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Fisioterapia. 2014;36(2):55---57
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EDITORIAL
The importance of physiotherapy within the
multidisciplinary treatment of eating disorders
La importancia de fisioterapia dentro del tratamiento multidisciplinar de
trastornos alimentarios
Why should patients with eating disorders
receive physiotherapy?
Anorexia and bulimia nervosa
Eating disorders are characterised by disturbances in eating behaviour often accompanied by feelings of distress and
concerns about one’s body weight or shape1 . Anorexia and
bulimia nervosa are two major formal diagnostic categories
of eating disorders1 . Anorexia nervosa is is characterised
by a distorted body image and excessive dieting that leads
to severe weight loss with a pathological fear of becoming fat. Excessive exercise affects up to 80% of anorexia
nervosa patients and has been associated with negative
emotionality2 .
The core feature of bulimia nervosa is loss of control over
the eating behaviour resulting in binge eating and purging.
Binge eating involves taking in an abnormally large quantity of food in a discrete time period and feeling a lack
of control during the episode1 . Compensatory behaviours
occur after a binge and might include vomiting, laxative or
other diet medication use, fasting, or excessive exercise1 .
Often, patients with bulimia nervosa eat at irregular intervals, and long periods of fasting trigger food cravings and
then binge/purge cycles1 .
It is known that cultural, social, and interpersonal factors can trigger onset of the illnesses, while changes in
neural networks can sustain anorexia and bulimia nervosa.
Both eating disorders are also associated with significant
impairment of physical health and psychosocial functioning
and carry increased risk of death3 . The physical abnormalities seen in anorexia nervosa seem to be largely secondary
to these patients’ disturbed eating habits and their compromised nutritional state3 . Hence most impairments are
reversed by restoration of healthy eating habits and sound
nutrition, with the possible exception of reduced bone density. The main physical features of anorexia nervosa include
decreased bone integrity (osteopenia leading to osteoporosis), weak proximal muscles, bradycardia, gastrointestinal
symptoms, dizziness and syncope and amenorrhea3 . The
physical abnormalities seen in bulimia nervosa are usually
minor unless vomiting, or laxative or diuretic misuse are frequent, in which case there is risk of electrolyte disturbance3 .
Anorexia and bulimia nervosa also present with psychiatric co-morbidity in a number of important areas, including
depression, bipolar disorder, anxiety disorders (obsessivecompulsive disorder, panic disorder, social anxiety disorder,
other phobias, and post-traumatic stress disorder) and
substance abuse3 . Because of co-morbid physical and psychiatric conditions, anorexia and bulimia nervosa have been
characterised as one of the most difficult psychiatric conditions to treat.
Binge Eating Disorder
Binge eating disorder (BED) is included in the last edition
of the Diagnostic and Statistical Manual Mental Disorders (DSM)1 . It is characterised by frequent and persistent
episodes of binge eating accompanied by feelings of loss of
control and marked distress in the absence of regular compensatory behaviours. Furthermore, binge eating episodes
are associated with 3 or more of the following: (a) eating
much more rapidly than normal, (b) eating until uncomfortably full, (c) eating large amounts of foods when not feeling
physically hungry, (d) eating alone because of being embarrassed by how much one is eating, and (e) feeling disgusted
with oneself, depressed, or very guilty after overeating.
To meet the DSM criteria1 , the binge eating occurs, on
average, at least once a week for 3 months. Physical
consequences of BED are largely due to a co-morbid obesity and a sedentary lifestyle4 . Obese individuals with BED
also demonstrate a greater eating disorder psychopathology, i.e. expressing more weight and shape concerns and
body dissatisfaction, increased emotional eating, and lower
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56
self-esteem compared with obese people without BED3 . In
addition, obese persons with BED have an elevated risk for
developing depression, bipolar disorder, anxiety disorders,
obsessive-compulsive disorder, panic disorder, social anxiety disorder, post-traumatic stress disorder and substance
abuse compared to obese people without BED3 .
What is the scientific evidence for
physiotherapy within the treatment of eating
disorders?
