Top 3 Nutrition Tips for Neuro PTs

Top 3 Nutrition Tips for Neuro PTs

By Dr. Sean M. Wells, PT, DPT, OCS, ATC/L, CSCS, CNPT, NSCA-CPT, Cert-DN

Physical therapists (PTs) are unique, doctorally-prepared health care providers who work often one-on-one with their clients several times per week. As direct access and primary care providers, PTs can help patients get better functionally and holistically through exercise and dietary interventions. Whether you are a PT working in a hospital or fitness gym, you will encounter patients that have neurological deficits. While most PTs have the go-to physical interventions many struggle to conjure up ways to help these patients with nutritional tips. Below our team at Nutritional Physical Therapy will outline how PTs can offer nutritional tips to patients with neurological deficits.

#1 Reduce Alcohol

Having an ice-cold beer or a glass of wine may be a great way to end a hectic day; however, research has shown that those that have neurological issues may be best to steer clear of this liquid libation.

The direct toxic effect of alcohol on the central nervous system has been well documented, particularly its effect on insulin and insulin-like growth factor (IGF) resistance and oxidative stress (De la Monte, Suzanne, et al. "The liver-brain axis of alcohol-mediated neurodegeneration: role of toxic lipids." International journal of environmental research and public health 6.7 (2009): 2055-2075.). Patients exposed to mild traumatic brain injury (TBI) have reduced neural potentiation and marked increases in inflammation when consuming alcohol ( Teng, Sophie X., et al. "Alcohol exposure after mild focal traumatic brain injury impairs neurological recovery and exacerbates localized neuroinflammation." Brain, behavior, and immunity 45 (2015): 145-156.). Reducing neural potential and increasing inflammation reduces neural plasticity and recovery. In TBI animal studies, subjects exposed to alcohol demonstrated reduced locomotion, impaired object recognition, and increased anxiety: all factors which PTs want to avoid in their patients when recovering from TBI.

In the periphery, for years researchers hypothesized that alcohol would induce thiamine (B1) deficiency, which would drive neurological diseases like beriberi. However, emerging evidence is showing that alcohol, or ethanol as it is known, is actually neurotoxic in and of itself (Mellion, Michelle, James M. Gilchrist, and Suzanne De La Monte. "Alcohol‐related peripheral neuropathy: Nutritional, toxic, or both?." Muscle & nerve 43.3 (2011): 309-316.). The term alcohol-related neuropathy (ALN) is a now a known diagnosis with substantial evidence that ethanol damages not only newly regenerating nerves but even well-established myelinated nerves. Pathological reports confirm that ALN induces a primary axonal lesion.

But how much is too much? Well, researchers Behse and Buchthal proposed that 100 ml of alcohol, which translates to 3 L of beer or 300 ml of spirits per day for 3 years, is the minimal amount of alcohol consumed by patients who develop polyneuropathy (Mellion, Michelle, James M. Gilchrist, and Suzanne De La Monte. "Alcohol‐related peripheral neuropathy: Nutritional, toxic, or both?." Muscle & nerve 43.3 (2011): 309-316.). This may seem like a lot of alcohol but it is equivalent to about to about 4 pints of beer and 5-6 small shots or 3 large shots of liquor per day, an amount that easily consumed by an alcoholic. Moreover, routine daily users of alcohol have an increased risk of lifetime “build up” of alcohol's deleterious effects, so some consumers may not have to drink the above proposed minimum to reach toxic thresholds. Most notably those that consume solely wine are at greater risk for neuropathy at lower daily doses (Mellion, Michelle, James M. Gilchrist, and Suzanne De La Monte. "Alcohol‐related peripheral neuropathy: Nutritional, toxic, or both?." Muscle & nerve 43.3 (2011): 309-316.). The increased risk with wine drinkers appears to be related to residual impurities such as lead, which are neurotoxic and bioaccumulative.

Beyond neuronal health and regeneration, large systematic reviews have demonstrated that acute alcohol consumption is clearly dose-dependent with fall risk (Taylor, Bruce, et al. "The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together." Drug and alcohol dependence 110.1-2 (2010): 108-116.). It is clear evidence that beyond 2 drinks the risk of falling goes up significantly, with most of these falls happening at home. As such, alcohol’s effects can be acute and chronic, both of which is a concern to the practicing physio.

