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[Physio Explained] Optimising nutrition after injury and surgery with Ben Steele-Turner

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In this episode, we discuss nutrition post injury and post surgery. We explore: 

  • The stress response and the impact of this on recovery from injury
  • Can macronutrient intake enhance recovery post surgery
  • Awareness and extent of caloric intake post surgery

Want to learn more about nutrition?  Ben Steele-Turner has recently done a brilliant Masterclass with us called “Nutrition for Physiotherapists: Surgery, Rehab & Performance” where he goes into further depth on this topic. 

👉🏻 You can watch his class now with our 7-day free trial: https://physio.network/masterclass-turner

Ben is a musculoskeletal physiotherapist based in the U.K. After completing a Physiotherapy BSc (Hons), Ben completed his MSc in Human Nutrition in 2018. Alongside clinical work, Ben is currently completing a PhD investigating physiotherapist-led weight management for people with knee osteoarthritis, is physiotherapist for Horsham Rugby Club and England Athletics. 

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @James_Armstrong_Physio from Physio Network

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

SPEAKER_01:

Your carbohydrate intake does its job, which facilitates protein and fats to do their job. So a lot of people way dial down the carbohydrates because they're like, Well, I'm not training, I'm not doing anything like that. I don't need so much energy. And then even if you are just getting enough protein, if we're really low on carbohydrates, your body then goes, I need to start using some of these amino acids through gluconeogenesis for energy. So in essence, then biologically you're then slightly below your protein. So you want to take in the carbohydrates to allow protein to do its job.

SPEAKER_00:

Welcome back to the Physio Explain podcast. Today I'm joined by Ben Steele Turner, a physiotherapist, nutritionist, and educator who's doing some really impressive work at the intersection of rehab and nutrition. Ben has a BSE honours degree in physiotherapy and an MSc in human nutrition, and he's currently completing his PhD at the University of Portsmouth, where he's researching how weight management and physiotherapy can work together for people with knee osteoarthritis. On top of that, he's also working with England Athletics and Horsham Rugby Club. He's also lectured on nutrition and sports injury management at a university level. Ben just released a brand new masterclass on nutrition in physiotherapy with Physio Network, following on from his hugely popular Nutrition 101 for Physiotherapists. In this episode, we dive into the role of nutrition after injury or surgery, including the stress response, the importance of fueling recovery, and how to stay within your scope of practice when discussing nutrition with patients. So if you're looking to better understand how nutrition can accelerate recovery, and if you want to optimise your patient's rehabilitation outcomes, then you'll definitely want to stick around for this one. I'm James Armstrong and this is Physio Explained. Ben, great to have you back on the Physio Explained podcast for a second time. It's been too long. How have you been?

SPEAKER_01:

I'm very well, James. So thank you so much to yourself and Physio Network for inviting me back on.

SPEAKER_00:

We could not, given that you've now produced another masterclass from us. And this masterclass builds on the previous masterclass you've already done around nutrition and how physiotherapists can utilize this knowledge and to help patients hugely. So today we're going to be talking about specifics of nutrition post-injury or surgery. And I thought we'd kick off really importantly with why are we talking about this? Why, as physiotherapists, are we talking about nutrition, post-injury, and/or surgery?

SPEAKER_01:

I think it's such an important topic, a little bit like we were just speaking about before we were recording. We need to go into this, and I mention it probably about 17 times across the masterclass, at always, always being aware of our scope of practice, also being aware that is going to differ depending on your knowledge, your specialty, where you are geographically. So obviously, we're speaking in the UK, but if you're a physio listening in a different country, this is really important. But post-muscoskeletal injury or surgery, but particularly orthopedic surgery, nutrition, what we're feeding our body, is this very important factor that isn't discussed in a standardized way. It's a little bit of if you go to a physiotherapist and they happen to be knowledgeable in it, then they might mention it. There's no kind of standardized if someone has X injury or X surgery, this is what we should be doing. I mean, it's similar point as we'll chat on earlier. So I think it's a really important thing to be aware of your scope of practice and absolutely never go beyond that and be referring on for dietetic and nutrition support where indicated, but also being aware that people, patients may ask about it, and we should have some evidence-informed input rather than just information that we've come across that we're not really sure about the legitimacy of it.

