PHYSIOTHERAPY TREATMENTS FOR EATING DISORDER RECOVERY

Education regarding the functions of the body is an important element of physiotherapy treatment in general. For those with eating disorders, understanding how the body works can be particularly important as it:

• Provides patients with an increased appreciation for their body(1)

• Increases the sense of ownership and connection with their body(1)

• May increase adherence to recommendations such as rest days from exercise, through promoting understanding about osteoporosis, muscle recovery and injury prevention(2)

Topics that are important to cover include(1,2):

• Basic anatomy/physiology

• Osteoporosis

• Muscle and bone functions

• Acceptable physical activity levels

• The purpose of exercise 

The role of exercise in eating disorder recovery:

• Exercise has many physical and mental health benefits including prevention of cardiovascular disease, diabetes mellitus, cancer, hypertension, osteoporosis and increased strength, along with reduced stress, anxiety and depression(3). Many of the benefits of exercise are helpful for those with eating disorders since issues such as osteoporosis, cardiovascular problems and decreased strength are prevalent(4)

• Historically, health professionals have recommended abstinence from exercise during eating disorder recovery and treatment, due to the high rates of complex medical complications(5,6). However, many professionals have questioned the practice of abstinence and have recognised the benefits of its inclusion in recovery programs(6). Although its importance is becoming recognised, implementation is not widespread(6)

Treatment involves:

• Safe re-commencement of appropriate levels of physical activity(7)

• Providing opportunities for patients to learn to listen to their physiological and psychological cues before, during and after exercise and using these internal signals to determine and adjust their engagement(8)

• Guiding patients to discover their exercise preferences and needs based on enjoyment and bodily cues(9)

• Education and guidance regarding moderation of exercise and inclusion of rest days(9)

Safe Exercise at Every Stage (SEES) guidelines(7):

• The SEES guidelines provide evidence-based information to medical and exercise professionals to support them in the management of dysfunctional exercise during eating disorder treatment

• It provides a framework for assessing each individual's current physical and psychological health status and using this to select safe exercise interventions

• As individuals progress through physical and psychological recovery, the guidelines provide a structured and graded program to increase physical activity levels appropriately

• The management of dysfunctional exercise is considerably different in athletes and therefore a separate SEES guideline has been written targeting this population 

Injuries

• Problems including over-use injuries, degenerative changes and stress fractures are common in patients with eating disorders, due to factors such as decreased bone density, muscle weakness and excessive exercise(2,10)
• Treatment involves prevention and management of these conditions through manual therapy treatments, exercise and education(2)
• Throughout treatment, adaptations may be required to ensure physiotherapy is safe for those with reduced bone health(2). For more information, view bone health section below.

Muscular stiffness

Increased muscular tension and stiffness throughout the body is common in patients with eating disorders(11), often being more pronounced in the:

• Legs

• Gluteal muscles

• Back

• Soles of the feet

• Muscles related to respiratory function

• Muscles related to eating

Treatment involves(1):

• Stretching

• Manual therapy

• Addressing underlying contributing factors such as poor posture, excessive exercise and injuries 

Low bone mineral density (BMD), osteopenia, osteoporosis and fragility fractures are common complications in eating disorders(2). As these problems typically occur at a younger age than average, it is important to address these problems to improve both current bone health and prognosis later in life(12)

There are many more risk factors for bone health concerns in those with eating disorders including(12):

• Hormonal changes associated with inadequate nutritional intake

• Amenorrhoea - absence of menstrual period

• Low body fat

• Low body weight

• Excessive exercise

• Inadequate nutrition

• Low testosterone levels in men

Assessment:

• Bone mineral density can be measured through a bone/DEXA/DXA scan, following referral from a GP(12)

• The 'fragility risk assessment' (FRAX) identifies fracture risk over the next 10 years(12)

Treatment:

• Deliver education to assist patients in understanding the condition and the effects of food intake and exercise on bone health(2)

• Guidance regarding exercise to improve bone health, prevent further deterioration of bone density and decrease risk of fractures(2)

• Careful consideration needs to be made regarding the amount and type of exercise/activity so that it does not use up energy needed to repair the body, as this may place bones at further risk or prevent their recovery(13) 

Appropriate exercise and activity(13):

• Generally, weight-bearing and muscle strengthening exercises promote bone strength and are most effective when movements, directions and speeds are varied

• Low impact exercise

• For those with diagnosis of osteoporosis and fractures (e.g., stress fractures) that are still healing

