Lifestyle Medicine For Physical Therapists

By empowering our patient’s with holistic lifestyle choices, we are investing in positive change for our respective communities.

Physical therapists (PT) and other healthcare providers already provide patient on a variety of topics. For example, physical therapists provide patient education on joint protection guidelines, proper lifting mechanics, energy conservation guidelines, pre- and post-surgical guidelines, caregiver training, and assistive device use. These are only a few areas PT’s provide education. However, in the next decade and beyond, physical therapist therapists will continue to play a leading role in lifestyle education and the wellness needs of the patient. The purpose of the article is to provide an overview of areas PT’s need to continue emphasizing in their clinical care of patients.

INTEGRATIVE LIFESTYLE MEDICINE

Integrative medicine is about including advice and recommendations from your doctor and healthcare provider into a patient’s health and wellness program. However, it is also about incorporating lifestyle changes such as managing stress, getting adequate sleep, eating nourishing foods, meditating, and performing fun and meaningful exercises.

What does “integrative, alternative, and complementary medicine” mean? The National Center for Complementary and Integrative Health (https://nccih.nih.gov) defines the terms as follows:

  • “If a non-mainstream practice is used together with conventional medicine, it’s considered ‘complementary.’”
  • “If a non-mainstream practice is used in place of conventional medicine, it’s considered ‘alternative.’”
  • Integrative health care involves “bringing conventional and complementary approaches together in a coordinated way.” The integrative approach typically involves pain management, relief of symptoms, and promoting healthy behaviors.

What is mind body medicine? The mind body medicine model includes self-care and self-awareness as a key component of care, treats the person in a holistic manner, aims to get at the root cause of an illness or disease, and encourages adopting a healthy lifestyle, which includes wholesome nutrition, meaningful exercise, restorative sleep, stress management strategies, meditation, mindfulness, balance between work and rest, and finally, involvement in healthy relationships. Some of the basic foundations of mind body medicine are that the program accounts for differences in each individual (not everyone gets the same program), the program is sustainable (the program is not a one-month- and-done routine), and the program is meaningful to the person. Some of the clinical uses of mind body medicine (or integrative healing) include treatment and care for anxiety, attention-deficit/hyperactivity disorder (ADHD), central sensitization (or heightened sensitivity to pain), depression, fibromyalgia, headache or migraines, pain, pain catastrophizing, post-traumatic stress disorder, sleep disorders, and chronic stress.1

SLEEP FOR HEALTH

Chronic sleep problems can increase your risk of heart attack, stroke, high blood pressure, diabetes, depression, and other medical problems. A person could lose sleep because he or she is experiencing pain, taking certain medications, or undergoing hormonal changes (such as menopause). Quality of sleep is considered good when a person can fall asleep relatively quickly (within 5 to 15 minutes), wake up easily, stay asleep almost continuously, and sleep long enough to feel refreshed the next day.2

The following are some of the results of sleep deprivation:3,4,5

  • Daytime fatigue, low energy, physical and mental tiredness, and weariness
  • Mood disturbances
  • Impaired cognitive functioning
  • Impaired memory and concentration
  • Difficulty sustaining attention with tasks
  • Slowed response times (good reaction times are critical for safe driving, safety at work, and preventing falls)
  • Increased incidence of colds and viruses, and a weakened immune system
  • Increased pain perception
  • Increased risk of falls
  • Decreased job performance
  • Reduced quality of life and inability to enjoy social relationships
  • A possible role in the current obesity epidemic
  • Decreased safety on the road, leading to car crashes

The American Academy of Sleep Medicine (AASM) recommends that “Adults should sleep 7 or more hours per night on a regular basis to promote optimal health.” The consensus statement from the AASM also indicates that “Sleeping less than 7 hours per night on a regular basis is associated with adverse health outcomes, including weight gain and obesity, diabetes, hypertension, heart disease and stroke, depression, and increased risk of death. Sleeping less than 7 hours per night is also associated with impaired immune function, increased pain, impaired performance, increased errors, and greater risk of accidents.”6