Evidence in anorexia and bulimia nervosa
A recent systematic review5 including 8 randomised controlled trials (RCTs) and involving 213 patients (age-range:
16-36 years) concluded that aerobic and resistance training
result in significantly increased muscle strength, body mass
index (BMI) and body fat percentage in anorexia patients. In
addition, aerobic exercise, yoga, massage and basic body
awareness therapy significantly lowered scores of eating
pathology and depressive symptoms in both anorexia and
bulimia nervosa patients5 . In particular the use of aerobic exercises in the treatment for anorexia nervosa is
not without controversy. Many patients with anorexia nervosa engage in excessive exercise, which can contribute to
ongoing weight loss. Clinicians often attempt to restrain
exercise in these patients, given that it can play a role
in the pathogenesis as well as progression of the disorder.
However, the current literature5 indicates that those who
exercise increase in weight and body fat compared with
non-exercisers.
There are several plausible explanations for the observed
weight gain results. First, participation in exercise-based
physiotherapy programmes may help to alleviate anxiety
and increase comfort with gaining weight. Second, being
given the opportunity to exercise during treatment might
increases overall compliance with the entire treatment programme, including adherence to meal plans. Third, patients
in an exercise-based physiotherapy programme are probably
less likely to exercise surreptitiously with a focus on burning
calories, whereas patients without opportunity to participate in a supervised exercise setting may exercise less at
a level that is detrimental to their health and focused on
burning calories.
Exercise-based physiotherapy may also benefit patients
with bulimia nervosa, and this in two ways5 . First, it may
facilitate complete abstinence through psychological pathways related to the recreational nature of the activity itself.
For example, the literature5 demonstrates that those who
exercise experience less anxiety and depressive symptoms.
Second, it may contribute to body image improvements.
Bulimic patients who exercise may experience less body dissatisfaction and a reduction of the uncomfortable internal
sensations of bloating and distention during eating.
Evidence in binge eating disorder
The evidence on physiotherapy in persons with BED is limited
to 3 RCTs involving 211 female community patients (agerange: 25-63years)6 . The limited literature on physiotherapy
EDITORIAL
in persons with BED however clearly demonstrates that aerobic and yoga exercises reduce the number of binges and BMI
of BED patients. Aerobic exercise also reduces depressive
symptoms 6 . Only combining cognitive behavioural therapy
(CBT) with aerobic exercise and not CBT alone reduces BMI6 .
Combining aerobic exercise with CBT is more effective in
reducing depressive symptoms than CBT alone.
Adding exercise to CBT may benefit binge eaters in two
ways, and this by two different mechanisms6 . First, it may
facilitate abstinence from binge-eating through psychological pathways related to the recreational nature of the
activity itself, i.e. those who exercise reported to experience less depressive symptoms. Secondly, physical activity
may buffer the effect that anxiety sensitivity (i.e. a fear of
anxiety and related sensations) has on binge eating.
General recommendations based on the
current scientific evidence
The UK National Institute for Health and Clinical Excellence guidelines7 recommend that people with eating
disorders should first be offered community- and outpatienttreatment and that inpatient care be used for those who do
not respond or who present with high risk. The current evidence clearly demonstrates that physiotherapists could have
a role within these first-stage community settings. Clear
guidance regarding the type of physiotherapy intervention
(aerobic exercise or yoga-related interventions) and optimal dose is however at the moment limited by the small
number of available RCTs and the variability of the interventions themselves in terms of frequency, intensity, and
duration. Physiotherapists should therefore assess the types
of exercises or techniques that would best fit a person’s
preferences8 . Probst et al.9 recently formulated 4 general
recommendations for physiotherapists working with eating
disorder patients:
Physiotherapists should offer a safe and well-structured
framework in which everybody knows the engagements and
in which the physiotherapist constantly provides information
related to the goals and content of the programme.
Within a physiotherapy approach, psycho-education
regarding bodily functions is an important issue. For example, it is important to explain the functions of the respiratory
system during breathing exercises. The therapist’s role
should also consist of thoroughly explaining that weight
gain is not synonymous with feeling fat, but with health,
attractiveness, and expressiveness. Other topics for psychoeducation are basic anatomy/physiology, osteoporosis, body
and sensory awareness, stress, anxiety, and coping strategies, normal healthy physical activity versus maladaptive
physical activity, and the influences of the media on sociocultural ideals.
