Managing Exercise and Activity and associated risks, in patients with AN and BN
Lynn HammondSpecialist Physiotherapist [email protected]
Physiotherapy in Eating Disorders Network
Affiliated to CPMHGroup of Physiotherapists all working in SEDUs in England and Scotland (part time of WTE)Adult and Adolescent servicesMeet 3 times a yearSpoke at congress 2003, since seen a growth in the group and it’s aimsProduction of Guidance notes and articles and possibility of our book are ongoing
Useful Documents and organisations
Physiotherapy Guidance Notes for Exercise and Physical Activity in Adult Patients with Anorexia Nervosa and Bulimia Nervosa June 2011. (Access throughicsp,RCPsych, Google)Managing Exercise and Activity with an Eating Disorder ( Access via Kate Brown Physiotherapist EDS Cambridge)Physiotherapy Guidance Notes for Osteoporosis and Exercise in Anorexia Nervosa and Bulimia Nervosa (Virtually complete by LynnHammond)?EDsAssessment form etc/ “pockets” within CPMH websiteMARSIPAN ( Oct 2010 Royal College of Psychiatrists and Royal College of Physicians)NOS – All about Osteoporosis, Exercise and Osteoporosis and AN and OsteoporosisBEAT
Where you might be asked to treat a patient who has an ED
SEDUGeneral Psychiatry/mental healthCommunityMedical wards
BMI – Weight (kg) / height (m) squared20-25 normal for women in ED (18.5- 25 cancer research UK)AN : Restricting type+Binge-Eating/purging typeAN below 17.5Medium risk 13-15High risk below 13BNBinge Eating Disorder
Health Risks particularly relevant to Physiotherapists
Re-feeding syndromeRe-feeding oedemaCardiovascular risksMusculo-skeletal risksOsteoporosis
Re-feeding syndrome and Exercise
Potentially fatal cardiac effectsOccurs when patients who have had their food severely restricted are given large amounts of food via oral, NG feeding or TPN.Leads to fluid and electrolyte shiftsConsequences of which includehypokalaemia(below 3mmol/l),hypophosphataemia(below 0.4mmol/l), hypomagnesaemia and altered glucose metabolism (below 3mmol/l).Treatment- Decisions in consultation with physicians in clinical nutrition and nutrition support teams. Initial low calorie feeding, step wise increases as soon as safe, electrolyte and clinical state monitoring and a diet rich in phosphate and low in carbohydrates.Always consult with MD teams regarding risks prior to any Physiotherapy. Skeletal and heart muscles require phosphate as does the body for repair. Exercise places unnecessary skeletal demand onphospates, in an already depleted situation, putting the heart at risk.
Re-feeding oedema and Exercise
Re-feeding oedema, a peripheral oedema is common in early stages of re-feeding.Often seen in those who had been vomiting or using laxatives prior to admission.It resolves within a few weeks spontaneously and rarely needs treatment.It must be distinguished from oedema secondary to heart failure.A physiotherapy assessment is required if the oedema is affecting function e.g. lifting heavy legs in/out bed, mobility, balance and tissue viability. Mobilising will be dependent upon the MD treatment plan and the patient’s physical risk.
Cardiac muscle atrophy, heart muscle shrinkage, reduced left ventricular mass, reduced contractile force, reduced stroke volume, reduced cardiac output leading tohypotension.Sinusbradycardiadue to inadequate dietary intake (high risk below 40)Mitral valveprolapse(rare due to weakened muscles holding the valve)Although low intensity exercise may be possible, CO may not be adequate for the body’s needs at a higher intensity. Exercising may place extreme stress upon the cardiac system and may increase the risk of a significant cardiac event. Dizziness and fainting may occur.
