1. Physiotherapy in Eating Disorders Yvonne Hull Physiotherapist, Bristol Eating Disorder Service. yhull@nhs.net

2. The Eating Disorders  ANOREXIA NERVOSA  Incidence of 0.3%  Mortality rate of 6-20%  Body weight maintained at 85% of expected level  Intense fear of gaining weight  Body image disturbance  Amenorrhea  BULIMIA NERVOSA  Incidence of 0.1 to 9%  Binge eating followed by purging  Maybe in the form of vomiting, laxatives, diuretics and over exercising  BINGE EATING DISORDER

5. BMI 11 - 15  Discuss damage to joints when muscles emaciated with pt & explain aches  Discuss postural changes due to muscle weakness, eg winged scapulae  Postural advice in sitting  Post meal supervision, sitting compulsory  Teach relaxation techniques

6. BMI 11-15 Gentle exs for specific painful spots, eg lumbar spine Massage to painful shoulders & heat Rx to relax muscles Quads exs & bridging in lying, in anticipation of mobilisation Check on patient’s footwear, in anticipation of walking (painful metatarsal heads)

7. BMI 15-17.5 STRETCHES PILATES SWISS BALLS YOGA TAI CHI Mobilise gently, introduce to different types of exs

8. BMI 17.5+ Avoid previous problem areas, usually high calorie burners Refer to healthy exercise group at STEPS Steer away from solitary exs, go to group/fun activities Encourage social side, classes at local sports centres Exercise to fit in with patient’s life

9. Over Exercise/ Activity SURREPTITIOUS  Going up and down stairs frequently, or getting off the bus three stops early OVERT  To burn off calories and induce weight loss  Activity is strenuous and physical often high cardiovascular burner, i.e. running, cycling, swimming  Performed in a rigid, obsessive manner  Often accompanied by feelings of guilt if not performed to expected high standard, or missed completely RESTLESSNESS  Often evident in very emaciated patients  Associated with sleep disturbance  Evident as rocking, rhythmic movements

10. Over Exercise Control Encourage patient  to talk to you about exercise  to exercise with others  to take classes  not to exercise at home  not to go back to previously problematic exercise modes  to reduce time periods of their day allocated to exercise  maybe to stop altogether, pause, and then restart a new exercise routine  to try new kinds of exercise

11. Worries Osteoporosis  Discuss with all patients prescribed exs  DEXA scans sometimes arranged Potassium levels  Regular blood tests necessary for bulimics/laxative abusers  If pot. level abnormal, STOP all exercise now

12. Motivational Cycle

13. References Carraro, A., Cognolato,S., Fiorellini Bernardis, A.L. (1998) Evaluation of a programme of adapted physical activity for ED patients. Eating and Weight Disorders. 3, (3), (110-4). Department of Health (2008) Improving Health: Changing Behaviour NHS Health Trainer Handbook. British Psychological Society Health Psychology Team. London: Crown. Hausenblas, H.A., Cook, B.J., & Chittester, N.I. (2008) Can exercise treat eating disorders? Exercise and Sport Sciences Reviews. 36, (!), 43-47 Mehler, P. S. (2003). Osteoporosis in Anorexia Nervosa: Prevention and Treatment. International Journal of Eating Disorders. 33, 113-126. Mond, J.M., Hay, P.J., Rogers, B., & Owen, C. (2006). An update on the definition of “excessive exercise” in eating disorder research. International Journal of Eating Disorders. 39, (2),147-153 Sundgot-Borgen, J., Rosenvinge, J.H., Bahr, R., & Sundgot Schneider, L. (2002) The effect of exercise, cognitive therapy, and nutritional counselling in treating bulimia nervosa. Medicine & Science in Sports and Exercise. 34, (2), 190-195 Thien, V., Thomas, A., Markin, D., & Birmingham, C.L. (2000) Pilot study of a graded exercise programme for the treatment of anorexia nervosa. International Journal of Eating Disorders 28 (1): 101-106 Vitousek, K., Watson, S. & Wilson, G.T., (1998). Enhancing motivation for change in treatment – resistant eating disorders. Clinical Psychology Review. 18, (4), 391-420.