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Physical Therapy in Eating Disorder Treatment Centers

Background and proposal for the inclusion of physical therapists on the comprehensive medical care team at the Eating Recovery

Center-Colorado at the inpatient, partial hospitalization, and outpatient levels

Megan Smith Doctor of Physical Therapy Student

University of Colorado-Anschutz Medical Campus May 2016

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Table of Contents Mission/Goal………………………………………………………………………3 Background information Eating Disorders……………………………………………………………3 Eating Disorder Not Otherwise Specified (EDNOS)………………3-4 Orthorexia…………………………………………………………..4 Medical Complications of Eating Disorders……………………….4-5 Refeeding Syndrome……………………………………………….5 Female Athlete Triad……………………………………………….5 Eating Disorder Treatment Centers……………………………………...…5-7 Eating Disorder Center of Denver………………………………….6-7 Eating Recovery Center……………………………………………7-8 Inpatient……………………………………………………7 Partial Hospitalization program……………………………7 Intensive Outpatient Program……………………………...8 Exercise and Eating Disorders Pathological Exercise………………………………………………8 Weight Restoration………………………………………………...8-9 Psychological Benefits……………………………………………..9 Evidence for Exercise.……………………………………………..9-10 Expert Opinion…………………………………………………….10-11 Conclusion…………………………………………………………11 Additional Considerations…………………………………………11-12 SWOT Analysis Strengths…………………………………………………………………...12-13 Weaknesses………………………………………………………………...13 Opportunities………………………………………………………………13 Threats and Challenges…………………………………………………….13-14 Timeline…………………………………………………………………………...15 Plan of Care………………………………………………………………………16-17 Table 1: Sample schedule…………………………………………………16

Table 2: Criteria for participation………………………………………...16 Protocol for Aerobic Exercise……………………………………………..17 Cost Analysis……………………………………………………………………..17-19

Table 3: Budget for Denver Health……………………………………….18 Figure 1: Break Even Analysis for Denver Health…………………………..18 Table 4: Budget for ERC………………………………………………….19 Figure 2: Break Even Analysis for ERC………………………………….19

Measurements of Success………………………………………………………..20 References………………………………………………………………………..21-22

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Mission and Goal

The goal of this new program is to implement physical therapy as part of the standard plan of care for patients at the Eating Recovery Center of Denver, CO. This is a novel approach to treatment that few, if any, treatment centers around the country include, and would help distinguish the ERC, providing care for all aspects of a patient’s medical condition, behavioral patterns, and their goals for returning to activity. Physical therapists are highly trained clinicians who are qualified to provide exercise therapy for patients with medical complications and psychosocial barriers. The goal of physical therapy will be to increase strength, prevent deconditioning, address mobility limitations and musculoskeletal complications, facilitate weight restoration, and decrease anxiety and eating disorder behaviors, which will increase compliance with inpatient and outpatient treatments. Ultimately, physical therapy may contribute to decreased length of stay or episode duration, and decreased relapse prevention by providing this guidance throughout the continuum of care. Background Information Eating Disorders

Eating disorders (ED) are a DSM-V classified psychiatric illness with both physical and psychological components, and can be divided into several subtypes. They are characterized by disturbed eating behaviors and psychopathology focused on food, eating and body image. Anorexia nervosa (AN) and bulimia nervosa (BN) are the most widely known disorders, but Eating Disorder Not Otherwise Specified is actually the most prevalent disorder, discussed below. Estimates for eating disorder lifetime prevalence is between 0.9% and 1.5% for women and 0.3-0.5% for men.1 Though the percentages appear small, this translates to millions of individuals.

Because of the co-morbid psychiatric and physical conditions associated with eating disorders, they are characterized as one of the most difficulty psychiatric illnesses to treat.1 According to numerous sources, eating disorders have significantly elevated mortality rates, and have the highest rate of any psychiatric illness.2 A fifth of individuals with anorexia who died had committed suicide. Most, but not all, patients have coexisting psychiatric diagnoses including depression, anxiety, obsessive-compulsive disorder (OCD), borderline personality disorder, bipolar disorder or phobias. Patients with anorexia and compulsive exercise exhibit a phenotype closely linked to OCD.3

Eating Disorder Not Otherwise Specified (EDNOS)

EDNOS is the most common disorder, representing 81% and 75% of adolescents and adults with ED respectively.4 Another source identifies EDNOS as accounting for 60% of all eating disorder cases.5 EDNOS encompasses patients with characteristics of other eating disorders, but who do not meet diagnostic criteria. Lifetime prevalence estimates for EDNOS is 4.6 for adults and 4.8 for adolescents. Included in this

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classification is binge-eating disorder (BED), sub-threshold binge eating disorder (SBED), and subclinical anorexia (SAN).

Characteristics show that EDNOS is as severe, if not more severe, than threshold eating disorders, classified anorexia nervosa (AN) or bulimia nervosa (BN). Compared to AN or BN, patients with EDNOS are more likely to have more severe psychopatholgy including anxiety and suicidality.5 Orthorexia

Orthorexia translates to “fixation on righteous eating” and is a relatively new term in eating disorders. It is not an official psychiatric diagnosis. The disorder is characterized by an obsession with the quality of food consumed, whereas anorexia is an obsession with the quantity of food. Though it begins innocently, patients become fixated with eating “pure” or healthy foods. They may only eat types of food that are “allowed”, and feel guilty if they do not adhere to their self-selected rules. Their rigidity may lead to health consequences, social isolation and inability to enjoy life due to their preoccupation.6

Characteristics include: ! Planning tomorrow’s food, spending 3+ hrs/day thinking about healthy food ! Skipping foods they used to enjoy ! Feeling guilt or self-loathing if they stray from their diet ! Feeling a sense of control when they stick to the ‘rules’ ! Experience a reduced quality of life or isolate themselves socially ! Fear of eating with others or dining out

Medical Complications of Eating Disorders

! Arrhythmias ! Hypotension ! Muscle atrophy and weakness ! Electrolyte imbalances

o Hypokalemia o Hyponaetremia

! Bradycardia ! Anemia ! Hormonal changes (reproductive, thyroid, growth hormones) ! Heart structure atrophies

o Related to hypovolemia o Low cardiac output, increased peripheral vascular resistance despite

hypotension ! Osteopenia/osteoporosis

o Fractures o Almost 90% of adult patients with AN have osteopenia and 50% have

osteoporosis after just a brief duration of this illness7 ! Complications in pregnancy

o Associated with preterm delivery o Low birth weight o Increased chance of C-section birth

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o Growth restrictions in infant o Low APGAR scores8

! Gastrointestinal complications o Loss of stomach peristalsis, constipation, SMA syndrome

! Tooth decay and esophagus damage due to purging behaviors Refeeding Syndrome

Refeeding syndrome may occur when patients have severely restricted intake, and begin the refeeding process. Treatment centers monitor patients closely and are equipped to prevent and address this potentially deadly syndrome. Consequences include:

! Arrhythmia ! Tachycardia ! Congestive heart failure ! Respiratory failure ! Seizures ! Hypophosphatemia ! Sudden cardiac death9

Female Athlete Triad

Female athlete triad refers to low energy availability (either by disordered eating or increased energy expenditure), amenorrhea, and low bone mineral density/osteoporosis. The triad, or any factor by itself, produces serious health risks and leads to increased musculoskeletal injuries in young athletes. Adolescent athletes should be regularly and closely monitored during seasonal and off-season in order to recognize and promptly address potential problems.10 It is crucial that high school and college coaches be educated on recognizing either disordered eating or pathological exercise behaviors in young athletes in order to prevent physical injury, or progression of the eating disorder. Under this proposal, the physical therapist, along with a dietician, may visit area schools or colleges to provide this necessary education to coaches and athletic department staff. Eating Disorder Treatment Centers

Treatment centers almost always strictly control patients’ activity level in attempt to discourage compensatory physical activity and limit calorie expenditure. Inpatient facilities may encourage patients to stay seated most of the day, and only get up or walk when truly necessary. For most patients, this activity while in treatment is far below their average, especially for regular exercisers or athletes. According to Dan Malone, PT, DPT, CCS, it is clear that this sub-threshold level of activity will lead to hospital-acquired deconditioning. Although nutrition and psychotherapy are the biggest components of restoring health in ED patients, physical therapy can supplement these therapies and contribute to preventing or reversing atrophy and deconditioning.

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The core components of eating disorder treatment are psychotherapy (which may include DBT, CBT, family therapy etc), nutrition, and medical care. Consequently, the core care team consists of psychologists and psychiatrists, medical doctors, and dieticians, with additional professionals depending on the facility.

Many treatment centers include some form of physical activity, including yoga and dance therapy.

Johns Hopkins Eating Disorder Center includes a daily walks, supervised gym time or relaxation/stretching group with nurses. While nurses can respond to medical complications, they are not trained in individualized exercise prescription. Dr. Angela Guarda, MD, medical director for the Eating Disorders Program at Johns Hopkins, responded via email about their limited use of physical therapy. The program only uses PT for specific patients who have a clear need for it, including very debilitated patients and those with assistive devices. Physical therapy is not used routinely for all patients out of concern that it will interfere with weight restoration and perpetuate compulsive exercise behaviors. She also highlights that many patients on the unit discretely perform isometric exercises, and the program aims to eliminate such behaviors.

It should be noted, however, that the following research indicates that physical therapy is more likely to reduce pathological exercise behaviors, and change patients’ view and relationship with exercise. The evidence also shows that centers should not be concerned about hindering weight restoration with physical therapy.

The reasons stated by Dr. Guarda are common themes, and almost identical to those cited by the Klarmen Center for Eating Disorders, a Harvard Medical School Affiliate. Dr. Thomas Weigel, MD also discussed the compulsive exercise component of many disorders, as well as the goal of weight gain in treatment, again with the fear that activity may hinder this progress. He states that ideally the center would have staff to prescribe individualized exercise protocols, and provide supervision and gradual exposure to exercise. Like Johns Hopkins, The Klarmen Center periodically refers to PT for patients that have a clear need, such as those with specific injuries. Like other centers, this program also offers yoga with a contracted instructor.

Monte Nido, with treatment centers in California, Oregon, Massachusetts and New York, does include strength training and physical therapy. Thus far, the program director has not responded to communication. The Eating Disorder Center of Denver (EDC-D)

The EDC-Denver provides partial day hospitalization, intensive outpatient and outpatient programs, however no inpatient program. They also offer a specialty track for athletes and performers. They address the physical and mental aspects of returning to sport after treatment. Sports psychologists and strength and conditioning consultants contribute to the patients’ plan of care, in addition to standard care providers.11

The addition of physical therapy to the ERC would add a component to treatment that competes with programs such as the ELITE track at the EDCD. The specialty track addresses special considerations regarding athletes, and helps them progress to high levels activity under guidance of a physical therapist. Physical therapists can advance patients safely, address psychosocial components of exercises, and educate patients on

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healthy exercise behaviors and the demand for adequate nutrition for such activities. The ERC can promote the addition of physical therapy, which may attract athletic or active individuals to the clinic for treatment, or referrals from physicians or coaches. The Eating Recovery Center (ERC) Denver, Colorado The Eating Recovery Center has 12 sites in 7 states around the country, offering all levels of care for adults and adolescents, both men and women, with eating disorders. The ERC treats a wide spectrum of eating disorders, as well as mood and anxiety disorders. The ERC is a private organization and not affiliated with a hospital or medical center. It is accredited through the Joint Commission, but specific accreditation for eating disorder treatment centers has yet to be established. The following are the levels of care available at the ERC-Denver, in which physical therapy will be offered.12 Inpatient Program

This program is for women and men who are acutely ill and have medical or mood instability as a result of their eating disorder. This is the highest level of care offered at any treatment center including the ERC, with a focus on achieving medical stability, weight restoration and interrupting eating disorder behaviors. Patients live at the

center full-time and there is 24/7 nursing care. The program has a strict schedule with almost every minute of the day planned from 6:20 to 10:00pm12. Patients work with physicians, psychiatrists, psychologists/counselors, nurses, and dieticians, and participate in sessions such as group therapies, skills groups, and fresh air time. Patients have 3 meals and 3 snacks throughout the day, all of which are supervised. Patients have the least amount of freedom and control in this setting. Once medically stable, patients may step down to

the residential unit. Patients with extremely low body weights and serious medical instability may be admitted to Denver Health’s ACUTE program for stabilization. Partial hospitalization program (PHP) Patients spend the day at the treatment center, and nights at home, much like a school day or workday. They will have all three meals and snacks at the center. Other centers offering partial-day programs allow patient to have dinner at home. Sessions throughout the day include skill building for dealing with real world issues, psychotherapy groups, art therapy, yoga, meal planning and grocery shopping. Patients are in the program from 7:45am to 7:00pm,12 leaving no time for activity or outpatient appointments.