Cardiovascular risks and exercise
Hypokalaemia(low potassium, less than 3mmol/L and especially sudden depletion) due to dieting, dehydration and purging behaviours (vomiting, use of laxatives, diuretics ) can lead toarrhythmias.Patients should not be exercising . Seek medical advice.Patients will have oral replacements and electrolytes should be tested regularly.Hypoglycaemia(low blood glucose less than 3mmol/L) a consequence of inadequate dietary intake, a starved state and demands from exercise.
As BMI reduces the muscle mass and muscle strength reducesSUSS testSit up- Squat-Stand test used in EDsSit-up from lyingRises from squat0: unable1: Able only using hands to help2: Able with noticeable difficulty3: Able with no difficulty
Musculo-skeletal risks and Exercise
Inadequate dietary intake and weight loss leads to significant reduction of muscle mass and strength, reducing support around joints.Exercising upon these weakened and vulnerable joints can lead tojoint damageand ultimatelydegenerative changes.Possible higher incidence ofRSIdue to the often rigid and repetitive nature of exercise upon a weakenedmusculo-skeletal system.Soft tissue injuriesfrom muscle fragility due to low weight, continued exercise and poor nutrition for healing.
Musculo-skeletal risks and Exercise
Postural difficulties,painandrisk of injury from poormusculo-skeletal stability, including the core muscles.Stress fracturesfrom repeated impact (associated with compulsive exercise) upon fragile bones.Metatarsal headscan becomepainful and vulnerable to fractureat low weight, due to changes in plantar fascia. It is advisable to suggest cushioned footwear when active.Osteoporotic/fragility fracturesdue to low bone density especially when exercising inappropriately. Spine, wrists and hips and stress fractures in lower legs and feet.
Osteoporosisis a common complication in AN.Below -2.5 osteoporosis, -1.0 to -2.5osteopeniaDXA scanThe body changes its hormone production in response to low body weight (lowering oestrogen and IGF1) and these changes reduce bone density.Lack of adequate nutrition contributes to the cause.Weight restoration is overwhelmingly the biggest piece of the jigsaw for protecting bones.
Osteoporosis and exercise
Many young people with AN have osteoporosis and may sustain fragility fractures at a much younger age than is seen in average women.Preventing these fractures is vital for future health.So we must teach our patients what to avoid, in terms of movements, activities and exercise.
What to avoid
The advice is dependent upon the degree of osteoporosis, whether there have been any fragility fractures and health.High impact exercisessuch as jumping, runningExercise and activities that increase the risk of fallingsuch as horse riding, skiing, ice-skatingContact sportsExercises in which you bend forwardsespecially touching toes in standing, sit-ups and crunchesSpinal flexion combined with twistingTake extra care when lifting, moving and handling
Osteoporosis and Exercise
Although exercise is known to have a beneficial effect on bone mineral density at a healthy weight, studies are conflicting and it cannot be said that exercise in those with AN is beneficial to bone density . If exercise contributes to further weight loss then the overall result will be detrimental to bone density.So weight restoration is our aim and we cannot tell our patients that exercising whilst underweight is beneficial.However if exercise, appropriate to BMI, helps with the ongoing weight restoration programme or if they continue to exercise anyway, then specific bone stimulating exercise (proven in the healthy weight population) would be the best advise. These exercises will be helpful once weight is restored.Manage compulsive exercise if it is a problem.
Recommended bone stimulating exercises
The types of activities recommended for people at high risk of fracture include:Strength-trainingexercises (exercises using body weight as resistance), especially for the back, plus hips, wrists, pelvic floor, core, foot and ankle.Weight-bearinglow to medium impact.Flexibilityexercises.Stability and balanceexercises to reduce the risk of falling.Classeswith controlled movements, Pilates and Taichi.
Role of Physiotherapy in relation to exercise inEDs
Dysfunctional exercise behaviour is a common feature in Eating Disorder patients.1. Promote exercise in the context of a healthy lifestyle (physiological and psychological wellbeing)2. Help patients to stop or reduce excessive/compulsive exercise behaviour3. Make recommendations on appropriate levels of physical activity and exercise (BMI related guidelines)Advise on and treatmusculo-skeletal problemsWhilst keeping in mind the necessary programme of weight restoration, the patients BMI and their physical health.
