What does physical therapy in eating disorder care look like in practical terms?

Honestly, it depends on the setting and not all settings offer physical therapy as standard of care. In eating disorder care, patients work with a multidisciplinary team of providers. Most often, the team includes a physician, psychotherapist, dietitian, psychiatrist, and care manager – all who are eating-disorder-informed and sensitive. It may also include occupational therapists, music therapists, chaplains, art therapists, physical therapists, and other movement specialists. We encourage physical therapy care in ALL settings as a benefit to the patient care continuum.

In non-emergency situations, which can be a variety of different settings, the first step in eating disorder care is an Initial Assessment. Depending on the patient’s needs, this assessment might be performed by a medical provider or by a mental health therapist. In the case of medical concerns, it’s likely the provider will also assess growth charts, labs, vital signs, and other indicators of physical health. The Initial Assessment results in a recommendation for which level of care will best meet the needs of the patient. Over the course of their care, patients may “step up” or “step down” through these levels of care. Most commonly, it is encouraged that the patient descends sequentially through all levels of care (ie. Acute Care to IR/RES to PHP to IOP to OP.)

In all levels of care, physical therapists support patients in identifying and reducing barriers to life-enhancing movement. While we’ll outline specific interventions and considerations for each level of care below, a thread throughout the continuum of care involves building skills and strategies–both physical and mental–that align movement/exercise with a recovery mindset. We provide A LOT of patient education to this end! This means that sometimes our sessions become more conversational versus movement-oriented, all depending on what the patient needs at that moment.

Throughout the length of stay at each level, the patient is invited to discuss their relationship with movement and reflect on its alignment with recovery goals. Motivational interviewing skills and strategies are utilized to assess for readiness to change and to engage patients in taking steps toward their desired changes. These are the discussions that we most hope are continued throughout the different levels of care.

While we aren’t psychotherapists, at times we will work with patients to apply therapeutic skills (ie. DBT, CBT) they have gained to create helpful shifts in their movement routines.

A few (non-exhaustive) examples of what this looks like include:

• Guidance in mindfulness skills, such as body scans, progressive muscle relaxation, breath work, postural expansion, grounding skills, or engaging with one’s senses to enhance safe body awareness before/during/after exercise. These skills also support the management of urges for movement and in tolerating change and the feeling of physical fullness that often accompanies weight restoration.

• Offering the opportunity to create a conversation with the body – providing skills to check in with feelings, body sensations, and needs. We most often implement this through use of the Wheels from Feelings Found, linked here.

• Utilizing distress tolerance skills, such as identifying the Pros and Cons of integrating a recovery day into a patient’s movement plan.

• Providing education by “checking the facts” about the body’s energy needs during periods of recovery from an injury, using the data that we collect to support decisions versus dictating what one should or should not do.

• Collaborating with patients to identify ways that they can lean on friends and family to support the changes they are making to their exercise participation.

• Allowing practice of different forms of movement in session and processing feelings and body sensations before/during/after.

• Building a movement program together for potential practice at home and in the community, processing what works and what doesn’t work, pivoting as needed to maintain in alignment with recovery goals.

We’ll touch on unique considerations for each level of care below, though we’ve also organized common PT interventions according to level of care in Table 1. Of note, parameters for exercise participation (ie. mode, intensity, duration) will vary across the treatment levels based on various medical and psychological criteria. We have both found the Safe Exercise at Every Stage (SEES) guidelines to be especially helpful in guiding the graded reintegration of movement for our patients.

Since eating disorders tend toward rigidity, we prioritize offering a variety of movement experiences (such as stretching, walking, yoga, resistance exercises, balance challenges, and playful games). This counters the eating disorder drive, while also enhancing flexibility, posture, balance, coordination, and strength.

Additionally, patients with eating disorders may present with orthopedic injuries and require what most people consider to be “traditional” physical therapy. Our approaches to orthopedic interventions vary a bit, due to the differences in our treatment settings. As a PT in private practice, Michelle treats orthopedic concerns regularly, through an ED-informed and sensitive lens. This involves being mindful about assigning “homework” and making sure that any movement recommendations align with recovery goals. Working within a larger health organization, Lisa addresses orthopedic needs when needed to facilitate patient participation in treatment (ie. working with a patient who enters a higher level of care after an orthopedic surgery, to allow for continued performance of the postsurgical home exercise program). However, her patients in OP care who have orthopedic concerns typically work with specialized PT’s within the broader organization for focused orthopedic care.