Under this proposed program, physical therapy will be implemented into the partial-day program schedule in order to progress patients toward their goal and provide the physical

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and psychological benefits of education and activity, which are highlighted throughout this proposal. Goal setting, individualized exercise plans and appropriate progression will be implemented and supervised by a Doctor of Physical Therapy. Patients may continue to participate in yoga on the weekend. Intensive Outpatient Program (IOP) Many centers include this service for patients who need more guidance than that just follow up appointments, but still participate in day-to-day activities or work. Sessions are typically 3-4 hours, a few nights per week. The ERC conducts 4-hour sessions, 3 days per week.12 The sessions include dinner, and offer education, nutrition guidance a support throughout the meal process. With this proposal, patients will continue IOP programming as scheduled, but may chose to attend outpatient physical therapy appointments in addition. Exercise and Eating Disorders Pathological Exercise

Estimated prevalence of excessive exercise for people with ED varies widely between 39 and 70%, however many studies have varied definitions of ‘excessive.’ Among patients with anorexia, 80% are estimated to have excessive exercise habits.1,13

Still researchers predominantly focus on exercise as it perpetuates ED instead of its treatment potential. It is important to address unhealthy levels of exercise, however exercise itself should not be viewed negatively. Instead, it should be moderated, or promoted in cases where it is absent, in patients who are appropriate for activity (e.g. medical clearance by MD). Furthermore, several studies suggest a model where the pathological motivation to exercise (dependency) is the distinguishing factor of eating disorders, not the exercise behavior itself (frequency, duration, type, intensity). Patients with ED do not differ from controls in physical activity level, but women with ED report increased compulsion to exercise.14 Physical therapists have a role in changing this pathological, compulsive relationship with exercise, and helping patients view exercise as part of a healthy lifestyle when used in moderation. There are many benefits to exercise: psychological (e.g. self esteem, anxiety, depression, body image) and physical (e.g. reducing chronic pain, substance abuse, obesity, osteoporosis).14 Exercise promotes self-regulation, reducing tension and negative mood, which may help patients deal with everyday stress, and decrease binging/purging behaviors. However, while there are benefits of exercise (improved mood and well-being, decreased anxiety), many pathological exercisers develop their dependency on exercise for these reasons. Weight Restoration

Eating disorder centers often worry that exercise will counteract their efforts to address body weight (discussed above in “Eating Disorder Treatment Centers”), however this philosophy is flawed. Patients’ exercise level does not predict the calories required for weight gain. Results from the available evidence show no negative effect

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on weight gain in patients with anorexia. In those with bulimia, exercise may contribute to weight loss.14 Other studies, such as the systematic review discussed below, show that exercise program participants actually gain more weight and body-fat than controls. The ability to exercise may decrease anxiety associated with weight gain, and improve overall compliance with eating disorder treatment.1

Furthermore, physical therapy treatment will begin with light strength training, and avoid aerobic or vigorous levels of activity until patients are appropriate. This will limit HR response and caloric expenditure. Strength training for 30 minutes requires about 100 calories, depending on patient weight. Patients in the partial day program at the ERC currently participate in 60 minutes of yoga, which requires >120 calories.15 If eating disorder facilities are allowing patients to participate in activities such as yoga and dance therapy, then the proposed physical therapy session clearly does not counteract the center’s goals of weight restoration. This expenditure is a relatively small portion of total calories consumed. More importantly, the physical and psychological benefits of exercise, discussed above, outweigh the expenditure.

Psychological Benefits

As stated earlier, allowing patients to exercise in a supervised and controlled setting may decrease anxiety and eating disorder behaviors. Exercise has also been shown to alleviate depressive symptoms in clinically depressed adults.16 This non-pharmacological treatment of depression, in conjunction with traditional therapies, may aid in addressing psychological components of eating disorders, facilitating progression through treatment and shorter episodes of care.

