ROLE OF PHYSIOTHERAPY IN EATING DISORDER RECOVERY

Clinical practice guidelines typically recommend a combination of medical, dietetic and psychological interventions for the treatment of eating disorders(1,2). However, with these protocols, the full recovery rate is estimated to be no greater than 50%, indicating the need for additional adjunct treatment methods(3). To achieve optimal health and recovery from an eating disorder, developing a positive relationship with both food and exercise is necessary(4). Dietitians typically address the food element, however there is currently no standard practice to guide the management and integration of exercise in eating disorder recovery(5).

Physiotherapists are well suited to address the frequently omitted exercise component(6,7). Physiotherapists can also address the physical consequences and side effects of eating disorders. Malnutrition can cause problems such as osteoporosis, decreased strength and overuse injuries(4). Furthermore, emotional and psychological strain can lead to symptoms such as poor posture, constrained respiration and muscle tension8. This may assist in a patient's recovery as the interdependence between the physical and mental health means that physical interventions are likely to have beneficial psychological effects for patients(9)

Physiotherapists work as a key member of a multidisciplinary team in eating disorder recovery, and need to ensure that they remain within their scope of assisting physical recovery and exercise. Therefore, it is important that patients are also regularly attending appointments with a dietitian, psychologist and GP(1,2). Physiotherapists in this area need to be careful to not provide advice or education regarding dietary intake, body image concerns or other psychological challenges that may be present(6) 

• In general, patients with eating disorders have high emotional sensitivity to body-related changes(10). Furthermore, certain physiotherapy-related problems such as poor posture can often be coping mechanisms for dealing with insecurities and body image concerns(6). Therefore, it is important that changes to posture, breathing etc. are made carefully over time, ensuring that the patient is comfortable with the pace(10)

• Patients with eating disorders often dislike being touched and generally have difficulty with physical closeness(11). It is highly important that informed consent is thoroughly gained and repeated throughout the treatment to ensure patients remain comfortable. Alternatives such as the use of foam rollers instead of massage may be beneficial for a time, while the patient gets more comfortable with physiotherapy and progresses in their recovery.

• Most patients with eating disorders have a very negative attitude towards their body and physical appearance and often perceive their body in a distorted way(11). They frequently experience their bodies "as something annoying(11)" and do not feel "at home(11)" in their body. Therefore, physiotherapy can cause patients to be intensely confronted by emotions as they experience and connect with their body. It is important that patients are well informed and aware of the aims of different treatments and treatment progresses at a speed they are comfortable with(11)

• Those with eating disorders are sometimes medically compromised and therefore additional care needs to be taken to ensure treatment is safe(5). This involves working closely with the patient's GP and dietitian, along with following protocol such as the 'SEES guidelines' to determine appropriate and safe levels of exercise(5) 

1. Hay P, Chinn D, Forbes D et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Australian & New Zealand Journal of Psychiatry. 2014;48(11):977-1008. doi:10.1177/0004867414555814

2. Hilbert A, Hoek H, Schmidt R. Evidence-based clinical guidelines for eating disorders: international comparison. Curr Opin Psychiatry. 2017;30(6):423-437. doi:10.1097/yco.0000000000000360

3. Reel J. Eating Disorders: An Encyclopedia Of Causes, Treatment, And Prevention. 1st ed. California: ABC-CLIO; 2013:360-370.

4. 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.

5. 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.

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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.