With this background in place, let’s dive into the different levels of eating disorder care and how physical therapists can support healing and recovery! For reference, we have placed our name next to the level of care where we have had professional experience.

Hospital/Medical Stabilization (Michelle)

Setting

Hospital-based treatment for patients with significant medical instability requiring specialized care.

 
PT Care Considerations

Due to malnutrition, functional mobility and gait stability are primary concerns for patients at this level. If fall risk is high and/or assistance is needed with functional mobility (ie. bed mobility, sit<>stand transfers from bed, chair, toilet, shower chair and ambulation in room and on unit), physical therapy sessions are implemented daily to reduce fall risk and attain independence with functional mobility. Once the patient is no longer at risk for falls AND is independent with functional mobility skills, they remain on the physical therapy caseload and are seen multiple times per week. These follow up sessions typically involve conversations around movement/exercise, what “counts”, and an exploration of different types of movement. Sometimes these sessions can be coupled with pet therapy volunteers. These can include dog walking (indoors and outdoors, depending on weather and medical/behavioral clearance), floor transfers, pet grooming tasks, and playing catch.

Intensive Residential (Lisa, Michelle)

Setting

Patients require comprehensive, daily medical monitoring and/or behavioral support and stay onsite. Goals at this level can include medical stabilization, weight restoration and/or symptom interruption.

PT Care Considerations
At this level of care, patients need to safely navigate their room, bathroom, and movement throughout the unit to various groups and the dining area. To this end, assessment and management of any barriers to their functional mobility are considerations of the physical therapist.
Physical therapists support discharge planning considerations as a patient anticipates returning to their home setting, work requirements, school environment and potentially sport participation.

Residential (Lisa)

Setting

Patients require less frequent medical monitoring than in IR, though they live onsite and benefit from round-the-clock support to focus on recovery. Patients have more significant opportunities to practice skills offsite at home or in the community on “passes.”

PT Care Considerations

Care at this level is very similar to IR, with an added element of planning and debriefing around home and community-based movement experiences. Increased attention is given to support interventions, such as movement planning and debriefing with the patient’s personal support team (ie. parents, friends).

Partial Hospitalization (PHP) (Lisa) 

Setting

A day program where patients spend most of their day (around 8 hours, Monday-Friday) onsite practicing recovery-based skills in meals, treatment groups, and individual sessions.

PT Care Considerations
Physical therapists offer movement-based groups incorporating education and enhancing flexibility, balance, coordination, and postural and core stability, as well as 1:1 sessions for continued skill building to align movement with recovery and to create distance from ED-driven exercise practices. Further attention may be given to development of a personalized home exercise program.

Intensive Outpatient (IOP) (Lisa, Michelle)

Setting

A structured 4-6 week outpatient program where patients spend 3 hours onsite, 2x/week, for a supported meal and group sessions. Different treatment programs may offer different hours and frequency.

 
PT Care Considerations
Physical therapists may provide an education-based group lecture to support incorporating a life-enhancing movement mindset and creating plans for personal exercise participation.

Outpatient (OP) (Michelle, Lisa)

Setting

Patients attend weekly (or less frequent) appointments with members of the ED treatment team.

PT Care Considerations
For those who have descended from higher levels of care, physical therapists facilitate continued skill building to align movement with recovery and to create distance from ED-driven exercise practices.

Some individuals do not require higher levels of care and are supported at the OP level throughout their ED care. Physical therapists provide 1:1 movement planning sessions for those who desire to incorporate regular exercise into their lives after a period of less structure with movement due to various ED-related barriers (ie. fear, chronic pain, all-or-nothing mindset),

Physical therapists are part of the broader OP team that leads education-based group lectures for various specialized treatment groups (ie. for those struggling with Binge Eating Disorder or those incorporating Family Based Treatment).

Table 1: