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an inTeRlink feature article
July 23, 2001

The Recreational Therapist Role in Prescribing Exercise to the Eating Disorder Patient

Jon Mitchell, CTRS, CLC
Robyn Eisenbach
University of Iowa Hospitals and Clinics

Anorexia nervosa and bulimia are psychiatric disorders that often lead to serious medical complications. Anorexia nervosa is primarily a disorder, which involves restriction of food intake to the point of starvation and weight loss. Bulimia is a syndrome of binge eating, usually followed by some form of purging, which may be self-induced vomiting, laxative use, or associated behaviors such as diuretic use, diet pill use, or excessive exercise. Morbidity and mortality rates among patients with eating disorders are among the highest recorded for psychiatric disturbances. Using the specific recreational therapy intervention for eating disordered clients, exercise prescription, this intervention will assist in the role modeling of healthy levels of exercise, balance of lifestyle choices, and improve the client's physical and psychological health. The distinctive feature of recreational therapy, that makes it different from other therapies, is the use of recreation activities as a mode of treatment. The recreational therapist has a unique perspective regarding the leisure and social needs of a client with an eating disorder. Recreational therapy can assist eating disordered clients in assuming greater control over their leisure lifestyle, and is a useful and effective addition to the treatment of the eating disordered client.

There are generic principles that are common to every training program, when these principles are applied to a particular individual, the principles are said to be the person's exercise prescription. Perhaps the best way to prescribe exercise to patients with an eating disorder is to first redefine what exercise is. Common definitions describe exercise as an activity for training or developing the body or mind. The average person with Anorexia or Bulimia Nervosa may interpret exercise as a way to cope with stressors or burn calories to help reduce weight. This sounds fine and may closely resemble what the rest of society has come to believe, but looking closely at what this really means to the person with an eating disorder, we see this distorted. Their intense fear of gaining weight, refusal to maintain a minimally normal body weight, and significant disturbance in the perception of the shape or size of his or her body drives these patients to over exercise. To these people exercise becomes an obsession. The client becomes obsessive in thought and compulsive in deed. Since society accepts exercise as a means of improving health, to persons with an eating disorder, it represents their freedom to engage in self-degrading behaviors under the guise of a socially accepted vehicle for improved wellness. A preoccupation with appearance may grow out of a preoccupation with health. This is one of many negative feedback cycles eating disordered patients face that yields stressed out, fatigued, and isolated individuals with low self-esteem.

Exercise becomes a perceived need and is often a determining factor for allowing them to feel like a success or failure. If their busy day didn't allow them to get their exercise done, they state an increase in stress and don't feel productive. Persons with Anorexia or Bulimia may feel they need to exercise, especially after eating. This perceived need also ties into the belief that their worthiness depends on how productive they are and since exercise is generally accepted as productive, the more of it the better. The person repeatedly exercises beyond the requirements for good health. Cardiovascular health requires that 2,000 to 3,500 calories be burned each week in aerobic exercise. After 3,500 calories are burned per week, the health benefits decrease, and the risk of injury increases. It should also be identified that many persons with an eating disorder also suffer from OCD or OCD traits, which further complicates these exercisers ability to regulate appropriate frequency, intensity, and time during their regime. The client may keep detailed records, scrupously observe a rigid diet, and constantly focus on an unattainable goal. Many times exercise becomes part of their daily rituals, in which they feel compelled to complete a specific number of repetitions, minutes, or miles depending on the activity.

There are a number of ways that the Recreational Therapist plays a distinct role in prescribing appropriate exercises and actually establishing a prescription. Of course, we must mention incorporating fun and play into the routine. The client focuses on challenge, and forgets that physical activity can be fun. Eating disorder clients' exercises of choice tend to be walking, running, and a multitude of house chores accompanied by vast quantities of sit-ups. These venues are usually pursued alone, to a high intensity, follow a rigid pattern, are a means for suppressing feelings, and allow few opportunities for breaks. This isn't a particularly healthy form of exercise, nor is it as fun as being in a group or with a partner.

As inherently social beings, we benefit significantly from participating in exercises with friends or any other people. Not only is exercising with others safer it yields opportunities for growth, emotional support, and healthy competition. Especially beneficial to exercising with friends is a potential sounding board for sorting out problems, rather than avoiding them and literally running away from them, as the typical over exerciser would do. Sociologists say we live in an age of narcissism, or self-absorption in our bodies and ourselves. Both men and women are expected to achieve perfect or near-perfect bodies: slim, toned, strong, agile, and aesthetically appealing. The closer people get to the cultural ideal, the more they notice the flaws that remain. They define self-worth in terms of performance. We all have at times experienced having ourselves being our worst enemy. This can especially be true when your standards are as high as those of the typical eating disorder. There is constant competition involved during the exercise routine for these people. Unfortunately, it is usually against themselves and unaccompanied by any joy or praise for successes. In this way, we see patients with eating disorders exercises as self esteem vacuums, where they are working hard, failing to meet expected (but unattainable) goals for themselves and therefore not deserving of external praise. This is justified in their mind as helping them to be thinner, more attractive, and therefore deserving of attention from others. The problem with this can be summed up in the adage, "you cannot, by doing something external, solve a problem that is internal". It isn't hard to see how this isolative, high-energy demanding, indirect approach to coping with problems is ineffective and tiring, thereby lowering self-esteem.