Evidence for Exercise A recent systemic review by Vancampfort et al examined 8 RCTs, 3 of which

were of strong methodological quality. They excluded studies where less than 2/3 of participants had a formal diagnosis of BN or AN. They concluded that aerobic and resistance training results in statistically significant increases in strength, BMI, and body-fat percentage in patients with anorexia. This review also indentified studies that show aerobic exercise, yoga, massage and body awareness therapy led to significantly lower scores of eating pathology and depressive symptoms in all ED patient. Physical therapy for patients with binge-eating disorder, including aerobic or yoga exercise, reduces number of binges and BMI.

One study mentioned in this review included adolescent patients with AN, and found that resistance training was well tolerated and did not negatively affect patients’ health or body mass. They concluded that strength training can occur at early stages of the disease.

Exercise, including aerobic activity and yoga, may reduce eating disorder behaviors and eating pathology in bulimia and binge-eating disorder. Exercise also contributes to decreased anxiety and improved body image.1

A review by Hausenblaus et al examined several exercise intervention studies with eating disorder populations. Two studies by Calogero and Pedrotty (one being the

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largest of all studies, n=254), used group exercise sessions, and found that the exercise group had decreased obligatory exercise scores compared to controls. The exercise group also gained more weight than the control group. Another study by Tokumura et al, despite small sample size, found statistically significant results favoring the exercise group. This group had higher BMIs and increased exercise capacity compared to controls. The exercise training, which was 30 minutes of stationary cycling, 5 days per week, did not have adverse effects on recovery of menstruation or ED relapse.14

Many clinicians view exercise as a cause of eating disorders, and imply that it should not be implemented in care. However it may be a useful in treatment as long as pathological exercise motivation is addressed.

Among the studies performed, there is no consensus on protocol in regards to session duration, type of exercise, frequency or intensity. Thus far, evidence for exercise in treatment has limited methodological quality, using small convenient samples, limited follow up, variability between control groups, short exercise interventions, and therefore the results may not be generalizable.

One recent review attempted to synthesize guidelines for exercise in eating disorder treatment. The article states that exercise, though used for other psychological illnesses, is overlooked in the eating disorder population. By examining current literature this article found 11 core themes in successful therapeutic exercise programs for eating disorders. The guidelines are: employ a team of relevant experts, monitor medical status, screen for exercise related psychopathology, create a written contract of how therapeutic exercise will be used, include a psycho-educational component, focus on positive reinforcement, develop a graded exercise program, begin with mild intensity exercise, modify the mode of exercise to the needs of the individual, incorporate nutrition, and debrief after exercise sessions.17 Physical therapists can address all of these core components as providers at eating disorder treatment centers.

The use of physical therapy as part of multidisciplinary care for eating disorders is still in its infancy, but is a promising development in treatment. Program directors identify lack of evidence as one reason that physical therapy has not been used. While there is a need for higher quality, larger studies with an established protocol, the evidence that is available indicates that exercise is safe and beneficial for patients with all types of eating disorders, and may lead to better outcomes. Furthermore, it has been shown that the supervised exercise programs do not exacerbate symptoms nor hinder patient treatment.

As this is a developing method of intervention with no established protocol, a physical therapist is the best professional to oversee activities and appropriately prescribe exercise. Hausenblaus et al suggest that future interventions should adhere to ACSM exercise guidelines, which physical therapists are trained to provide. Expert Opinion

An international cross-sectional survey was conducted with physical therapists that have experience in the field of EDs. Twenty-eight physical therapists from three continents participated, and concluded that the key role of physical therapists is in improving body awareness during physical activity as well as with psycho-education on healthy does of activity. The participating physical therapists provided details on interventions currently used for this population which include: physical interventions

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(exercise), manual therapy (joint mobilizations, soft tissue) for patients with low BMI and there was a need to work on joints, heart and breathing, psychotherapy interventions (relaxation techniques, mindfulness, rational-emotive therapy), education on adjusting physical activity and including body awareness, and the use of Basic Body Awareness Therapy (common in Scandinavia) to “change the experience of exercise and movement.” Therapists should help the patient be aware of their current physical condition, and accept changes in body weight. They guide patients to a new perspective on physical activity and body image. Of these therapists, 73% strongly agree and 21% agree that physical therapists should have a central role in delivering physical activity in person with ED.18

Michelle Laging, PT, DPT conveyed her professional opinion through personal

communications. She is a physical therapist at Denver Health Medical Center, and the primary PT at the ACUTE program for treatment of severe eating disorders. She works with patients who have extremely low BMIs or medical complications that prevent them from admission to standard treatment centers. In her opinion, physical therapists can greatly benefit patients in various settings of eating disorder treatment. Unfortunately, this is a missed opportunity for most patients. She initiates much-needed patient education and individualized activity programs. However, there is no follow through once patients leave the unit and progress to other treatment centers. Physical therapists should educate on the appropriate balance between nutrition and exercise, an issue that is often skipped over, unless the patient is an athlete. On the ACUTE floor, patients have clear limitations in mobility, which impact ADLs, transfers, balance or gait, and the role for PT is more obvious in this acute care setting. However, physical therapists are the appropriate clinicians for this task in any level of treatment. As doctors of the profession, they are trained experts in providing exercise and appropriate progression with consideration for patients’ medical status. Physical therapists can treat a variety of other conditions as well, and know when to refer to other providers. She also acknowledges the benefits of other professionals who may provide care in conjunction with PT. The Conclusion

The evidence, though somewhat limited methodologically, does support aerobic and resistance training as part of multi-disciplinary treatment for eating disorders. Supervised exercise programs have positive effects on body weight, body composition, eating disorder behaviors, anxiety and other psychological factors, exercise capacity, and compliance with treatment. Additional Considerations

Eating disorder treatment facilities have been scrutinized for becoming luxurious, spa-like, and bribing clinicians for referrals. This is highlighted in a recent New York Times article, in which the ERC is discussed both positively and negatively.19 Centers are becoming more money driven than patient-focused. Physical therapy at these treatment centers will illustrate a priority for patient-focused care aimed at treating physical and psychosocial conditions, and not simply adding an “amenity.”

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There are numerous articles addressing the lack of insurance coverage for eating disorder treatment. The addition of physical therapy, a skilled service provided by healthcare professionals, and routinely used in acute care settings, may aid in legitimizing treatment centers, such as the ERC, making it more likely for insurance companies to cover costs. Long term, these services may contribute to accreditation, and reimbursement rates for centers providing highly skilled services may increase. SWOT Analysis Strengths

! Physical therapists are doctorate level professionals, and are the most appropriate providers to prescribe, monitor and progress exercise for medically complex individuals. They can address important components of eating disorder treatment.

o Given the high percentage of individuals who exhibit excessive and compulsive exercise behaviors (80% among patients with AN), there is a clear role for physical therapy in education and introduction to healthy levels of activity.13

o Activity should be promoted among patients who do not exercise, and instead use other detrimental compensatory behaviors. Physical therapists are trained to progress exercise appropriately for non-exercisers and educate on how to make it part of a healthy lifestyle

! Current available evidence supports exercise for eating disorder treatment o Patients who participate in exercise programs may increase BMI and

body-fat composition above that of controls1 o Patients may also be more compliant with overall treatment, and decrease

anxiety and eating disorder behaviors o This may lead to better outcomes and quicker discharge or progression to

step-down programs. The ERC will be able to market this, which may increase referrals or patients choosing ERC for treatment

! Physical therapists can also address psychosocial aspects of a patient’s treatment. o Physical therapists can educate and change patients’ perspective and

relationship with exercise, and promote body awareness ! Physical therapists will be part of the medical team and participate in rounds,

offering a professional opinion on each patient. o PT will monitor vitals and response to exercise. PT can perform formal

evaluations and outcome measures when indicated. ! Provides a level of care that competes with the Eating Disorder Center of

Denver’s treatment for athletes ! Athletes or active individuals will be more likely to choose the ERC given the

opportunity to receive guidance from a physical therapist ! May promote ERC compared to other treatment facilities if it offers evidence-

based treatment and involves doctorate level professionals trained to handle the complications of eating disorders

! There will be an established protocol and requirements that patients must meet to begin/continue participation

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o There will be criteria for returning to aerobic activity and appropriate progression for return to sport

o This provides incentives for patients to comply with treatment ! The physical therapist works part time, and is able to address patients in all levels

of care: inpatient, outpatient and partial hospitalization programs o ERC will continue yoga, or other activity therapies.

! Promotes Denver Health physical therapy as a clinic that can treat patients with eating disorders or complications from EDs, assisting them with activity progression and education

! Few variable costs ! Treatment is provided by a licensed medical professional, adding legitimacy to

the treatment center, and proves medical necessity.

Weaknesses ! Billing

o ERC will implement billing for physical therapy, requiring increased cost ! Program requires taking PT away from Denver Health clinic

Opportunities

! Patients may choose to continue or initiate outpatient appointments with the physical therapist in order to safely return to previous level of activity. This is especially beneficial for athletes returning to competitive levels of activity.

o Plan to expand outpatient hours depending on interest and program growth o Increased profit with increase in outpatient utilization

! Education with NCAA coaches on eating disorders and athletes, using NEDA Coaches Toolkit

o Single fee paid by athletic department o Meet with all coaches at the beginning of school year

! Physical therapist will be offered the opportunity to pursue a Nutrition Certification for Healthcare Professionals

! Physical therapist will represent the program at eating disorder conferences ! Expansion of physical therapy programming to other ERC sites nationwide

Threats/Challenges

! Use of other therapies (yoga, dance, recreational therapy etc) provided by non-medical professionals

! Concern for encouraging exercise with patients who have pathological/compensatory exercise behaviors (Discussed in Background Info)

o The purpose of implementing a physical therapist in the care team is to educate and encourage healthy doses of exercises, regardless of a patient’s prior level of activity. Exercise has countless benefits for physical and mental health. Providers should be encouraging various modes of exercise (Pilates, yoga, cycling), and weight-bearing exercise is beneficial for bone growth. However patients should be educated that with exercise, comes an increased demand for balanced nutrition and adequate calorie expenditure.

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! Concern for hindering patient’s weight restoration (discussed in Background Info) o Studies show that exercise/physical therapy in eating disorder

rehabilitation programs does not hinder weight restoration, and may contribute to increases in BMI. Strength training in physical therapy will help build muscle mass and reverse atrophy and muscle damage that has occurred from the disorder. Furthermore, the addition of physical therapy may calm anxieties related to mealtime, decrease ED symptoms, and leads to increased compliance with treatment.

o 30-minute sessions of strength training require about 100 calories, depending on patient weight. Patients currently participate in 60 minutes of yoga, which is estimated to require >120 calories

! The benefits of activity highlighted earlier, and possible contribution to weight gain and treatment adherence, outweigh expenditure

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Timeline

2+ weeks • Background research and development of business plan • Handouts for proposal to ERC

Week 0-2

• Meetings with ERC and Denver Health • Draft contract with DH and ERC

Week 3-5

• Purchase supplies • Finanlize and create documents for plan of care, protocol, criteria for progression, exercise logs

Week 6

• Set up gym and office space • Meetings with multidisiplinary care team • Meet with outpatient care team, supply PT handouts

Week 7

• Day 1: Patient meetings, goal setting • Day 2: Rounds, patient meetings (inpatient and partial)

Week 8

• Full inpatient and partial programs begin • Begin outpatient appointments

Week 9-13

• Market for outpatient referrals: Meetings with family physicians, nutritionist offices in metro area to educate on the role of PT for patients with eating disorders, or with complications from eating disroders, and outpatient services offered

Week 20 & 32

• Program review with ERC and DH representatives after 3 and 6 months of physical therapy services to assess success and patient response

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The Plan of Care The physical therapist will be employed by Denver Health Medical Center, as this

center is home to the ACUTE program for the severe eating disorders, and currently has a primary physical therapist for this population, as discussed earlier. The PT will work 2.5 days per week, totaling 21 hours, for example Tuesday, Thursday and Friday. Below is a sample schedule. Inpatient and partial-day time blocks may be interchangeable based on each program’s schedule and patient tolerance.

Outpatient appointments may be physical evaluations and treatment, or discussion-based meetings with patients.