PTs are likely to see neurological patients for balance retraining, fall reduction, functional training, and strength work, particularly in an outpatient setting where patients have easy access to alcohol at home. As such, it is vitally important for PTs to screen for alcohol use in patients with neurological conditions like TBI, stroke, and peripheral neuropathy. Such a screening can be easily peppered in during a history or review of systems. Moreover, astute PTs can look for signs of acute and chronic alcohol use. An acute bout of alcohol abuse will present with headache, slurred speech, poor judgement red eyes, strong odor of booze, and acute balance loss; for chronic users, alcohol can present with trophic changes in the skin/nails/hair, loss of peripheral sensation, impaired memory/recall, and reduced balance. Note that in the Mellion study above those with ALN often presented without signs of malnutrition; as such, the PT examining for nutritional deficits (e.g. low mass, impaired skin/nails/hair may) not identify a chronic alcohol abuser based solely on nutritional status alone. Even light alcohol use for those recovering from a neurological deficits can be counterproductive. Encouraging patients to abstain or cut-back, add spacer-days between consumption days, and to seeking appropriate alcohol counseling is a must for PTs seeing patients with neurological issues. Other drink options are available to those who wish to continue to consume alcohol-tasting beverages. Non-alcoholic beer and wine are a good choice for those wishing to maintain the taste of alcoholic beverages. Sparkling water and mocktails abound for those wishing to get a “buzz” without the alcohol from spirits. Consuming teas such as green, white, and oolong tea is also a great tasting beverage which may actually provide a boost in antioxidant polyphenols to help nerves heal.

#2 Omega 3

Omega 3, a polyunsaturated fatty acid comprised of EPA, DHA, and DPA, has been hot in the press lately. From curing bouts of inflammation to reversing depression, Omega 3 seems to be the poster child for the supplement and keto diet crazies. Before we, as healthcare providers, make any recommendations for nutrition changes we must consider and weigh the benefits versus the risks within the literature.

Omega 3 has certain evidence for its role in neurodevelopment and neuro-maintenance. Omega 3 helps in metabolism and inflammation as well. Neurologically, Omega 3 has been shown to down-regulate age-related microglial activation, decreased activation of sphingomyelinase and caspase 3 and restored long-term potentiation and improved spatial memory in aged rats (Dyall, Simon C. "Long-chain omega-3 fatty acids and the brain: a review of the independent and shared effects of EPA, DPA and DHA." Frontiers in aging neuroscience 7 (2015): 52.). Perhaps these mechanisms are why some researchers cite that acute administration of omega 3 after neural injury and dietary exposure before or after injury improve neurological outcomes in experimental spinal cord injury (SCI) and TBI. The mechanisms involved in such insults include decreased neuroinflammation and oxidative stress, neurotrophic support, and activation of cell survival pathways (Michael-Titus, Adina T., and John V. Priestley. "Omega-3 fatty acids and traumatic neurological injury: from neuroprotection to neuroplasticity?." Trends in neurosciences 37.1 (2014): 30-38.).

One human trial on TBI can be found on the reduction of inflammation and improvement in Glasgow Coma Scale (GCS) for patients with TBI. The authors found that taking 50 mg/kg oral omega 3 capsules per night after TBI could significantly reduce the serum level of IL-6 and improve the GCS at day 7 from 8.9 to 9.9 (p=.05) (Soltani, Farhad, et al. "The effect of omega-3 fatty acids prescription on serum levels of IL-6 and IL-1β in patients with traumatic brain injury." Medical Studies/Studia Medyczne 34.4 (2018): 276-280.). In another randomized clinical trial with patients that had SCI, researchers found positive impacts on inflammatory markers (IL-B) and a reduction in depression scores with patients on a “anti-inflammatory” diet. The diet intervention included omega 3 supplementation (BID, 500 mg EPA and 250 mg DHA), reduction of refined grains, elimination of hydrogenated oils, and other supplements such as zinc, turmeric, etc. (Allison, David J., and David S. Ditor. "Targeting inflammation to influence mood following spinal cord injury: a randomized clinical trial." Journal of neuroinflammation 12.1 (2015): 204.)

