide nutritional counselling to their clients.

“Arthritis, both osteo and rheumatoid categories, are common presentations at physio clinics, and … current best practice is to consider body weight, and there is a further link with waist circumference.

“Yet another common clinical presentation is tendonitis, and there is a clear link between metabolic syndrome and the risk of tendonitis – something physiotherapists are experts in managing.

“We also know that obesity, an increased waist circumference and metabolic syndrome can be influenced by diet.

“So, I ask the question, how can we truly look after our patient’s health and provide the best possible outcome without discussing nutrition?”

APA Exercise and Sports Physiotherapists have a base level of knowledge in the nutrition field, says Mr Wynd, and many have experience working in the field.

“I believe this is adequate to start the conversation at least – however, if specialist advice is required, we would typically refer to a dietician or expert in their field.”

Michael Dermansky, Senior Physiotherapist and Managing Director of MD Health, agrees, saying physiotherapists are long-term, trusted health professionals who treat conditions with nutritional components.

“Physiotherapists are very good at building good, long-term health relationships with their patients.

“We often see patients for long-term conditions, such as knee arthritis, chronic lower back pain and other long-term inflammatory conditions, such as rheumatoid arthritis. 

“So, we’re often … trusted health advisors to the patient, and they rely on us for good quality health information.

“Many long-term conditions have a nutritional component, such as maintaining a healthy weight reduces the load on the knees in the case of arthritis.

“So, understanding foods that reduce inflammation, such as turmeric, which has anti-inflammatory properties, can directly benefit and improve the outcomes of the conditions we see every day.”

Despite nutrition being integral to a patient’s recovery, two important skills aren’t part of a physiotherapist’s training, says Dermansky.

“Firstly, the technical knowledge of understanding human nutrition, the general requirements of patient’s nutritional needs and the specific requirements for particular conditions. 

“I’ve completed a Graduate Diploma in Nutrition to understand this area better, but this depth of training is not required on a general basis.

“A good short course that covers the basics of nutrition and how it applies to physiotherapy conditions is enough.”

The second skill, nutritional counselling, is a bit tougher as it requires important soft skills to help people change habits, explains Mr Dermansky.

“Changing nutrition habits involves patients changing things at home, which can be difficult. 

“Nutritional habits are quite dependant on a patient’s understanding of nutrition, food habits, the food environment they have grown up in, tastes, likes and dislikes. 

“Teaching change takes time and experience and a skill that needs to develop over time for the physiotherapist.”

Nutrition in rehabilitation and recovery

Patients aren’t used to speaking to physiotherapists about nutrition and eating habits, so they won’t volunteer this information unless asked, says Mr Dermansky.

And asking is critical, as nutrition plays a significant role in injury recovery.

“Patients [should] follow a good, regular diet with meals that meet their nutritional needs. 

“A combination of protein and carbohydrate in meals is extremely important in building muscle and soft tissue repair. 

“Your body needs these elements for the building blocks of repair. If you don’t have adequate protein and carbohydrates in your diet, your body finds a way to achieve its energy requirements by breaking down muscle and using protein as fuel. As a result, it slows down your ability to build muscle and recover.

“Secondly, exercising and adding ‘load’, which we do during the rehabilitation phase of an injury management program, is a stress to the body, releasing a combination of adrenaline and cortisol. 

“Unfortunately, cortisol dampens your immune system and causes you to retain body fat. To reduce the production of cortisol, you need to consume enough energy, in the form of carbohydrates, before and after your session to minimise this response.”

“Eating good quality protein before and after your workout will stunt the cortisol response of training and help begin the resynthesis of muscle tissue.

Within 15 minutes of the end of the session, you should aim to consume 15-20 grams of protein (1 x 95 g of tuna).

Within 1.5 -2 hours of exercising:

• Eating a post-workout meal replaces the depleted energy and promotes the recovery process further
• Eating this meal within 90 minutes or so of your training session should prevent hunger cravings later in the day
• In the 90-120 minutes following your workout, your metabolic rate is still elevated, and your absorption of carbohydrates is higher
• To continue to restore your hydration status to a normal level, water will suffice
• Structure of the meal:
• 1 cup of high-energy carbohydrates such as Oats or rice
• 1 cup of low-energy carbohydrates such as Broccoli, carrots, and apples for long-term energy
• High-quality protein, such as tuna, chicken or cottage cheese
• Good quality fats – 1 teaspoon of flaxseed oil, which is a very high source of Omega 3 fatty acids

Illnesses that impact nutrient absorption

Chronic diseases, such as Chohn’s disease and diverticulitis, can affect the bowel and gut and, as a result, nutrient absorption, explains Mr Dermansky. 