The Recreational Therapist working closely with persons having an eating disorder will also be able to assist them in encouraging that their exercise activities are properly motivated. These people will tell you outright that many times when they exercise or have exercised, it was primarily to burn calories and fat, deal with guilt from eating, or to avoid feelings. This is a form of purging and should not be called exercise. They will even say that they "need" to exercise rather than they "want" to exercise. If the exercise is motivated by eating disorder driven guilt, perceived "need", obsessive urge, or solely to burn fat (for below minimum target weight individuals) it needs to be called something other than exercise. To me, a better word for activities driven this way would be punishment. When you discuss this with eating disorder patients, they can relate and are usually surprised by the accuracy of this concept. This is a core concept for our exercise education groups and has helped eating disorder patients closely look at their use of the word exercise as a distortion of the true behaviors…purging and self-punishment. Teaching these persons that they are deserving of praise and are productive even in the absence of exercise and busy work is a challenging but necessary aspect of their treatment. Dr. Arnold E. Andersen, an internationally renown physician who heads the program at the University of Iowa Hospitals and Clinics, likes to tell our patients that they are human beings, not human-doings.

Another significant concept to assist prescribing exercise to persons with Anorexia or Bulimia Nervosa is the idea of considering total daily physical activity. Many of our subjects are students, workaholics, or not in work or school at all, but are active most of the day. Even though they may have walked to work or school, remained on their feet, participated in P.E. and after school sports, and fulfilled compulsive chores, they haven't "exercised" until they have visited the gym for at least 60 minutes of increased intense cardiovascular work. It should be mentioned here that a contributory factor to this belief is the health related media, in a nation dominated by predominantly obese and sedentary individuals. For many of us, our jobs may entail sitting at a desk or in front of a computer for eight hours per day, sitting in traffic jams, and then finally collapsing into a vegetative state at the TV or computer. This working majority of us could be said to "need" exercise in order to prevent or combat obesity, low energy, low cardio respiratory functioning, and many other associated concerns. Eating disorder patients however, have expended significant calories throughout their day and maintained a heart rate and respirations above resting rate, thereby eliminating the "need" for exercise.
Recreational Therapists play a significant role as ambassadors to promote stress management indirectly or directly to our clients. This topic warrants its own article, but can be touched on with regards to utilizing physical exercises as techniques many of us do use exercise to lower stress or to cope with stressors in our lives. To many persons with an eating disorder, relaxation or passive self-nurturing activities have disappeared from their lives. Replacing these means of reducing stress are active and seemingly "productive" asocial activities, devoid of pleasure or fun. In order to cope with their problems, we often see our clients avoid their situations, "stuff" their emotions, and attempt to externally control their internal struggles by exercising, restricting food intake, or purging. As any good stress management programs will emphasize, in order to relieve perceived stress, clients must tune into these problems, instead of stuffing their feelings or running away from the problem. These problems are in a sense "sent to the back burner", and as the pressure from these unresolved issues fester, stress boils to an overflow, leaving the person feeling overwhelmed. This stress "boil" can often be the driving force for excessive exercise. It may present itself as misplaced anger, guilt, disappointment, or dissatisfaction.

We have to bear in mind the compromised physical and mental capacities of persons with an eating disorder. Many have exercised and restricted to the point of exhausting their necessary stores of body fat. This prompts their body to break down muscle, organ, and tissues to provide the body with energy. The compromised heart and skeletal muscles reduces the functional capacity for the person's body to perform at, and recover from, an optimal level of physical activity. A decrease in cardiac chamber size, cardiac wall thickness, myocardial oxygen uptake, bradycardia, and hypotension are all possible associated secondary conditions to the clients' eating disorder. These secondary conditions can inhibit the exercise prescription, and could potentially be a life-threatening situation. The ability of anorectic patients to exercise at the level they do is surprising in view of their decreased cardiac capacity to respond to exercise demand. Most of these secondary conditions are reversible with weight gain.

There is much debate and uncertainty to the degree of which cognitive functioning and decision-making skills are compromised. We regularly observe eating disorder patients demonstrate a limited capacity to chose appropriate exercises, self-regulate obsessive-compulsive behaviors, and maintain a safe regime. The restricted mood and flat affect often displayed by persons with eating disorders, combined with frequent preoccupation with thoughts, can give the impression that there is a decrease in mental capacity. These patients' minds are actually very busy with their preoccupied thoughts…calculating calories, keeping mental food logs, worrying, and focusing on their dissatisfaction with performance or physical appearance. Theodore Reothke once said, "A mind too active is no mind at all".
Exercise prescription can also help restore another common medical problem of eating disorder clients, bone density. Decreased bone density very often to the degree of osteoporosis and osteopenia has been noted in women with chronic anorexia nervosa. Fractures or the vertebrae, sternum, and long bones are common complications among the eating disorder patients.