The American Academy of Sleep Medicine recommends the following sleep guidelines for specific age groups in a 24-hour period to promote optimal health:7

  • Infants one to twelve months of age should sleep 12 to 16 hours (including naps)
  • Children one to two years of age should sleep 11 to 14 hours (including naps)
  • Children three to five years of age should sleep 10 to 13 hours (including naps)
  • Children six to twelve years of age should sleep 9 to 12 hours
  • Teenagers thirteen to eighteen years of age should sleep 8 to 10 hours

From a direct physical therapy perspective, the following are key reasons for sleep:

  • Al-Sharman et al. (2013)8 indicate that “sleep facilitates learning clinically relevant functional motor tasks.”
  • Siengsukon et al. (2009)9 indicate that despite certain unanswered questions in sleep research, “therapists should consider encouraging sleep following therapy sessions as well as promoting healthy sleep in their patients with chronic stroke to promote offline motor learning of the skills practiced during rehabilitation.”

Table 1 outline 10 practical sleep improvement tips physical therapists may use with their patients.10

Table 1. Sleep Improvement Guidelines

  • Establish a sleep routine – Have regular bedtime and waking hours by going to bed when sleepy, at a relatively consistent time, and getting up at the same time each day to synchronize your body clock.
  • Create a comfortable room – Make sure your room is dark, quiet, and cool but comfortable. In most cases, room temperatures below 54 degrees Fahrenheit and above 75 degrees Fahrenheit will disrupt sleep.11 Also, keep the room well ventilated.
  • Unwind before bedtime – Allow at least one hour to unwind before bedtime12 by avoiding, during that time, stimulating activities such as watching a movie, reading an intense book, having emotional discussions, or playing competitive games like chess.
  • Exercise regularly – A study by Reid et al. (2010)13 indicate that engaging in moderate aerobic physical activity generally improves “sleep quality, mood, and quality of life in older adults with chronic insomnia.” Get regular exercise in the afternoon or early evening, but avoid it close to bedtime.12
  • Getting bright light at the right time – Early bright light exposure is very helpful in synchronizing your body clock and helping to wake you in the morning—the best source is sunlight.3 If you can’t get outdoors early in the morning, have breakfast near a window or on a balcony, porch, or patio. The timing of bright light exposure might be adjusted to late afternoon or evening by a sleep medicine physician if a patient has certain difficulties, such as falling asleep too early, working late shifts, or traveling by air frequently.14
  • Avoid alcohol near bedtime – Consuming alcohol near bedtime fragments and disrupts sleep.12 Also, a study indicates that stopping alcohol consumption at bedtime can improve sleep conditions.15
  • Avoid caffeine near bedtime – Avoid caffeinated foods and beverages (coffee, tea, chocolate, sodas, or colas) close to bedtime since caffeine is a stimulant and disturbs sleep.16 The effects of caffeine can remain in the body for three to five hours.17
  • Avoid smoking – Avoid smoking and other tobacco products within two hours of bedtime since nicotine is a stimulant that disturbs sleep.12 Better yet, let help our patients to quit smoking for all the health benefits.
  • Avoid excess fluids near bedtime – Avoid excess consumption of fluids within two hours of bedtime to prevent frequent bathroom trips at night.16 Also, empty your bladder (and bowels, if necessary) before going to sleep to prevent bathroom trips that can interfere with sleep.
  • Create a sleep routine – For example, the patient can try powering down all your electronic devices, washing the hands and face and brushing and flossing the teeth, smelling some lavender essential oils, gently massaging the neck, back, and foot for one minute, or taking a moment of personal reflection to be grateful for another day.

STRESS MANAGEMENT FOR HEALTH

Some causes of stress include chronic overstimulation of the senses (excessive noise or overcrowding), lack of sleep, poor diet, overtraining with exercise, information overload (due in large part to cellular phones and the Internet), and constant barrage of news via various media outlets, financial concerns, relationship problems, or job issues. Finding the root causes of their stress and try to find strategies to correct or manage their triggers. A trigger for one person may not even register as stress in another person. For example, some individuals consider standing in long lines or being stuck in freeway traffic as a high level of stress. Other individuals may look at these situations as a way to slow down their hectic life or listen to soothing music. Our bodies cannot be in a constant state of “fight or flight” (sympathetic nervous system) where the stress hormones are dominant. We need to have balance where we are in a state of “rest and digest” (parasympathetic nervous system) to allow for digestion, healing, and recovery.