• Exercises where one foot remains on the ground e.g., walking, side steps

• Moderate impact exercise

• For those with diagnosis of osteoporosis without any fractures

• Exercise where a moderate force is created by both feet leaving the ground e.g., running, skipping, jumps, hops, ball games

• High impact exercise

• Exercise where a large force is created e.g., star jumps, high vertical jumps and drop landings

• Strengthening core and back muscles is also highly important to assist with reducing the risk of a vertebral fracture 

Pelvic floor dysfunction has been observed in 22% of hospitalised eating disorder patients(14). Pelvic health is impacted by eating disorders in a number of ways:

• Chronic constipation is often seen in eating disorders(15). This can lead to straining during defecation, increasing pressure on the pelvic floor muscles(2,15)

• Excessive exercise, particularly high impact exercises such as running, increases intra-abdominal pressure increasing the load on the pelvic floor(2,16)

• Low oestrogen levels and inadequate nutrition can cause atrophy of the pelvic floor(2)

Associated problems include:

• Stress urinary incontinence - involuntary leakage on exertion, sneezing or coughing(2,16)

• Urge urinary incontinence - involuntary leakage accompanied by or immediately preceded by feelings of urgency(16)

• Faecal incontinence(15)

• Pelvic organ prolapse(2)

Treatment

• Pelvic floor exercises and education, best provided by a physiotherapist with specialist training in women's health(14) 

Constrained breathing patterns are frequently observed in patients with eating disorders, as there is a strong relationship between breathing, emotions and the regulation of emotions(11). Those with eating disorders have a tendency to avoid emotions or have difficulty expressing them. This ongoing internalisation of anxiety may result in a pattern of muscular tension and constrained breathing, which may become habitual over time(11)

Frequent patterns observed(11):

• Highly costal breathing pattern, with decreased diaphragmatic breathing

• Over-activity of respiratory muscles

• Decreased movement of ribs and diaphragm

• Shortened inspiratory and expiratory phases

• Tense/tight expiration

• Shallow inspiration

• Unawareness of breathing

• Sense of withholding their breath

Treatment:

• Diaphragmatic breathing exercises
• Increases awareness of breathing and ability to sense one's own body(11)
• Increases depth and length of breath(1)
• Lowers respiration frequency(1)
• Relaxation of relevant respiratory muscles that are over-active

Benefits of relaxing one's breathing pattern include(11):

• Increased relaxation

• Decreased muscular tension

• A new sense of owning the body in a positive way  

Manual therapy has many benefits in the treatment of patients with eating disorders. It is very important to note that these patients often dislike being touched, having to reveal certain body areas and generally have difficulty with physical closeness(1). Therefore, it is vital that thorough informed consent is obtained and patients do not undergo any treatments that they are uncomfortable with.

Massage can be used to address a range of problems associated with eating disorders including:

• Oedema - often seen in the physical restoration stage of recovery(2)

• Poor distal circulation(17)

• Release of muscle tension that may be contributing to other physical problems such as poor posture(1)

• Promoting relaxation and anxiety management(2)

• Encouraging acceptance to touch(2)

Passive mobilisation can be utilised for:

• Relaxation and increasing awareness of the body(1)

• Encouraging acceptance to touch(2)

• Addressing joint stiffness(1) 

Those with eating disorders commonly experience postural changes for a variety of reasons:

• Patients with eating disorders tend to experience a disconnect from their body, causing lack of awareness of body shape/size, along with difficulty perceiving, understanding and responding to bodily sensations and states(18). This decreased awareness of one's body can cause patients to be unaware of their posture and movements(11)

• Posture may be altered due to patient's insecurities about certain body parts, therefore forming a coping mechanism(2)

• Can result from weakened muscles and low muscle mass(19)

• During recovery, restricted levels of physical activity combined with weight changes can impact posture(2)

Frequent patterns in patients with eating disorders include(11):

• Forward head posture

• Elevated/shrugged shoulders

• Protracted shoulders

• Increased lumbar lordosis and anterior pelvic tilt - leads to pain in muscles of back and pelvis and contributes to constrained breathing patterns

• Difficulty stabilising back and pelvis in a neutral position

• Decreased stability and control of the trunk muscles

• Decreased rotation in the upper body during gait

• Overactivity of global muscles and underactivity of local muscles 

• Occasionally, patients may have impaired balance as a result of decreased muscular strength, postural changes and impairments resulting from vitamin B12 deficiency peripheral neuropathy(2)

• Treatment involves structured exercise interventions to improve balance, that are low intensity and acknowledge the individual's medical state and requirements for restricted exercise(2) 

1. Probst M, Majeweski M, Albertsen M et al. Physiotherapy for patients with anorexia nervosa. Advances in Eating Disorders: Theory, Research and Practice. 2013;1(3):224-238.

