Lifestyle Medicine: The Role of the Physical Therapist


[Letter]. Perm J 2020; 24:18.192 [Full Citation]

Re: Bodai BI, Nakata TE, Wong WT, et al. Lifestyle medicine: A brief review of its dramatic impact on health and survival. Perm J 2018;22:17-025. DOI:

Dear Editors, Authors, and Readers,

I applaud the authors of the article Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival by Bodai et al.1 I would like to suggest an addition to the article. It cites the root cause of most chronic diseases as poor nutrition and physical inactivity. With regard to physical inactivity, physical therapists must be involved as a resource for healthy lifestyle recommendations, just as exercise coaches and lifestyle coaches are cited in the article.

As a pelvic health and manual physical therapist who has studied, practiced, and implemented patient education of a whole-food, plant-based diet, I am aware of the evidence-based benefit, have experienced personal change, as well as witnessed change in family, friends, and patients while on a whole-food, plant-based diet. My career, of course, is focused on the benefit and practice of exercise and overcoming movement impairment, but movement is not optimal without optimal nutrition.

With regard to physical inactivity, the article provides a box titled Moving Forward: Health Lifestyle Recommendations and Resources for Daily Practice, which provides 2 lists identifying team members engaged in promotion of a healthy lifestyle and promotion of exercise programs. Physical therapy should be included under both lists because we are experts in movement, and we daily address the causes and/or the manifestations of physical inactivity. We spend many years earning doctoral-level degrees, studying, and training to understand human movement from a molecular to a motivational level. Further, we are legally deemed wellness practitioners.

As in many medical school programs, nutrition is only briefly touched on in physical therapy programs. However, in June 2015, the American Physical Therapy Association adopted the motion RC 12-15, The Role of The Physical Therapist in Diet and Nutrition, which cites, “As diet and nutrition are key components of primary, secondary, and tertiary prevention of many conditions managed by physical therapists, it is the role of the physical therapist to evaluate for and provide information on diet and nutritional issues to patients, clients, and the community within the scope of physical therapists practice. This includes appropriate referrals to nutrition and dietary medical professionals when the required advice and education lie outside the education level of the physical therapist.”2 The motion goes on to cite an article by Dean,3 stating “a compelling argument can be made that clinical competencies in the 21st century physical therapy need to include assessment of smoking and smoking cessation (or at least its initiation), basic nutritional assessment and counseling, recommendations for physical activity and exercise, stress assessment and basic stress reduction recommendations, and sleep assessment and basic sleep hygiene recommendations.” Further, the motion cites the Commission on Accreditation in Physical Therapy Education’s Current Evaluative Criteria to meet education standards, that physical therapists “CC-5.50 provide culturally competent physical therapy services for prevention, health promotion, fitness and wellness to individuals, groups, and communities.”4

The motion goes on to recommend that future physical therapy educational programming include the study of nutrition. Following motion RC 12-15, there has been an increase in physical therapy continuing education available for physical therapists to study and obtain continuing medical education units in nutrition. This leads me to plead that Lifestyle Medicine welcome physical therapy to help steer the proper evidence-based direction of education of physical therapists.

What is the case for physical therapy involvement? There are many implications for physical therapy involvement. I will touch on 3 general reasons:

1) Nutrition may be a physical therapist’s starting place.

What do we do with a patient whose obesity has contributed to osteoarthritis of the knee when they are being told to lose weight, exercise, and strengthen the knee before a surgery, but they have pain with movement?

Patients with lifestyle-induced, chronic-disease states may present with various neurofasciomusculoskeletal pathology, making movement difficult. How can we start to make movement easier to achieve the goal of physical activity? How can we maintain that movement? Screening for dietary involvement is necessary. For instance, food can be the catalyst for weight loss to initiate prehabilitation that may otherwise be laborious and painful. As we start to see more and more advanced stages of chronic disease, I think we will find more and more that our starting place is, in the very least, nutrition screening, nutrition conversation, nutrition referral, and nutrition leadership by example.

2) Not all types of exercise are appropriate for all patients.