Table 2 outline 10 practical stress improvement tips physical therapists may use with their patients.1

Table 2. Stress Improvement Guidelines

  • Smiling – Encourage patients to find more reasons to smile and laugh. Also, as clinicians we should smile more when appropriate – Smiling tends to relax the facial muscles (compared to frowning) and may improve your mood.18
  • Exercise – A good exercise program can include walking, hiking, biking, swimming, yoga, tai chi, qigong or Pilates.
  • Engage in relaxing hobbies – Hobbies such as in playing music, painting, writing, pottery, fishing, and gardening may be relaxing.
  • Pets – Play with your pets may help control stress.
  • Massage – Getting a massage or use self-massage to relax upper- and lower-body muscles.
  • Aromatherapy – The smells of lavender, rose, vanilla, and lemongrass can put you in a relaxed mood.
  • Nature – Go outside for a walk to get fresh air and natural light and to look off into the distance. For example, look at the clouds, distant trees, or out over the ocean or lake without squinting. Gazing into the distance tends to relax while prolonged close-up work may lead to stress.19,20
  • Relaxed breathing – Diaphragmatic breathing features either breathing in through the nose and exhaling through the mouth, or breathing in and out through the nose. This technique used in many type of stress reduction and anxiety management programs.21
  • Try a stress reduction app such as Headspace (www.headspace.com) or Calm (www.calm.com)
  • Try self-meditation or self-relaxation (also known as self-hypnosis). See Table 3 for self-guided relaxation technique.
  • Try a progressive muscle relaxation routine. See Table 4 for a physical progressive relaxation routine by pioneering psychiatrist Edmund Jacobson, MD, PhD (1888-1983).22

Table 3. Self-Relaxation or Self-Hypnosis Guidelines

Perform this self-relaxation routine either in the morning or before you go to sleep:

  • Start by getting comfortable in a quiet room.
  • Perform five deep breaths using the abdomen. Try holding each breath for 3 seconds.
  • Make sure your eyes are closed as you think of a relaxing place.
  • Continue breathing. As you relax, think of a relaxing color (such as blue, green, or pink) for five breaths.
  • Imagine the color slowly making its way from your head down to your feet.
  • Slowly ease yourself into relaxation by counting down from 5 through 1 as you visualize large blue, green, or pink numbers in your head.
  • Do the positive self-talk for least 5 to 10 slow breaths. Talk to yourself about positive things you want to reinforce such as:
    • — “My body is going to heal itself.”
    • — “I am going to get better.”
    • — “I am going to get an A on the exam.”
    • — “I am no longer fearful.”
  • Slowly ease yourself back out of relaxation by counting up from 1 through 5 as you visualize the large blue, green, or pink numbers in your head.
  • End by opening your eyes and enjoy the day. Or, close your eyes and go to sleep.

Table 4. Self-Relaxation or Self-Hypnosis Guidelines

  • To start, breathe in and out slowly three times using diaphragmatic breathing.
  • Take a deep chest breath, and then relax with a diaphragmatic breath.
  • Wrinkle up your forehead for five seconds, and then relax with two diaphragmatic breaths.
  • Frown for five seconds, and then relax with two diaphragmatic breaths.
  • Press your lips together for five seconds, and then relax with two diaphragmatic breaths.
  • Shrug for five seconds, and then relax with two diaphragmatic breaths.
  • Tighten your arm muscles for five seconds, and then relax with two diaphragmatic breaths.
  • Make a fist for five seconds, and then relax with two diaphragmatic breaths.
  • Tighten your abdominal muscles for five seconds, and then relax with two diaphragmatic breaths.
  • Tighten your buttock muscles for five seconds, and then relax with two diaphragmatic breaths.
  • Tighten your thigh muscles for five seconds, and then relax with two diaphragmatic breaths.
  • Flex your toes toward you tightly for five seconds, and then relax with two diaphragmatic breaths.
  • Point your toes away from you tightly for five seconds, and then relax with two diaphragmatic breaths.
  • Squeeze your toes tightly for five seconds, and then relax with two diaphragmatic breaths.
  • To end, smile lightly for five seconds, and then relax with two diaphragmatic breaths.