SPEAKER_00:

Absolutely. And you know, having done the masterclass myself, it really does highlight how significant the impact is of maybe not having the right nutritional advice as a patient coming out of surgery or trying to recover from a hefty injury, such as like an ACL rupture or reconstruction.

SPEAKER_01:

Yeah, absolutely. This probably leads us on to the first point, which is the stress response. Stress response, which I speak about in the first physio network masterclass I did a couple of years ago. But in short, for this podcast, the stress response basically describes the situation once your body's gone through a trauma, like wound healing, your body's gone through a trauma, which can be a major musculoskeletal injury, ACL rupture, Achilles tendon rupture, big fracture, or a big surgery. So, like a ligament reconstruction or Achilles tendon repair, something like this. What the stress response is describing is the situation where your body diverts its attention to the healed area. So you've had your ACL reconstruction, you've got this knee that requires healing, your body's priority is we need to get this better, and it will utilize your reserves, your energy reserves to fuel that. And you're the best reserve of namely amino acids, so protein, is your skeletal muscle mass. So this is one of the reasons why atrophy is so quick in this patient population is because your body's saying, I need amino acids for protein and maybe a bit for energy as well. There's a whole load of amino acids in the muscle, so I'll I can utilize some of that for the knee, which is fine and that will happen, but we want to try and reduce that as much as we can. And from it, while there are other rehabilitation approaches, from a nutrition point of view, a very easy win, big green tick is are they eating enough protein? Are they getting enough calories? Can we provide that nutrition to help the healing? So it's a really important topic to touch upon.

SPEAKER_00:

And I think just making patients aware of this, because quite often, if you say, because we haven't got this standardized speed or approach, a lot of times patients just will not have even thought about what you said there, let alone some of the physios listening to this probably maybe not pay as much attention as it needs.

SPEAKER_01:

Yeah, there's a number of factors that lead into that. So one is not thought about it, two is let's take an ACL reconstruction as the kind of hallmark example. Big surgery probably don't feel too great initially after, so then your appetite might go down, so you might not eat so much. A lot of people's initial reaction is I'm not really doing anything, I'm sat watching Netflix or another streaming service, so I won't eat so much because I'm not doing as much activity. But what the stress response is makes us think, actually, our metabolic rate is being ramped up, and this can be really high. Sort of figures are quoted around sort of 20 to 50 percent in those early stages post-operatively. So we do that is the priority, and then there's a really good paper that's referenced in one of the segments of the masterclass that talks about this, but other factors like people's eating rituals, uh, there's more to just food when people are taking in food, but your normal rituals of eating, so timing around work commitments, home commitments, and that can be massively disturbed and interrupted with people's lifestyle after injury or surgery. Our other thing, as well, is very well-meaning. People think, oh, I need to lose a bit of weight, so now's a good time, I'll start losing some weight. Although we spoke about that two years ago when we last spoke, James, with the Neo A. Actually, now is not the time to try and lose weight. We're speaking as two physios. Our main job when it comes to this injury or surgery rehab, I can speak at the knee, that's my area of interest. We want to get those quads back, get the hamstring back, get the calf back. As much as we can mitigate or limit those muscle mass losses, the better. And one thing that can do that is making sure people know protein intake's pretty important. Getting enough calories is quite important. So, yeah, the awareness is really key.

SPEAKER_00:

Absolutely, yeah. And you see this, you hear people sort of say this I'm really sedentary now, I can't do this, I can't do that, so therefore I need to stop eating so much. And it's when they've had this, it's actually the not the opposite, but really quite not helpful.

SPEAKER_01:

I like to think about it as a sliding scale. Obviously, if you're thinking about your calorie intake, the sliding scale might get twisted up when you're being more active, you know, you need to fuel that training. And then because a lot of people go, Well, I've had the injury or the surgery, I'm not as active, so that sliding scale comes back down, and then ignore the effect of that headwind of the stress response that actually your body needs to fuel this healing, and that's going to push the slider back to the right again. Obviously, it's individual, it's may not necessarily gonna go all the way back up, but they just take in that downward slide and forget that there are forces of this healing requirement that are pushing it back upwards.

