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What is the role of Physical Therapy in the treatment of eating disorders?
Physical Therapists are experts in physical activity prescription and management among a variety of patient populations. Many examples of the roles Physical Therapists play exist in a number of patient conditions.
- Physical activity recommendations are emerging for populations of people with spinal cord injury and arthritis.
- The Canadian Pediatric Society offers physical activity recommendations for children with juvenile idiopathic arthritis, hemophilia, asthma and cystic fibrosis.
- Physical Therapy plays a major role in the management and treatment of osteoporosis, osteopenia and low bone density.
However, no guidelines or recommendations exist for children and adolescents with eating disorders and our understanding of negative exercise behaviours is limited. The Physical Therapy profession can play a significant role in the management of eating disorders through exercise prescription.
Prevalence of Eating Disorders
Eating disorders are more prevalent than most people (and health professionals) think:
- Five percent of women in Canada have experienced an eating disorder before reaching adulthood (Eating Disorders in Adolescents: Position Paper of the Society For Adolescent Medicine, 2003)
- Thirty to eighty percent of eating disorder patients with anorexia nervosa and bulimia nervosa engage in unhealthy exercise, referred to as excessive exercise or compulsive exercise. (Shroff, 2006 & Davis, 1997)
- Negative exercise behaviours and cognitions often precede the onset of an eating disorder. As well, excessive exercise in eating disorders, is a predictor of poor outcome, relapse (Strober, 1997) and longer inpatient treatment. (Solenberger, 2001)
Eating Disorders Defined
An eating disorder is a medical condition diagnosed by the criteria in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition (DSM-IV).
- Anorexia nervosa is characterized by weight loss or failure to gain weight during a period of growth, leading to a weight that is less than 85% of that expected for height and age, an intense fear of gaining weight, a distorted body image and loss of at least 3 consecutive menstrual cycles.
- The core features of bulimia nervosa are binge eating and purging. Compensatory behaviours occur after a binge, such as vomiting, laxative or diet medication use, fasting or excessive exercise.
Management of Physical Activity and Eating Disorders
The current management of physical activity in eating disorder patients varies enormously. (Davies, 2007) Traditionally, patients have been put on bed rest to reduce caloric expenditure. However, the management of physical activity in eating disorders is changing with the following evidence:
- A literature review of the effects of exercise interventions in patients with eating disorders reported that patients with eating disorders can safely engage in exercise programs during treatment. (Hausenblas, 2007)
- Supervised exercise prescription in eating disorders has been shown in the literature to not adversely affect weight gain or the return of menstruation.
- The evidence indicates there is increased treatment compliance, improved therapeutic relationship, decreased food preoccupation, decreased bulimic symptoms and decreased negative exercise behaviours with supervised exercise.
- As well, eating disorder patients considered “improving body experience” as a core element of their treatment (Vanderlinden, 2007).
Role of Physical Therapy in Treating Eating Disorders
As a Physical Therapist in the Eating Disorders Program at the McMaster Children’s Hospital in Hamilton, Ontario, Canada, I assess and manage the physical activity of inpatients with anorexia nervosa and bulimia nervosa. While developing the role of the Physical Therapist in eating disorders, I created physical activity guidelines for children and adolescents with anorexia nervosa and bulimia nervosa. These guidelines act as a tool to help clinically guide my management of their physical activity.
I primarily work with the inpatient population who are admitted for medical stabilization, weight restoration or symptom interruption. The following criteria direct the level and type of physical activity I recommend:
- vital sign instability,
- low percentage of ideal body weight,
- severity of negative exercise behaviours (The Compulsive Exercise Test, H. Goodwin, in press),
- low bone mineral density/fracture risk
- menstrual dysfunction.
Most Physical Therapy interventions target patients classified as severe or moderate according to this criteria.
Treating Patients with Severe Eating Disorder
Patients with a severe eating disorder would be expected to rest and reduce activity. Physical activity is individually prescribed and supervised. It is at a low intensity and is of short duration, and includes; lying, sitting or 4 point; range of motion, stretching exercises and yoga poses. (See images).
Treating Patients with Moderate Eating Disorder
Patients with a moderate eating disorder are progressed to standing range of motion, stretching exercises and yoga poses. Education and activity planning for low bone mineral density/fracture risk is ongoing, as an increase in bone mineral density has an average delay of 21 months from weight restoration.
Impact physical activities (i.e. gymnastics, jumping) and moderate intensity resistance training are contraindicated. (From Physical Activity and Bone Heath, Position Stand of the American College of Sports Medicine)
Also important to note is that there appears to be no benefit of exercise on bone mineral density, if a patient has amenorrhea or loss of menses (Academy of Eating Disorders, Catherine Gordon, and Philip Mehler, 2009) Most patients resume menses within 6 months when they reach 90% of their ideal body weight. Aerobic exercise can be resumed at 90% ideal body weight; however, a longer weight stabilization period improves outcomes.
Compulsive Exercise Test Important to Understanding Behaviour
Understanding a person’s exercise behaviours is important in the management of their physical activity. The Compulsive Exercise Test provides an assessment of five core features of compulsive exercise.
- The avoidance of affective withdrawal symptoms and guilt if unable to exercise , therefore making up for missed exercise or exercising despite illness or injury.
- Exercise for weight and shape reasons.
- Exercise for mood improvement, an increased positive affect or decreased negative affect.
- Lack of exercise enjoyment. Exercise is viewed as a chore to be completed from which the exerciser derives little or no enjoyment.