NOTE: This same routine may be performed by mentally imaging you are tensing the muscles without actually contracting the muscles.

SUTAINABLE EXERCISE FOR HEALTH

Sustainable exercise is not about promising miracle cures or quick-fix solutions, trying to sell a specific product, or finding a one-size-fits-all exercise routine. Every person has the freedom of choice to pursue whatever lifestyle, activity, sport, or exercise he or she wishes. For this reason, physical therapists need to help patient explore different types of movement patterns or exercises to find the one(s) which resonate with them. One patient may like hiking, dancing, yoga, tai chi, qigong, Pilates, or labyrinth walking, while another patient may enjoy weight training, walking, biking, swimming, or sports like soccer or tennis. Table 5 outlines some types of mind-body movements which may be introduced in physical therapy to help improve home program compliance:1

Table 5. Forms of Mind-Body Movements

  • LABYRINTH WALKING – labyrinth is an ancient meditative tool. Labyrinth walking may be used in correctional facilities to improve coping, mental health facilities for reflection, stress reduction, and the exploration of personal wellness and be incorporated in healing gardens in cancer treatment centers. A labyrinth is unlike a maze because a walking labyrinth has one path that brings you to the center and out again, while a maze generally has multiple paths and is designed to make you lose your way. A labyrinth, on the other hand, is designed to help a person find their way physically, mentally, and spiritually.
  • PILATES – The Pilates system created by German-born Joseph H. Pilates (1880-1967). It is a form of body work that uses controlled movements and poses to improve strength, flexibility, balance and mental concentration. Joseph Pilates developed many original exercise machines such as the Reformer, Cadillac, Wunda Chair, and Ladder Barrel, and created a bodyweight mat exercise series program consisting of 34 original poses. The original mat and apparatus based exercises can be modified to accommodate those with pain and/or injury and to challenge elite athlete.
  • TAI CHI – T’ai Chi (also known as T’ai Chi Ch’uan or Tai Qi) is a form of traditional Chinese martial art or exercise where a series of slow controlled multidirectional movements helps to improve balance, flexibility, strength and agility, and also helps to improve mental concentration and promote relaxation. T’ai Chi is sometimes considered as a mind in action or meditation in motion. There are several styles of Tai Chi, such as the Yang (a very popular form), Chen, Wu, Hao, and Sun styles, with some forms having around 108 postures and movements (considered the long form), and other forms around 24 movements (considered the short form). The benefits of the short form includes that is it easier to learn and consumes less time. The long form on the other hand benefits a person since it is physically and mentally more challenging.
  • QIGONG (also written as qi gong and pronounced as “chee-goong”) – Qigong is a traditional Chinese movement therapy and ancient martial art approach to healing that harnesses internal energy through movement (postures involving strength, flexibility, and balance), breathing exercises, relaxation, and meditation. Qi (breath, air, spirit) in Chinese stands for “energy of life” and gong means “work” or “practice.” Thus, Qi Gong (also known as qigong) means “working with the energy of life.”
  • YOGA – Yoga is a science and art that has evolved over the years to be recognized for its health benefits. Yoga’s aim was to primarily calm the mind and prepare the body for meditation, but in in our contemporary Western world, yoga tends to place an emphasis on the physical postures (called asanas) and coordinated breathing and less on its meditative aspects. Some teach that yoga is the skill of “effortless effort.”

NUTRITION FOR HEALTH

Good nutrition is not only about calories and consuming adequate protein, carbohydrates, fats, vitamins and mineral, but using food as medicine to heal and restore the body. In physical therapy, nutrition can be a very tool to help control inflammation and pain.