It is amazing to see such positive benefits; unfortunately it is difficult to tell which of these dietary interventions made the impact -- perhaps it is all of the above changes, which is ideal. But to clearly see that Omega 3 has a positive impact could not be determined for those with SCI. It should be clear to the practicing physio, that although both animal models and human studies of brain and spinal cord injury suggest they may provide benefits, there has been no clinical trials evaluating the effects of solely Omega 3 on resilience to, or treatment, of SCI; the data shows support on only one small trial for those with TBI.

With such promising animal trials and early clinical trials in humans, what could be the risks with Omega 3? Two case levels studies highlight the potential negative effects Omega 3 supplementation can have on platelet aggregation. The one study highlights a patient who sustained a lethal epidural bleed after a fall while taking both Omega 3 and warfarin (Gross, Brian W., et al. "Omega-3 fatty acid supplementation and warfarin: a lethal combination in traumatic brain injury." Journal of trauma nursing 24.1 (2017): 15-18.). The blood loss in this case could not be stopped and the patient died due to added thinning of the blood by both the Omega 3 and warfarin. The other case study showed how Omega 3 may have been responsible for a cervical epidural hematoma following an epidural (Beasley, Drew, and Johnathan H. Goree. "Cervical epidural hematoma following interlaminar epidural steroid injection via the contralateral oblique view in patient taking omega-3 fatty acids." (2019): 253-255.). Other risks specific to Omega 3 supplementation, which is the predominant “dosing” seen within the literature, is contamination. Several large studies show that Omega 3 supplements sources from small and large fish, and those distilled or “filtered”, all contained high levels of PCBs, a known toxin (https://nutritionfacts.org/video/pcbs-in-childrens-fish-oil-supplements/). This is particularly troublesome for development in children. Other contaminants in fish-sourced Omega 3 supplements include DDT, dioxin, and mercury, which can actually negate much of the positive neurological effects the Omega 3 is trying to exert. Such contaminants are also found in the fish consumed in diets. As such, it may be best to source Omega 3 from plant-based sources such as flax and chia seeds, walnuts, greens, and algal-based Omega 3 supplements, which don’t carry the burdensome toxins. Algal based supplements have been shown to not carry these toxins yet boost serum Omega levels just as well as standard fish-based supplements (Sarter, Barbara, et al. "Blood docosahexaenoic acid and eicosapentaenoic acid in vegans: Associations with age and gender and effects of an algal-derived omega-3 fatty acid supplement." Clinical nutrition 34.2 (2015): 212-218.)

What does this all mean for the practicing PT? Well, the emerging evidence is not sufficient to recommend adding Omega 3 supplements into patients with neurological compromise. In the light of the SCI trial cited above, it may be best for PTs, instead, to encourage a healthy dietary pattern low in refined grains, rich in fruits/vegetables containing natural Omega 3, and high in anti-inflammatory spices like turmeric and teas. A risk of contamination in marine animals make fish-sourced Omega 3 a risk for developing children as well as adults in the long term. As the evidence shows, if flax and other plant-sources of Omega 3s are not available, algal oil supplements are sufficient for spiking serum Omega 3. It should be said that PTs should collaborate with registered dietitians (RDs), intensivists, and registered nurses (RNs) to optimize patients’ diets, particularly in the inpatient setting.  

#3 Fruits

Our last tip for neuro PT is low-hanging fruit. All jokes aside, fruit does not get enough support within medicine or physical therapy. Functional foods have been a fun fad-word that incites people to think they are “hacking” their body with simple tricks like whole, natural foods. Physicians, alternatively, use the phrase of “lifestyle medicine” to help patients recover through food and other wellness-based interventions. Regardless of the term, fruit stands out as one of the easy dietary changes patients with neurological problems can ingest with minimal to no side effects.