SPEAKER_00:

Want to take your physio skills to the next level? Look no further than our masterclass video lectures for world leading experts with over 150 hours of video content and a new class added every month. Masterclass is the fastest way to build your clinical skills, provide better patient care, and tick off your CPD or CEUs. Click the link in the show notes to try Physio Network's masterclasses for free today. Absolutely. Yeah, so it is really important that we have this conversation with patients in whatever kind of level you they're. So we've talked about the importance of kind of the adequate nutrition during injury and surgery have you talked about protein there, Ben. Is is there anything else that you would say outside of protein and a calorie intake? Is there anything other than that?

SPEAKER_01:

Yeah, the micronutrients are really important. Hard to say the most important one, but vitamin C, particularly after soft tissue injury, I guess, is for the purpose of this, the one that's worth talking about. That's because vitamin C is a cofactor in collagen synthesis. So when we're trying to heal, in essence, a lot of that is rebuilding and resynthesizing collagen, and that can't happen without vitamin C. So the example that I always use is way back in 1600, 1700, there was a very prevalent disease among sailors in the Navy called scurvy. And scurvy is your teeth start to fall out, your bones start to degrade, your joints start to break. And scurvy, they didn't know at the time what it was, but scurvy is just a vitamin C deficiency. So it's when you have no vitamin C, your body stops synthesizing collagen. So that's an extreme example, obviously, of which scurvy is incredibly rare now, but that's if we have no vitamin C. And then the other important caveat is that vitamin C is water soluble, so you can't store it. So in those first couple of weeks when you're at home recovering from your injury or your surgery, you can't rely on vitamin C stores in the way that you can with other micronutrients. So you've got to be having it. Like that's kind of like daily on the checklist, right? Vitamin C. And that doesn't mean you have to take a supplement, right? We're talking a couple of satsumas, kiwi fruit, some berries, pineapple, melon, green veg. This is the sort of thing that from a health general healthy lifestyle advice people should be having anyway. But it's just an extra thing going, you know, actually, that's really important. And then carbohydrates, which is obviously a macronutrient, is another one because carbohydrate's primary role, other than being very tasty, is to provide energy, right, for training and fueling recovery and performance. However, carbohydrate also has a really important function, which I speak about in the first masterclass from a couple of years ago, which is protein and fat sparing. So your carbohydrate intake does its job, which facilitates protein and fats to do their job. So a lot of people way dial down the carbohydrates because they're like, Well, I'm not training, I'm not doing anything like that. I don't need so much energy. And then even if you are just getting enough protein, if we're really low on carbohydrates, your body then goes, I need to start using some of these amino acids through gluconeogenesis for energy. So, in essence, then biologically, you're then slightly below your protein. So you want to take in the carbohydrates to allow protein to do its job. So protein and energy are you're probably your top two, getting enough calories of the micronutrients. Vitamin C is really important, but we'll be here all day if we chat about all of them. And then carbohydrates, one where I'd say give people the freedom that you do need to eat something. This is an important time. And tying it into physio, you know, in a couple of months' time, the rehab's gonna really start stepping up a notch and it's gonna start looking like normal training that's taking into account your knee. And for your normal training, I have no doubt that you might be hopefully supplementing it or looking at your optimal nutrition intake if we're gonna go to all this trouble to come up with the best rehab plan we absolutely can, give it a good foundation, one of which being optimal nutrition intake.

SPEAKER_00:

Absolutely. Putting you on the spot a bit, Ben, in terms of numbers, facts, figures, etc., do we have anything that tells us roughly for certain surgeries, certain injuries, or I think probably surgeries, maybe more, how much our calorie need goes up? So for instance, maybe like our basic metabolic rate or whatever, how much that increases when we have such some certain surgeries?