Whenever possible, physiotherapists should design their
exercises in such a way that the patients can also try these
exercises outside the therapy-sessions, on their own, or with
a partner. This can be successfully done with breathing exercises, relaxation training, and stress coping strategies. It
is important that patients assume responsibility for their
therapy.
Physiotherapists should invite their patients to express
any feelings they experience during the exercises and should
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EDITORIAL
57
encourage patients to further deal with their feelings in
for example associated psychotherapy sessions. Continual
exposure to body-oriented situations in physiotherapy will
enable patients to discover any changing attitudes during
the exercises and will enable them to become familiar with
these changes. Visual feedback with for example mirrorand video-exposure intensifies the kinesthetic sensations
by providing a new perspective on the body. The underlying message of all exercises and discussions is self-respect,
which will enable the patients to build up love and respect
for their own body. For this purpose, it is important that during the physiotherapy sessions, the patients become aware
that in addition to outward appearance, there are other values and personal aspects that are at least equally important
in life.
In conclusion, it is unequivocal that the role of
physiotherapists in the multidisciplinary treatment of
eating disorders should be further promoted. Governments should address funding for necessary physiotherapy
service improvements. The Spanish Physiotherapy Association should take the lead in bridging the collaboration
gap between physical and mental health care by promoting
a policy of coordinated and integrated mental and physical health care including physiotherapy for all persons
with eating disorders. The integration of physiotherapy in
the treatment of eating disorders with an ultimate goal
of providing optimal treatment to this vulnerable patient
population, will be an important challenge for the Spanish
Physiotherapy Association.
Davy Vancampfort a,b,∗ , Michel Probst a,b
University Psychiatric Centre KU Leuven, campus
Kortenberg, KULeuven Department of Neurosciences,
Belgium
b
KU Leuven Department of Rehabilitation Sciences,
Leuven, Belgium
a
Conflicts of interest
Davy Vancampfort is funded by
Foundation---Flanders (FWO-Vlaanderen).
2. Vansteelandt K, Pieters G, Probst M, Vanderlinden J. Drive
for thinness, affect regulation and physical activity in eating disorders: a daily life study. Behav Res Ther. 2007;45:
1717---34.
3. Treasure J, Claudino AM, Zucker N. Eating disorders. Lancet.
2010;375:583---93.
4. Vancampfort D, Vanderlinden J, Stubbs B, Soundy A, Pieters G,
De Hert M, et al. Physical activity correlates in persons with
binge eating disorder: a systematic review. Eur Eat Disord Rev.
2014;22:1---8.
5. Vancampfort D, Vanderlinden J, De Hert M, Adámkova M, Skjaerven LH, Matamoros DC, et al. A systematic review on physical
therapy interventions for patients with binge eating disorder.
Disabil Rehabil. 2013;35:2191---6.
6. Vancampfort D, Vanderlinden J, De Hert M, Soundy A, Adámkova
M, Skjaerven LH, Catalán Matamoros D., et al. A systematic review of physical therapy interventions for patients with
anorexia and bulemia nervosa. Disabil Rehabil 2013; in press.
7. National Collaborating Centre for Mental Health. National Clinical Practice Guideline: eating disorders: core interventions in the
treatment and management of anorexia nervosa, bulimia nervosa, and related eating disorders. National Institute for Clinical
Excellence. 2004.
8. Probst M, Knapen J, Poot G, Vancampfort D. Psychomotor therapy
and psychiatry: What is in a name? Open Complement Med J.
2010;2:105---13.
9. Probst M, Majewski ML, Albertsen MN, Catalan-Matamoros D,
Danielsen M, De Herdt A, et al. Physiotherapy for patients with
anorexia nervosa. Advances in Eating Disorders: Theory, Research
and Practice. 2013;1:224---38.
the
Research
References
1. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition Arlington, VA: American Psychiatric Association; 2013.
Corresponding author.
E-mail address: [email protected]
(D. Vancampfort).
∗
14 January 2014; 14 January 2014