Any form of exercise or physical activity associated with disordered eating attitudes, beliefs and behaviours,with an inability or unwillingness to cut down or stop exercising even though it is detrimental to health.When exercise and activity becomes compulsive the health benefits are lost and the exercise becomes more harmful to the body than helpful.
Physical activity (any movements that exert muscles) includes:ADLOccupational activitiesRecreational activitiesPlaySportExercise
Physical activity and exercise may be:Planned and structuredsuch as sport, gym, runningIncidentalsuch ashoovering, shopping, cleaningPhysical activity and exercise may be:OVERT- Openly and deliberately to burn calories. Solitary and obsessive e.g. runningCOVERT-can be rigid strenuous activities in secret e.g. star jumps, or in less obvious ways e.g. always going upstairs on the pretext of fetching things, getting off the bus a stop earlier to walk, or sitting in a way that uses constant muscle contractionsPERSISTANT RESTLESSNESS-highly repetitious movements such as tapping and rocking or pacing and standing for long periods of time (Low levels ofleptinat low weight).
Managing Compulsive exercise Behaviour
Exercise can become a very powerful tool in maintaining an ED because of the strong influence that it can have on weight control.It is not possible to become physiologically addicted to exercise but for some the psychological dependence is so strong, it is almost identical to a real addiction.Itmay require a period of abstinenceandgentle graded reintroductionwith constant vigilance to keep under control.
Managing Compulsive Exercise
A CBT approachand the use of “The Tool”can help identify the individual reasons for compulsively exercising, so that thoughts and behaviours can be challenged and new healthier ways of thinking and behaving can take place.
Managing Compulsive Exercise
Educatepatients about what constitutes ‘healthy/non-compulsive’ exercise.Equip patients with the skillsthat will enable them to regain control of their exercise behaviour,E.g. using distraction, talking rather than using behaviours to manage feelings, activity diaries, pros and cons lists, goal planning and step by step changes, anxiety management etcEquip patients with knowledgeto help with making healthy choices,E.g.leptin, health risks, body composition and fitness etc
BMI related Guidelines
Role is to educate and promote healthy exercise and activity:In relation to BMI, physical healthand whether dietary intake is sufficient to support an increased activity level.Find a healthy balance between activity levels and nutritional intake.
BMI 14 and below
Exercise is not recommended as weight gain is the main prioritySpecific Physiotherapy treatment and exercises may be prescribed for physical problems such as:Mobility difficulties/ difficulty climbing stairsBalance impairment /risk of fallsPostural problems/ pain/ pain caused by OPoedema/circulatory problems/ tissue viability
BMI 14 to 15
Following assessment it may be appropriate to recommend exercises in lying and sitting such as:Gentle PilatesStretchesRelaxation techniques
BMI 15 to 17
Gradual progression to moderate weight bearing activitiesSessions monitored and supervised with a measurable time framePreferably in groups, such as:PilatesTai ChiYoga (be cautious of some yoga poses)Swiss ball
BMI 17 to healthy BMI
Patients still on a weight restoration programme, so any recommendations must not compromise thisGroup exercises are preferable, social, enjoyableUtilize community facilities once a week to begin withsuch as : Badminton/Pilates/dance/swimmingAssistance with planning amount, time, type, especially if compulsive exercise has been a feature.Becoming increasingly active/ fit in with lifestyle
At a healthy weight
Ongoing support to help patients find a healthy balance between activity levels and nutritional intakeAdjustments must take into account, physical health, pre-morbid exercise behaviour, occupation, recreation preferences, lifestyle and nutritional balanceEnjoyable and variedGroups or exercising with othersLearn to respect their bodies, miss sessionsHave a snack before or after exerciseSeek help and support if compulsive exercising behaviour returns