Physical Therapy & Clinical Nutrition


Physical Therapy & Clinical Nutrition

Eziah Syed

Clinically Necessary, Good For Patients & Good For Business

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Article Summary

  • APTA advocates for PTs to incorporate nutritional screening and providing advice is in scope of practice.
  • There is established clinical evidence with growing new research and new nutritional solutions specifically designed for rehabilitation that will enhance patient outcomes — leading national practices in PT are deploying MEND.
  • Nutrition consult is reimbursable and nutrition sales creates a revenue stream for PTs that helps offset some of the margin erosion — nutrition is good for patients and good for practice.

Full Article

In a priorarticle, we reviewed the regulatory support for physical therapists to educate and counsel patients in nutrition as within their scope of practice as encouraged by APTA. We also reviewed the clinical evidence for nutritional therapies that are supported by strong science in the form of randomized double blind placebo controlled trials which show statistically and clinically significant results. In a changing environment with increasing margin pressures and a shifting value based payment model, nutrition will become important for PT practices — already industry leaders and large national PT businesses are incorporating nutrition in their practices. In this article we will focus on the business model and how to effectively incorporate nutrition into your practice to benefit both your patients and your bottom line.

The Clinical Case APTA Guidance

To recap, during injury or surgery, the body’s nutritional needs increase above the baseline:

  • The body enters a higher metabolic state and requires more energy
  • Trauma and lack of use leads to muscle atrophy, which prolongs recovery
  • The immune system is weakened due to stress and shock
  • Risk of wound infection is increased
  • Persistent inflammation will delay return of function
  • Trauma and physiological stress lead to increased fatigue

The more severe the trauma, the harder the body has to work and the more its nutritional needs increase. And as per large hospital studies and general population studies (e.g. 16 thousand person study by the Journal of Nutrition),we are undernourished as a society. Hospital studies have shown that upwards of 50% of patients are undernourished. A recentNY Times articlerevealed that frail patients have a difficult time recovering, even from minor operations.

These two factors, increased nutritional needs during trauma and general poor nutrition status of patients, leads to the strong clinical case for nutritional intervention strategies.. And, at MEND we believe that we can go beyond the general strategy of “increasing calories, carbs and protein” and give patients moretargeted nutrientsdepending on the nature of their condition.

Now to the governing body for PTs, the American Physical Therapy Association (APTA) and their position on nutrition.

APTA states:

“Diet and nutrition are key components of many conditions managed by physical therapists. What’s more, nutrition can directly affect recovery and function while an individual is under a physical therapist’s care. It makes sense, then, for physical therapists to be concerned with and address nutritional intake and eating patterns of their patients and clients.”(APTA: Nutrition Physical Therapy).

“…it is the role of the physical therapist to screen for and provide information on diet and nutritional issues to patients, clients, and the community…House of Delegates P06-15-22-17).

PT Attitudes Beliefs

Intuitively all PTs understand targeted nutrition is needed during recovery, especially for patients who are malnourished and nutrient deficient. However, until now many have been hesitant to incorporate nutrition into their practice. We believe there are four primary reasons:

  1. Incorrectly believe that nutritional advice is outside of their scope of practice.
  2. Underestimate their knowledge or ability to provide advice.
  3. Are concerned that their referring MD providers will believe that the PTs are overstepping their scope of practice.
  4. Don’t want to appear like they are peddling product or “snake oil”.

We will address each of these concerns:

  1. Scope of practice:as we stated at the outset, APTA has correctly recognized the critical role of nutrition in healing and recovery and placed it within scope of practice. We have shared APTAs encouragement to utilize nutrition and a state by state guidance. So long as the PT is staying within the guidelines, for example recommending a supplement product for a specific condition that they are treating, this is within scope and within the duty of a PT. It is important to review the state by state guidance, however, recommending supplements is allowable in virtually all states.
  2. Knowledge:Scopes of practice evolve along with training. PTs working for the U.S military for example routinely order imaging and interpret results while private practice therapists are not legally permitted to do so. PTs can now conduct EMGs with extra training. And as diagnostic Ultrasound continues to gain value for musculoskeletal conditions that will also be considered an appropriate tool for PTs. The state of Wisconsin as of 2016 allowed PTs to order Radiographs. Direct Access laws across the country have put PTs as the first line of defence for musculoskeletal conditions. Therefore general medical screening including nutrition has to be within their scope of practice to effectively diagnose and treat patients. At MEND we recognized early that PTs are undervalued front line providers who can provide critical nutrition screening and advice – that’s why we have been collaborating with PTs from the outset (one of our founders is a PT). Unfortunately, nutrition hasn’t been a part of their curriculum, just as it hasn’t traditionally been for MDs. MEND has developed products that help PTs navigate “healing” nutrition like a GPS system – type in the address and the GPS will guide you through.