The nutrition book Nutrition and Diagnosis-Related Care23 outlines the basic principles of the Mediterranean or an anti-inflammatory diet:

  • Focus on a plant-based diet
  • Focus on foods rich in antioxidants and phytochemicals
  • Eat fresh and minimize processed foods
  • Eat “super-foods” such as salmon, blueberries, bananas, broccoli, avocado, or dark chocolate (at least 70% cocoa)
  • Drink green or oolong tea
  • Use spices and herbs such as oregano, cinnamon, dill, turmeric, curcumin, ginger, or garlic

The nutrition book Krause’s Food & the Nutrition Care Process24 states that after athletes are injured, the inflammatory stage of healing is affected by foods. The authors indicate that a “diet high in trans fats, saturated fats and some omega-6 vegetable oils has been shown to promote inflammation, whereas a diet high in monosaturated fat [such as olive and avocado] and essential omega-3 fats has been shown to be anti-inflammatory. The authors also state that “It is believed that nightshade plants aggravate the inflammation that causes pain, swelling, and stiffness in the joints of some patients with arthritis.” Finally, the authors outline the following principles of the anti-inflammatory diet:

  • Consume colorful vegetables and fruits, and also include anti-inflammatory spices and herbs such as turmeric, garlic, ginger, rosemary, oregano, cocoa, ginger, clove, coriander, cinnamon, nutmeg, black pepper, parsley, sage, dill, and basil.
  • Eat a low glycemic diet.
  • Eat nuts and seeds.
  • Adjust the quality and quantity of fats to include olive oil, coconut oil, and avocados and decrease excess animal protein and omega-6 fatty acids (such as soybean, corn, safflower, and sunflower oils). Also, avoid hydrogenated fats and trans fats.
  • Get adequate sources of probiotics from sources such as fermented and cultured foods.
  • Be aware of any food allergies and food sensitivities and minimize or avoid these foods. Common food allergens include eggs, milk, fish, shellfish, wheat, tree nuts, peanuts, and soybeans.
  • Avoid chemical and pesticides which can irritate your immune system.
  • Drink alcohol in moderation.
  • Get enough sleep.
  • Keep stress levels under control.

There are studies which in general discuss inflammation and diets25,26,27 and may be useful for clinicians wishing to learn more. There is also the free Dietary Inflammation Index (DII Screener) app at the Apple Store and additional information about the app at Connecting Health Innovations (http://chi-llc.net). Finally, see Table 6 for nutrients having anti-inflammatory effects.

Table 6: Dietary Inflammatory Index

The following nutrients are arranged from the highest to lowest level of anti-inflammatory effects.

  • Magnesium
  • Turmeric
  • Beta carotene
  • Genistein
  • Vitamin A
  • Tea
  • Quercetin
  • Wine (red)
  • Luteolin
  • Vitamin E

Adapted from Cavicchia et al. (2009)24 and Shivappa et al. (2014)28.

CONCLUSION

In conclusion, physical therapists are in a leadership position to empower patients and clients with healthy lifestyle habits which will not only be beneficial during therapy and rehabilitation, but also reducing risk factors and preventing many diseases. As PT’s if we empower our patients with holistic lifestyle choices, we are all in turn investing into positive change our respective communities.