SPEAKER_01:

The figures are often quoted go back to a paper by an author called Robert Demling, 2009. And between 20 to 50 percent, 20% for a more minor injury, 50% for a more major surgery. So this might be like major trauma, maybe a total knee replacement, some something like this. And then other figures that I've seen quoted, like the main culprit is if would be outside our scope for physiotherapy, but burns. So if you have really significant burns over a large proportion of your body, this can start ramping your calorie requirements up by like two to three times because of your the extent of the wound healing is so extensive. So yeah, so you're like it's not massive and it's not forever. It's not if you have an ACL reconstruction, you then require this many extra calories for the rest of your life. But in those early stages, it's really important. So if someone asked me, the number I would get give is 20 to 50 percent. I think 50% being really where it's quite a major trauma, but in terms of metabolic rate increase, that's the numbers we're looking at.

SPEAKER_00:

I think it's quite useful. That to me is a stark number. And somebody who said to me, actually, you need to increase your intake by 20, 30, 40, 50 percent. It really is kind of oh, actually, crikey.

SPEAKER_01:

Yeah. Just a little bit going back to the scope of practice. Obviously, we're chatting about this for physiotherapists, and within physiotherapy scope of practice, we can't be prescriptive. So we can we could lean back on that as evidence and guidelines, but we do need to be careful that we are not dietitians, and so we're not prescribing this. This is to enhance our care, not step outside scope. So I I would be careful giving very specific numbers, but in terms of saying what the evidence says, then that would be where I'd be heading towards.

SPEAKER_00:

Brilliant. That's a good example there of how we can stay within that scope of practice and you give advice without, as you said, quite rightly, prescribing and advising someone goes and does something. Brilliant. So we talk about scope of practice in this last section of today's podcast, really. And what are your sort of tips around that? And then leading on from that, how and who might you refer to and when?

SPEAKER_01:

Yeah, this is a podcast topic in itself. Obviously, I've spent the last however many years after physio and then the masters in nutrition. Having done physio, I thought this was an area physio should know about. We need to be, as we would with any other presentation, we would have on our mind is this something where I am the sole person who can help? And if not, who's the right person that I can get involved, right? And it's no different with nutrition. If somebody's asking for very specific tailored advice, which they might ask you as a physiotherapist, my input would be you should be referring to a dietitian or a registered nutritionist. Dieticians are in the UK an HCPC registered health profession. Nutritionists is a bit more of a vague term. There's no one kind of clear-cut registration body in the same way as there is the HCPC. Or other signs, for instance, if someone's just showing signs of reds or eating disorder, so relative energy deficiency, then we should be going down that referral route towards them. Or yeah, when people want a specific dietary plan, that's not our role. In the same way, if someone was to go to a dietitian to get a dietary role, we might hope that the dietitians would say, Oh, it's really important that you follow your physio exercises because now we're getting you enough protein, you need to listen to what the physio says in terms of getting this muscle mass up and strengthening. We're just flipping that vice versa. We're then providing the rehab and we're just clued up enough to raise that as a conversation point. And one thing I think is really important because at the moment it seems like it is this grey area. It may be that one individual physiotherapist has had success with one dietary approach, and then they might go, Oh, well, I did this and this worked, or I did this and this work. And so I feel like because of the paucity of guidance, it opens up the space for that. And that's probably a thing that as a profession, maybe I'm biased, but as a profession, we need to take stock of and say this is the basic guidelines and advice and education piece that we give, and that's where it stops to stop this kind of complete gray zone.

SPEAKER_00:

Yeah, absolutely. And I think it's a really good kind of area, place to pause and stop there for today, Ben, because it is at just that point whereby where does our role stop? And with masterclasses that you've done, the new one coming out as well. Really, I think it's about giving us awareness and confidence to be able to educate patients on the importance, but not necessarily tell them exactly what to do.

SPEAKER_01:

Yeah, I think that that's a really nice way of looking at it.

SPEAKER_00:

Brilliant. Ben, thank you so much for those listening who want to find out more about how you can build your confidence and help raise awareness around nutrition and as you've heard today, how important it is for patients who've undergone surgery or have had a significant injury. Then do head onto the show notes and find out how you can access the masterclasses. To get more information, hit the show notes below. Thanks a lot, Ben. I'll no doubt speak to you again soon. Yeah, thanks so much, James.