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The Right Mix
Monday January 23, 2012


Older adults' often poor dietary habits can negatively affect physical rehabilitation, but with a thorough assessment, a therapist can detect problems that may interfere with healing and address those issues — either directly or through a referral. "Nutrition is one of the most overlooked aspects that can help rehabilitate or remediate functional recovery," said Jim Tholany, DPT, at Performance Spine & Sports Medicine in Lawrenceville, N.J. "The body is powered by the nutrients in the food we eat."

A well-balanced diet rich in protein and nutrients will allow patients to rehab as fast as possible and avoid roadblocks in the recovery process, Tholany said.

Dana Hilz, PT, DPT, CSCS, at Cascade Sport and Spine in Centralia, Wash., dubbed nutrition the missing link in physical therapy. Without good nutrition, she said, "the patient isn't going to have as good a chance of healing or recovery from an injury or surgery."

In fact, rehabilitating patients may need higher caloric intake than normal. "When someone has an injury, the body turns up the metabolic rate for the process of healing, so they burn more calories," said Cindy Bailey, DPT, OCS, SCS, ATC, EMT, at Los Angeles Orthopaedic Hospital.

Bailey said a thin person will need to consume more calories than usual to give the healing tissue enough nourishment. She said she recommends eating more protein, in balance with carbohydrates and fats — 40% protein, 30% carbohydrates and 30% fats. However, an overweight person can eat about the same or less than usual, cutting back on carbohydrate and fat intake, she said.

"The healing process is determined so much by whether you have the nutritional components to draw into the healing tissue," Bailey said, adding poor nutrient intake may delay healing.

Wendy Fox, DPT, GCS, WCS, a physical therapist at Women & Infants Hospital of Rhode Island in Providence, said she times her patient appointments to avoid disrupting meals for deconditioned or post-op oncology patients, and she consults with their dieticians.

Poor diet creates downward spiral

An inadequate diet can lead to injuries or other conditions for which older patients will need physical therapy, according to Jill Horbacewicz, PT, MA, PhD, chair/director and associate professor of the Touro College Physical Therapy Department in New York.

"Nutrition is important for the body to heal properly but also for prevention of disease," Horbacewicz said. For example, lack of calcium can lead to osteoporosis and being overweight can contribute to osteoarthritis, she said.

Australian researchers reported in the May 15, 2011, Journal of Nutrition Health & Aging that malnutrition in older adults was associated with reduced mobility and a greater risk of falling during the elders' admission to a tertiary teaching hospital.

Endocrinologist and geriatrician John E. Morley, MD, at St. Louis University, outlined the pathophysiology associated with frailty in older adults in a different article in the same journal Aug. 15, 2011. Poor eating and anorexia, he said, leads to lack of muscle mass, which in turn, limits a person's ability to move about and reduces gait speed. In reverse, anemia, depression and cognitive decline can contribute to fatigue and poor food intake.

Many factors associated with aging contribute to inadequate intake of healthy, nutrient-rich foods, putting older adults at greater risk for problems. "When elders eat alone, often their nutritional needs are out of balance," Bailey said. She explained people who live alone tend not to eat as often or as healthily.

Tholany said older adults often lose their senses of smell and taste, which can reduce their appetites and caloric intake. Problems with teeth or dentures also can deter healthy eating. People experiencing difficulty chewing often eat soft foods, missing out on more healthy options requiring mastication. "Dentition has a big effect on elders and whether they are getting good nutrition or not," Bailey said.

The cost of healthy food works against lower-income older adults, but community resources, such as Meals on Wheels, can help provide well-balanced meals, Bailey said.

Limited access to fruits and vegetables, leading to inadequate dietary fiber, can result in constipation or fecal incontinence, said Fox, who works with older women experiencing pelvic floor disorders. She asks patients to record daily fiber intake and, if deficient, to gradually increase fiber consumption. Constipation also can occur when patients forget to drink enough fluids, she said.

Nutrition interventions by PTs

PTs should take an inventory of each patient's health in general, social support, barriers to care and diet, Horbacewicz said. "Nutrition plays a role in the body's ability to perform physical tasks, and we need to consider it," she said.

Bailey assesses patients' nutritional status. In addition to asking about what they eat, she assesses the quality of their nail beds, skin and eyes. She may consult with a physician to learn more about the patient's general health and medication regimen.

With cardio-pulmonary rehabilitation, Horbacewicz said, the PT also should ask about salt intake because it could contribute to fluid retention and may increase blood pressure. "I'm sure there are other people telling them this as well, but we are trying to be holistic in our approach," she said.

In addition to discussing the importance of consuming a healthy, balanced diet, PTs can recommend supplements. "The tissues involved would determine what we are going to tell the person to put more of in their diet," Bailey said. "It's usually protein or calcium."

Tholany suggested patients take fish oil and vitamin D supplements, which is important for bone health. Bailey sometimes recommends coenzyme Q10, a tissue builder, or amino acids to complete amino acid protein chains, depending on the person's diet, she said.

Horbacewicz cautioned against thinking a supplement or vitamin is a magic solution, preferring a more comprehensive approach to improving food intake. "It's hard to pin down any specific thing," she said. "It's more relevant to discuss general guidelines for each type of dysfunction."

An article in Jan. 20, 2010 issue of the Cochrane Review supports that assertion. The authors reviewed 23 clinical trials and found only weak evidence in support of protein and energy supplements in elderly patients recovering from hip fractures.

Referals may be one of the answers. For a patient with dental issues, Bailey would refer to a dentist and recommend liquid nutritional supplements. She also refers patients with nutritional deficits to nutritionists or social workers to assess the home environment. •

Debra Anscombe Wood is a freelance writer.

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Monday January 23, 2012
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