A general exercise program of walking for 30 minutes, 5x/wk may work for many people, but it won’t work for all. This could be because of movement impairment or simply motivation or interest. What brings meaning to movement for a patient? The answer will be different for everyone. Simply assigning an exercise coach may not be appropriate owing to impairment. Proper physical therapy evaluation, intervention, and communication with an exercise coach may be necessary. By the same token, asking a patient to join a walking program may not be a meaningful form of exercise to them, and physical therapy may need to assist in finding a safe alternative that gives meaning and maintains motivation.

3) Physical therapists will spend more minutes over a period of time (weeks) with a patient evaluating, setting goals, implementing programs, and re-assessing.

Each contact is a potential moment to check if a patient is achieving and maintaining the nutrition goals set by other practitioners. There is a learning curve to implementing and following a whole-food, plant-based diet. It requires support from a team of practitioners, family, friends, and coworkers. Not every patient will get support from all of these sources. We can be one more person on the side of support.

How do physicians, dieticians, and other practitioners move forward with physical therapists as a team to help patients make dietary transitions for better function and health? I offer these simple suggestions: 1) when writing physical therapy referrals, add a note requesting the physical therapist follow-up with the dietary prescription; 2) volunteer to give an educational lecture to your local team of physical therapists highlighting the goals of your request to follow-up with patients on diet; 3) notify physical therapy clinics of any Lifestyle Medicine continuing education.

I look forward to seeing how these great groups of knowledgeable practitioners can impact health and survival. We are better together!

Rachel S Worman, PT, DPT, MPT
Senior Physical Therapist
Roseville Medical Center, CA

How to Cite this Article

Worman RS. Lifestyle medicine: The role of the physical therapist [Letter]. Perm J 2020;24:18.192. DOI:


1. Bodai BI, Nakata TE, Wong WT, et al. Lifestyle medicine: A brief review of its dramatic impact on health and survival. Perm J 2018;22:17-025. DOI:
2. Griffin SR, Stravlo, M. Memorandum re: 2015 House of Delegates packet I, background papers, and House of Delegates handbook [Internet]. Alexandria, VA: American Physical Therapy Association: 2015 Mar 31 [cited 2018 Jul 27]. Available from:
3. Dean E. Physical therapy in the 21st century (Part 1): Toward practice informed by epidemiology and the crisis of lifestyle conditions. Physiother Theory Pract 2009;25: 330-53.
4. Evaluative criteria: PT programs [Internet]. Alexandria, VA: Commission on Accreditation in Physical Therapy Education; 2014 Aug [cited 2018 Jul]. Available from: 

Response to Dr Worman

On behalf of all of our coauthors, we wish to thank Dr Worman for reviewing our article regarding Lifestyle Medicine and for preparing such an insightful comment. She points out the importance of physical therapists as a significant part of the team that must be assembled as the messengers of a healthy lifestyle. She correctly identifies the role that physical therapists can play in our overall health.

It is correct, and sad to say, that most professional schools that offer health-related degrees largely ignore any education regarding nutrition. It is great to note that the American Physical Therapy Association has mentioned this and has recently adopted a motion to address this inadequacy. More professional associations must urgently take note of this and follow their lead.

Although we all recognize that not all forms of exercise are appropriate for each patient, perhaps because of other comorbid conditions, such as being wheelchair bound, this recognition adds further support to the important role of physical therapists with the knowledge to suggest alternative approaches to promote exercise and other physical activities that may achieve similar results.

Dr Worman addresses the unique opportunity that physical therapists have to access patients because they often provide long-term, follow-up care. This enables them to introduce lifestyle changes. As she correctly points out, there is a “learning curve” to implementing a whole-food, plant-based diet. Thus, they have the opportunity to progressively monitor their interventions, address ongoing challenges, and reinforce recommendations.

We are grateful for this important letter to the editor and greatly appreciate Dr Worman’s recommendations. It is our hope that her message will be resoundingly heard.

Balazs Bodai, MD
The Breast Cancer Survivorship Institute, Sacramento, CA


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