The cheat sheet above makes it very simple, one doesn’t need a nutrition degree and these solutions are focused on PT domains and musculoskeletal challenges. With this approach, a PT can feel confident to stay within their scope of practice and providing guidance that they can feel comfortable with. There is no need to step outside of their area of expertise…MEND’s products are backed by published clinical studies and being quickly adopted by leading hospitals and medical providers.

3) Surgeon response.As the research and evidence continues to support nutritional therapies for its important role in healing, the MD community is increasingly buying in. Our experience with leading orthopedic surgeons has been overwhelmingly supportive when introduced to our science and products. Although, many have openly acknowledged that “we are behind in this area and need to catch up” and others have said “there is a buzz about nutrition in orthopedics that didn’t exist 4 or 5 years ago.”

Orthopedics Nutrition

Feedback from orthopedic leaders:

“MEND aligns with our philosophy of providing our patients comprehensive multimodal care to deliver the best possible results…for our total joint population, this new nutritional therapy will help to enhance outcomes.Michael Suk, M.D., J.D., chair of the Geisinger Department of Orthopedic Surgery.

“I have been discussing nutrition with my colleagues for more than a decade…I appreciate MEND advancing important research in this area.Neil Sheth, M.D., Chief Orthopedics Pennsylvania Hospital.

“I am impressed with MEND’s science and the caliber of the company’s medical and sports clients.”Kyle Anderson, M.D., Owner Anderson Sports Medicine, Team Physician Detroit Lions

These are three highly regarded leaders in orthopedics giving us a nod. We have many more quotes like these from the top leaders. At the end of the day, what MDs care about is the efficacy and safety. We have the science and the support of numerous leaders and adoption into many hospitals. PTs can feel confident in recommending MEND to their patients and can share the clinicals with MDs who may be unaware of the science. Simply send MEND whitepapers and product literature and share info on adoption by leaders and hospitals. From everything we’ve heard in our conversations with surgeons, they will be very supportive.

4) Don’t want to “sell”.This is a really simple one, if one believes in the purpose and the science, incorporating nutrition is not selling, it is a clinical tool and a professional responsibility. The objective isn’t to push product but rather to make use of every tool in the toolbox to enhance patient healing, recovery and well-being. A PT’s professional responsibility is to be aware of the latest science, make patients aware of the critical role of nutrition and to share information on scientifically valid solutions.

Business Model

Now to the business model and why nutrition makes good business sense. PT practices are feeling incredible margin pressures with increasing rents and salaries and regular cuts in reimbursement rates. Looming on the horizon is another cut to Medicare reimbursements — this time by 8%, which was approved and will be implemented in 2021 despite strong opposition from PTs. We have spoken to PTs in New York City, where MEND is based, who have said that they are shutting down their practices because the business model is no longer viable. There are two ways in which nutrition can help:

  1. Nutrition counseling is reimbursable for PTs:so long as a PT is providing nutritional council within the context of treating a specific condition (e.g. ACL recovery), this is reimbursable through insurance as as patient education. So a PT may spend some time with a patient on explaining the science of nutrition and healing and provide the literature and science on MEND’s products. We have published a lot of educational material in our blog that can be leveraged. This type of patient education that is specifically related to their PT condition is billable to insurance. And given the science behind enhanced outcomes from nutritional optimization, insurance companies will welcome this as it will save them costs from downstream complications. Hospitals are paying for MEND as they see the bottom line benefits of enhanced outcomes. Now we aren’t advocating for PTs to become RDs and begin providing general nutrition advice. But if a patient has an upcoming joint replacement surgery, we think it is incumbent on the PT to know that muscle atrophy and weakness could present serious challenges and persist for years and that MEND Joint Replacement will enhance the patient’s recovery.
  2. Rebates to PTs:clinical nutrition is a big and growing business. As more and more science is published by MEND and others, it will only grow and become more and more important to medicine as we publish more research. At MEND, rather than put our products into drugstores, we would prefer to work with medical professionals and support their efforts to increase the well-being of their patients. Patients can source scientifically valid products directly from their trusted medical provider in a more convenient way rather than buy from a drugstore with unproven products with no clinical backing. MEND is simply shifting the margin that would go to retailers over to PTs, we think this makes great sense for the PT, the patient and for us.

By incorporating nutrition, not only will PTs do the right thing for patients, but they will claim back some of the margin that has been eroded. It’s simply good for business and the world needs more high functioning PT practices, we can’t afford to have practices shut down. To be effective, however, it must be a part of a core philosophy of multimodal care and integrated into treatment approach and protocol.

In the research that we’ve done with patients, they appreciate their medical provider recommending solutions as it takes the work out of it for them to do the research on their own. We have made it exceedingly simple to implement MEND — there is no cost and no overhead to PTs. Many of our partners have called it “a no brainer.”

To learn more, please email us