REFERENCES

  1. Altug Z. Integrative Healing: Developing Wellness in the Mind and Body. Springville, UT: Plain Sight Publishing; 2018.
  2. Akerstedt T, Hume K, Minors D, et al. Good sleep—its timing and physiological sleep characteristics. Journal of Sleep Research 1997; 6 (4): 221–229.
  3. Ancoli-Israel S, Cooke JR. Prevalence and comorbidity of insomnia and effect on functioning in elderly populations. Journal of the American Geriatrics Society 2005; 53 (Supplement 7): S264–71.
  4. Kundermann B, Krieg JC, Schreiber W, et al. The effect of sleep deprivation on pain. Pain Research & Management 2004; 9 (1): 25–32.
  5. Walker MP. The role of sleep in cognition and emotion. Annals of the New York Academy of Sciences 2009; 1156: 168–197.
  6. Watson NF, Badr MS, Belenky G, et al. Recommended amount of sleep for a healthy adult: A joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. 2015; Journal of Clinical Sleep Medicine 11 (6): 591–592.
  7. Paruthi S, Brooks LJ, D’Ambrosio C, et al. Recommended amount of sleep for pediatric populations: A consensus statement of the American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine 2016; 12 (6): 785–786.
  8. Al-Sharman A, and Siengsukon CF. Sleep enhances learning of a functional motor task in young adults. Physical Therapy 2013; 93 (12): 1625–1635.
  9. Siengsukon CF, Boyd LA. Does sleep promote motor learning? Implications for physical rehabilitation. Physical Therapy 2009; 89 (4): 370–383.
  10. Siengsukon CF, Al-Dughmi M, Stevens S. Sleep health promotion: Practical information for physical therapists. Physical Therapy 2017; 97 (8): 826–836.
  11. National Sleep Foundation. Sleeping smart. National Sleep Foundation. www.sleepfoundation.org. Accessed August 8, 2018
  12. Kryger MH, Roth T, Dement WC. Principles and Practice of Sleep Medicine, 6th ed. Philadelphia, PA: Elsevier; 2016.
  13. Reid KJ, Baron KG, Lu B, et al. Aerobic exercise improves self-reported sleep and quality of life in older adults with insomnia. Sleep Medicine 2010; 11 (9): 934–940.
  14. Zee PC, Goldstein CA. Treatment of shift work disorder and jet lag. Current Treatment Options in Neurology 2010; 12 (5): 396–411.
  15. Morita E, Miyazaki S, Okawa M. Pilot study on the effects of a 1-day sleep education program: Influence on sleep of stopping alcohol intake at bedtime. Nagoya Journal of Medical Science 2012; 74 (3–4): 359–365.
  16. Attarian HP. Sleep Disorders in Women: A Guide to Practical Management. Totowa, New Jersey: Humana Press; 2010.
  17. Ancoli-Israel S. All I Want Is a Good Night’s Sleep. St. Louis, MO: Mosby-Yearbook; 1996.
  18. Hess U, Blairy S. Facial mimicry and emotional contagion to dynamic emotional facial expressions and their influence on decoding accuracy. International Journal of Psychophysiology 2001; 40 (2): 129–141.
  19. Birnbaum MH. Nearpoint visual stress: A physiological model. Journal of the American Optometric Association 1984; 55 (11): 825–835.
  20. Birnbaum MH. Nearpoint visual stress: Clinical implications. Journal of the American Optometric Association 1985; 56 (6): 480–490.
  21. Haff GG, Triplett NT. (Eds.). Essentials of Strength Training and Conditioning, 4th ed. Champaign IL: Human Kinetics; 2016.
  22. Jacobson E. You Must Relax, 5th ed. New York, NY: McGraw-Hill Book Company, Inc; 1976.
  23. Escott-Stump S. Nutrition and Diagnosis-Related Care, 8th ed. Philadelphia, PA: Wolters Kluwer; 2015.
  24. Mahan LK, Raymond JL. Krause’s Food & the Nutrition Care Process, 14th ed. St. Louis, MO: Elsevier; 2017.
  25. Cavicchia PP, Steck SE, Hurley TG, et al. A new dietary inflammatory index predicts interval changes in serum high-sensitivity C-reactive protein. The Journal of Nutrition 2009; 139 (12): 2365–2372.
  26. Minihane AM, Vinoy S, Russell WR, et al. Low-grade inflammation, diet composition and health: Current research evidence and its translation. The British Journal of Nutrition 2015; 114 (7): 999–1012.
  27. Olendzki BC, Silverstein TD, Persuitte GM, et al. An anti-inflammatory diet as treatment for inflammatory bowel disease: A case series report. Nutrition Journal 2014; 13:5.
  28. Shivappa N, Steck SE, Hurley TG, et al. Designing and developing a literature-derived, population-based Dietary Inflammatory Index. Public Health Nutrition 2014; 17 (8): 1689–1696.

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