From a preventative standpoint fruit can help prevent stroke (CVA), Parkinson’s, and diabetes, which affects peripheral neuropathy. Whole, unprocessed fruit has been shown to reduce oxidative stress, reduce body mass, and improve endothelial function: all essential in the reduction of CVAs (Larsson, Susanna C. "Dietary approaches for stroke prevention." Stroke 48.10 (2017): 2905-2911.). Dietary flavonoids in citrus and berries can offer marked neuroprotection from degenerative brain diseases, such as Parkinson’s and Alzheimer’s diseases (Söhretoglu, Didem, and R. R. J. Arroo. "Dietary Flavonoids and The Prevention of Degenerative Diseases." Studium Press LLC, USA, 2015.). Antioxidation seems to be the primary effect that flavonoids exert; however, other mechanisms such as kinase action and the gut biome are likely at play as well. Fruit also, according to a large systematic review, reduces and can reverse the effects of diabetes (Wang, Ping‐Yu, et al. "Higher intake of fruits, vegetables or their fiber reduces the risk of type 2 diabetes: A meta‐analysis." Journal of diabetes investigation 7.1 (2016): 56-69.). As many PTs know, diabetes can often drive peripheral artery disease, which directly impacts balance and gait.

Beyond prevention fruit can also improve neurological functioning. In a recent double blinded placebo controlled trial, subjects who consumed the equivalent of 1 cup of blueberries daily had marked improvement in verbal recall and parallel processing (Miller, Marshall G., et al. "Dietary blueberry improves cognition among older adults in a randomized, double-blind, placebo-controlled trial." European journal of nutrition 57.3 (2018): 1169-1180.). A different study looking at subjects with mild cognitive impairment found blueberry-treated participants exhibited increased blood oxygen level-dependent activation in the left precentral gyrus, left middle frontal gyrus, and left inferior parietal lobe during working memory load conditions (Boespflug, Erin L., et al. "Enhanced neural activation with blueberry supplementation in mild cognitive impairment." Nutritional neuroscience 21.4 (2018): 297-305.). In several other studies, ranging from 7-10 year old children to healthy older adults, found that blueberry consumption increased working memory, cerebral blood flow, and/or parallel processing. If memory and other cognitive measures aren’t enough to convince you to recommend a patient to increase fruit consumption, then perhaps we should look at some PT specific functional measurements.

In a study done in 2015 researchers provided older adults either a carrot rich drink or 2 cups of frozen blueberries daily. The intervention period was for 6 weeks with pre- and post-intervention testing done examining grip strength, gait speed (usual and with dual tasking), executive functioning, and reaction time. At the end of the treatment period the blueberry group demonstrated significant improvements relative to the carrot group in performance (i.e., number of step errors) of a challenging dual-task adaptive gait test that were independent of differences in gait speed. Usual gait speed and dual-task gait speed was also improved within the blueberry group pre- to post-intervention (Schrager, Matthew A., et al. "Effects of blueberry supplementation on measures of functional mobility in older adults." Applied Physiology, Nutrition, and Metabolism 40.6 (2015): 543-549.). Now that is the power of fruit!

Physios ought to see that fruit can be neuroprotective as well as interventional. Recommending patients increase fruit is an easy and almost risk-free recommendation. With the exception of kiwi and citrus fruits, most fruits have relatively low rates of allergy risk yet offer huge rewards. Moreover, fruit is a cost-effective treatment relative to several other prescribed medications, which may carry adverse event risk. Fruits which seem to confer the most benefit offer high flavonoids, polyphenols, and fiber. PTs ought to recommend fresh, whole fruits, not juices or processed can fruits in syrups. Most current dietary guidelines recommend 5 servings of fruit per day, with most Americans obtaining roughly 1 serving per day, mostly in juice form. As such, PTs can make a huge impact on their patients’ neurological recovery by asking them to commit to increasing fruit consumption and encouraging RD, physician, and RN follow-through on a high fruit diet.

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Disclaimer: The above article is written as opinion piece and does not convey specific legal and/or practice act advice. Students and participants need to check their State laws, practice act, and other legal restrictions before implementing nutrition interventions or assessments. The consumer of this article and our courses acknowledge that the State laws, practice acts, and restrictions can and do change. The Nutritional Physical Therapy team cannot be held liable for changes to such laws: the student, PT, or person engaged in such nutrition actions are responsible for examining laws and regulations as they see fit.