Digressing to the basic physiology of exercise, it is important to remind the client with an eating disorder what is happening to their body during exercise. When the muscles are strained, they are broken down. Over the following 48 hrs or so, the body, utilizing ingested food and periods of rest, rebuilds the lost tissues. The alarming combination of over exercising and restricting food intake renders the body helpless against the process of tearing the body down faster than it can rebuild.

Conforming to the concept of keeping energy input approximate to energy output, we prescribe an exercise with low F.I.T. (Frequency, Intensity, and Time) for the period in which they are restoring weight and until after at least 6 months of attaining their goal weight. It should be understood that at no time do we discuss the number of calories being burned or the client's weight, other than the general guideline of balancing energy input to energy output. We start the patient off with a frequency of only two to three times per week, have limits on intensity that don't allow their heart rate to exceed 55 - 60% of their maximal heart rate, and have a 20 minute limit on continual physical activity. We do also allow a five to ten minute warm-up and a five to ten minute warm-down on the front and back end of the exercise.

Upon admission to UIHC, patients with an eating disorder are required to remain relatively sedentary to interrupt their focus on physical activities as a primary segment of their day. This allows the patient having an eating disorder to focus on thought distortion, family problems, body image, self esteem, and many other core issues that often sprout the compulsive urges to over exercise or exercise for the wrong reasons. Equally important, this initial period of exercising at a reduced F.I.T. will allow the body tissues to restore and replenish. These factors will yield a mind and body more able to handle stress of exercise and responsibility of initiating and performing it appropriately.

Specific types of exercise we prescribe are low impact, low intensity, and have a small risk of falling or collisions. This prevents significant jarring of bones, damage to joints, tendons, and muscles that are made weak from these persons' poor nutrition. The exercises are to be performed with a partner or in a group as often as possible. Especially beneficial are modalities such as weight lifting, walking, and stationary cycling. These can be easily structured to start with lighter workloads and slowly progress to higher ones. This conditions the clients' bone density and lean tissue to progress accordingly. Building and maintaining muscle and bone mass requires weight-bearing exercise. Individual requirements vary depending on age and level of fitness. Overdoing weight-bearing exercise can tear down muscle tissue instead of building it, and also damage bones, joints, cartilage, tendons, and ligaments. Our prescription centers around the idea that their degraded body tissues and loss of weight need time to recover, so they will begin with a light work load and gradually progress to a more moderate one. The patients are able to restore lost weight and participate in physical activities during their stay, which greatly reduces anxiety from being sedentary and feel like all they are gaining is fat tissue.

Successful treatment of patients with eating disorders relies on the joint efforts of a variety of professions in the human services field. The most effective approach has been to follow a cognitive behavioral model and utilize a multidisciplinary team. Integral players in this team are physicians, nurses, dieticians, psychiatrists, occupational therapists, recreational therapists and social workers. The recreational therapist has a unique opportunity to allow patients to practice appropriate physical activities and teach exercises within the parameters of the prescription. Many of the professionals on our team have frequent discussion groups to address problems and concerns our patients focus on. The Recreational Therapist provides hands-on participation in guided activities to stimulate the patient to function in a similar fashion to that which they would do outside of the hospitalized setting. We are able to process through emotional struggles and catch inappropriate behaviors as they arise and even before they would happen, rather than significantly later than the stress inducing trigger took place.

Throughout our exercise sessions, we process how patients can be working on high self-esteem, body image, social skills, coping skills, and stress management. One of our best exercise groups to address all of these areas is aquatic therapy. We require the patient to wear a swimming suit, take them to an area surrounded by fitness equipment and full-length mirrors, and allow them to experience fun exercises in the water. Participants are able to improve not only a very safe modality of exercise, but directly requires the patient to address body image concerns and overcome fears of looking in the mirror. This has proven to be one of the most rewarding experiences for our patients as the high degree of initial anxiety yields a high degree of self-satisfaction upon completion of the activity.

Exercise prescription is one of the many ways in which the Recreational Therapist can intervene to foster improved rate of recovery for eating disorder patients. Our efforts in close conjunction with the multidisciplinary team, are paving the way for eating disorder patients to enjoy an active and healthy lifestyle in an appropriate balance with their nutrition and social lives. These individuals are more emotionally stable, more able to physically function closer to functional capacity, and demonstrate sounder cognitive skills than prior to beginning treatment. Most enjoyably, these persons are able to derive more fun out of their daily lives and can better balance the amount of work with play.


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