- Exercise rigidity. When exercise is practiced according to a strict schedule. (Goodwin, in press)
Eating disorders have the highest mortality rate of any mental disorder (Crow, 2009). Earlier identification and intervention is associated with improved outcomes and better long term prognosis.
Identifying Clients with Eating Disorders
How can we identify those people at risk for eating disorders earlier? Athletes are distributed along a spectrum between health and disease. (Nattiv, 2007) For most female athletes, participation in sports is a positive experience, providing improved physical fitness, enhanced self-esteem, and better physical and mental health; however, studies have reported disordered eating in up to 62% of female athletes.
Disordered eating is not the same as an eating disorder. Disordered eating includes a wide range of abnormal eating behaviours, such as those seen in anorexia and bulimia, chronic restrained eating or compulsive eating. Disordered eating also has negative effects on overall health. Symptoms of low energy availability (with or without an eating disorder), loss of menstrual cycles and low bone mass, alone or in combination, pose significant health risks to physically active girls.
Loss of menstruation is not a normal response to training. It is a clear indication that health is being compromised. The prevalence of loss of menstrual cycles is much greater in the athletic population (3-66%) than in the general female population (2-4%).
Peak bone mass is largely established by the end of adolescence, loss of menstrual cycles can lead to bone loss which increases fracture risk and may not be reversible. Adolescence marks the period of greatest risk for onset of eating disorders.
While, all female athletes are at risk, sports with an aesthetic component such as ballet, figure skating, and gymnastics, endurance sports, such as running or those sports tied to a weight class, such as rowing or wrestling, are believed to have a greater eating disorder risk among athletes.
Prevention of eating disorders and recognition of eating disorder risk should be a priority of those who work with athletes. The Joint Position Paper on Nutrition and Athletic Performance for the Dieticians of Canada, the American College of Sports Medicine and American Dietetic Association encourages those who work with female athletes to monitor changes in exercise performance and energy level, normal menstrual function, stress fractures, recurrent injury or illness, and general overall well-being.
The Coaching Association of Canada recommends that screening for eating disorders should occur at a pre-participation exam or annual health exam.
As well, recommendations from a study on the use of the pre-participation exam in Canadian Interuniversity Sport to screen for the Female Athlete Triad (the name for the triad of medical disorders including, low energy availability, menstrual dysfunction and low bone mass) reported that better efforts needed to made to increase awareness of the triad and its risks among female athletes.
About the Author
Lisa Scott is a Physiotherapist at the Adolescent Medicine and Eating Disorders Program at McMaster Children’s Hospital in Hamilton, Ontario. Lisa completed her Bachelor of Science (Physical Therapy) at the University of Toronto in 1997 and her Bachelor of Education at Brock University in Hamilton in 2001. She has been employed as a physiotherapist at McMaster Hospital since 2000.
This article was originally published in the Ontario Physiotherapy Association’s journal, Physiotherapy Today as part of the Innovation in Practice program.
For more references and correspondence you can contact Lisa via email.
- Shroff, H., et al. Features Associated with Excessive Exercise in Women with Eating Disorders. International Journal of Eating Disorders, 2006
- Davis, C. et al. The Prevalence of High-Level Exercise in the Eating Disorders: Etiological Implications. Comprehensive Psychiatry, 1997
- Davies, S. et al. The Inpatient Management of Physical Activity in Young People with Anorexia Nervosa, European Eating Disorders Review, 2007
- Strober, M. The Long-term course of Severe Anorexia Nervosa in adolescents: Survival analysis of recovery, relapse and outcome predictors over 10-15 years in a Prospective Study. International Journal of Eating Disorders, 1997
- Solenberger, S. Exercise and eating disorders: A 3-year inpatient hospital records analysis. Eating Behaviours, 2001
- Vanderlinden, J . et al. Which Elements in the Treatment of Eating Disorders Are Necessary ‘Ingredients’ in the Recovery Process?-A Comparison between the Patient’s and Therapist’s View, European Eating Disorders Review, 2007
- Hausenblas, H. et al. Can Exercise Treat Eating Disorders? Exercise and Sports Science Review, 2008
- Goodwin, H. et al. Psychometric Evaluation of the Compulsive Exercise Test (CET) in an Adolescent Population: Links with Eating Psychopathology, European Eating Disorders Review, in press.
- Crow, S.J., Peterson, C.B., Swanson, S.A., Raymond, N.C., Specker, S., Eckert, E.D., Mitchell, J.E. (2009) Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry 166, 1342-1346.
- Nattiv, A., M. Manore, F. Sanborn, J. Sundgot-Borgen, M. Warren, American College of Sports Medicine Position Stand on The Female Athlete Triad, Medicine and Science in Sports and Exercise, 2007
- American College of Sports Medicine Position Stand on Physical Activity and Bone Health
- Eating Disorders in Adolescents: Position Paper of the Society For Adolescent Medicine, 2003
- Beals, Katherine and Nanna Meyer, Female Athlete Triad Update, Clinics in Sports Medicine, 2007
- Academy of Eating Disorders, Catherine Gordon, and Philip Mehler, 2009
- Rumball, J. et al. Use of the Preparticipation Physical Examination Form to Screen for the Female Athlete Triad in Canadian Interuniversity Sport Universities, Clinical Journal of Sport Medicine, 2005
- Eating Disorders-Signs, Screening, Confronting, Coaching Association of Canada, 2010
- Joint Position Paper on Nutrition and Athletic Performance, the Dieticians of Canada, the American College of Sports Medicine and American Dietetic Association