2. Brown K. Physiotherapy In Eating Disorders. 1st ed. The Physiotherapy Eating Disorders Professional Network Group; 2018:1-5. https://cpmh.csp.org.uk/content/physiotherapy-eating-disorders. Accessed November 18, 2020

3. Warburton D, Nicole C, Bredin S. Health benefits of physical activity: the evidence. Can Med Assoc J. 2006;174(6):801-809. doi: 10.1503/cmaj.051351

4. National Eating Disorders Association. Warning Signs and Symptoms. National Eating Disorders Association website. https://www.nationaleatingdisorders.org/warning-signs-and-symptoms. Published 2018. Accessed November 21, 2020.

5. Davies R. The treatment of compulsive physical activity in anorexia nervosa lacks a conceptual base. Advances in Eating Disorders: Theory, Research and Practice. 2015;3(1):103-112. doi:10.1080/21662630.2014.892835

6. Quesnel D, Libben M, Oelke N, Clark M. I, Willis-Stewart S, Caperchione C. Is abstinence really the best option? Exploring the role of exercise in the treatment and management of eating disorders. Eat Disord. 2018;26(3):290-310. doi:10.1080/10640266.2017.1397421

7. Dobinson A, Cooper M, Quesnel, D. Safe Exercise at Every Stage (SEES): A Guideline for Managing Exercise in Eating Disorder Treatment. Safe Exercise at Every Stage website. https://www.safeexerciseateverystage.com/access-sees-guidelines. Published 2019. Accessed 20th November, 2020

8. Taranis L, Meyer C. Associations between specific components of compulsive exercise and eating-disordered cognitions and behaviors among young women. International Journal of Eating Disorders. 2011;44(5):452-458. doi:10.1002/eat.20838

9. Reel J. J. The Right 'Dose' of Activity: Health Educators Should Promote Mindful and Intuitive Exercise. J Community Med Health Educ. 2012;2(9). doi:10.4172/2161-0711.1000e111

10. National Eating Disorders Association. Compulsive Exercise. National Eating Disorders Association website. https://www.nationaleatingdisorders.org/learn/general-information/compulsive-exercise. Updated 2018. Accessed November 20th, 2020.

11. Kolnes L. Embodying the body in anorexia nervosa - a physiotherapeutic approach. J Bodyw Mov Ther. 2012;16(3):281-288. doi:10.1016/j.jbmt.2011.12.005

12. Hammond L. Physiotherapy Guidance Notes For Osteoporosis And Exercise In Anorexia Nervosa And Bulimia Nervosa. 1st ed. The Physiotherapy Eating Disorders Professional Network Group; 2015:1-27. https://cpmh.csp.org.uk/content/physiotherapy-eating-disorders. Accessed November 18, 2020.

13. Hammond L. Exercise, Activity & Osteoporosis With An Eating Disorder. 1st ed.; 2019:1-7. https://cpmh.csp.org.uk/content/physiotherapy-eating-disorders. Accessed November 18, 2020.

14. Abraham S, Kellow J. Do the digestive tract symptoms in eating disorder patients represent functional gastrointestinal disorders?. BMC Gastroenterol. 2013;13(1):1-6. doi:10.1186/1471-230x-13-38

15. Cortes E, Singh K, Reid W. Anorexia nervosa and pelvic floor dysfunction. International Urogynecological Journal. 2003;14:254=255. doi:10.1007/s00192-003-1082-z

16. Bo K. Urinary Incontinence, Pelvic Floor Dysfunction, Exercise and Sport. Sports Medicine. 2004;34(7):451-464. doi:10.2165/00007256-200434070-00004

17. Mandy A, Broadbridge H. The role of physiotherapy in anorexia nervosa management. British Journal of Therapy and Rehabilitation. 1998;5(6):284-290. doi:10.12968/bjtr.1998.5.6.14069

18. Pollatos O, Kurz A, Albrecht J et al. Reduced perception of bodily signals in anorexia nervosa. Eat Behav. 2008;9(4):381-388. doi:10.1016/j.eatbeh.2008.02.001

19. Mond J, Hay P, Rodgers B, Owen C. An update on the definition of "excessive exercise" in eating disorders research. International Journal of Eating Disorders. 2006;39(2):147-153. doi:10.1002/eat.20214