“If the patient has these types of inflammatory bowel diseases, it is important that they see a dietitian for proper advice as it is usually outside the scope of general nutritional advice.

Other significant illnesses, such as severe COVID, pneumonia, and operations, can affect nutritional needs in patients.

“They would have lost a significant amount of muscle mass which will affect the recovery of injuries and getting back to normal levels of fitness. 

“This is where appropriate intakes of protein, carbohydrates and good quality fats are important for the fastest recovery and getting patients back on track. 

“This is the role where physiotherapists can play a big part in good nutritional education.”

Chronic pain and inflammation

Chronic pain often leads to raised cortisol levels, explains Dermansky, which can cause chronic inflammation throughout the body, decrease the ability to build muscle and lead to body fat retention.

Patients can alleviate the possible impact of pain and inflammation through good nutritional habits, such as:

• Regular meals (in particular not skipping meals)
• Good quality protein, carbohydrates and fats during meals
• Drinking regular water
• Protein and a small amount of carbohydrate following exercise/physiotherapy sessions

“All contribute to minimising elevating cortisol levels, which affects chronic pain. 

“Good nutrition, unfortunately, is not a cure for chronic pain, but is one element that assists in the management of the overall picture of chronic pain.”

Food with anti-inflammatory properties

The following foods have anti-inflammatory properties:

• Tomatoes – As they are a rich source of lycopene, which is a potent antioxidant. Lycopene reduces the production of inflammatory cytokines and improves antioxidant defences reducing the risk of inflammatory diseases.
• Virgin olive oil – Contains numerous phenolic compounds, particularly oleocanthal, which have a potent anti-inflammatory effect. Its anti-inflammatory effect is similar to the common anti-inflammatory medication ibuprofen.
• Green leafy vegetables (such as spinach and kale) – These contain a number of nutrients that have anti-inflammatory properties, including Vitamin A, D, E and K.  In addition, they contain alpha-linolenic acid, an omega-3 fatty acid, which has anti-inflammatory benefits.
• Nuts (such as almonds and walnuts) contain calcium, magnesium, zinc, Vitamin E and Omega-3 fatty acids, which all have anti-inflammatory properties. 
• Fatty fish (such as salmon, mackerel, tuna, and sardines) all contain high amounts of alpha-linolenic acid, an omega-3 fatty acid that is anti-inflammatory because they down-regulate the mRNA levels of pro-inflammatory genes for IL-8, COX2 (inflammatory cytokines) and activate nitric oxide synthase.
• Berries (such as strawberries, blueberries and cherries) – contain polyphenol compounds, particularly anthocyanins, which can modulate the inflammatory state.

Nutrients that are important in healing

There is a combination of nutrients that are important for healing, says Mr Dermansky, including:

Adequate macronutrients (kilojoules for energy) – The body needs energy to heal. If you are restricting your kilojoule intake in order ‘to lose weight’, this puts your body in a catabolic state, utilising muscle mass as a source of fuel to make up for the energy shortfall. 
This defeats the purpose of exercising and rehabilitation to build muscle mass and repair and will slow the healing response. This does not mean you can eat anything you want because excessive empty kilojoules from high-fat/sugar foods contain little nutrients, which are pro-inflammatory and will affect your health in the long term. 

Eating good quality carbohydrates, proteins and fats to meet at least your resting metabolic rate needs will ensure that you have the energy your body needs to repair and heal.

High-quality protein – Contained in meat, chicken, fish, eggs and dairy, are an important building block for your body to heal, repair and build muscle. Adequate protein is essential, especially after exercising (at least 15-20g of protein) and in general, it is a recommendation to have at least 0.8g of protein per kilogram body weight per day (if you are 80kg, you need 64g of protein which is about 230g of tuna).

Vitamins A, C and Zinc – All these micro-nutrients are essential for tissue repair and collagen production, fighting infections and keeping your skin healthy.

Vitamin A – Green leafy vegetables, apricots, carrots, cheese, eggs, and liver
Vitamin C – Broccoli, Kiwi, Sweet bell peppers, strawberries
Zinc – Eggs, fish, liver, meats, chicken and nuts