Table 1: Sample Physical Therapist Schedule Day 1 and 2 7:30-8:30am Reviewing patient charts/status and new admits

Patient rounds with care team 8:30-10:00 New patient individual meetings (inpatient and partial)

Re-evaluations with current patients to discuss goals, patient education 10:00-10:45 Adolescent inpatient group 11:00-11:45 Adult inpatient group

Document participation, patient progression after sessions 12:00-1:00pm Lunch 1:00-2:00 Adolescent partial day program

With add-ons from residential 2:00-3:00 Adolescent partial day program

With add-ons from residential 3:00-4:30 Outpatient appointments

30 minutes each 3 patients

Day 3 8:00am - 12:00pm Outpatient appointments

30 minutes each 8 patients

Table 2: Criteria for participation in group physical therapy Medical Behavioral BMI 16+ or up 1 point from admit BMI* Consuming 100% of meal plan (no

replacements) Hemodynamically stable Hb >8

Respectful to other patients in group (One warning given)

Normal glucose and electrolyte blood values Participates in psycho-therapy No lines or tubes Patient demonstrates pattern of weight

restoration if that is goal No concerning dysrhythmias or angina Resting SBP >80mmHg20

SpO2 >89%

Normal HR and BP response to activity (Sit to stand, ambulation)

Independent with ambulation and sit to stand *Lois Neaton, PT, physical therapist at Melrose Center (MN) contributed to these guidelines

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Patients will be assessed on an individual basis and the physical therapist will decide if there are additional medical concerns or circumstances that indicate PT should be held. The other care team members will also provide their professional opinions on each patient during rounds, and voice any concerns or contraindications to exercise. The physical therapist will educate patients and care team members that exercise is neither a reward nor a punishment. It is part of each patient’s physical and psychological recovery, and must occur in combination with other therapies. In the inpatient setting, patients cannot expect to participate in exercise if the nutrition and psychotherapy components of treatment are not in place. Protocol for Aerobic Exercise Program

Aerobic exercise programs will typically occur in Intensive Outpatient, and possibly partial-day programs. Patients must have a BMI within normal limits (>18.5) to begin aerobic exercise training. Female patients must have active menses or estrodial levels that indicate normal levels for menses.21 All criteria above also apply. Patients must demonstrate compliance with nutrition plan if this is still a concern. If the patient loses weight, the physical therapist will consult with the patient’s physician or dietician.

The program will begin with 20-30 minutes of walking or other moderate intensity aerobic activity (40-60% of HRmax, RPE 11-13). The program will progress depending on patient goals and prior level of activity. A submaximal test may be performed to educate patient on target RPE based on heart rate.

It should be noted that with the inclusion of physical therapists on the care team, all providers would be aware of the patient’s activity level. Treatment, particularly nutrition, can be adjusted to meet the increased demand. Cost Analysis

As illustrated in the tables and figures below, the Eating Recovery Center will experience an initial net loss due to expenses. However, if the demand for outpatient appointments increases, there is a break-even point. This would occur if the half-day on Friday becomes a full 8-hour day, with all appointments filled. Denver Health will begin the program with a net profit, however there may be additional costs not addressed here. DHMC may or may not need to staff the void left by the physical therapist now working at the ERC.

Most importantly, despite the initial cost to the ERC, the benefit to patients, discussed in depth throughout this proposal, far outweigh the cost. The ERC would offer a service that very few facilities nationwide offer. This sets the ERC apart, and as mentioned earlier, may lead to increased referrals and patients choosing the ERC for treatment.

The graphs below demonstrate break-even analysis based on the growth of outpatient services. The start-up costs for each clinic are not included in the graphs, but can be found in the tables below. Denver Health will pay an initial $185 and the ERC will pay $1400.

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Table 3. Budget for Denver Health Medical Center Item Cost Per year Fixed Costs Step up (x2) $90 Ankle weights (x4) $50 Yoga mats (preexisting) $0 Physioballs (x3) $25 65” ball x2

$20 55” ball x1

Total $185 PT salary & benefits for time at ERC $35/hour x1.322

$955.50/week $47,775

Variable Costs Exercise log printing $.03/page x 28 new

pts/week= $0.84/wk 23 $42

Theraband (50yd) $73 yellow $84 Green $100 Black

$257 ($4.94/wk)

Reimbursement $60/hour $1260 per week (21

hours) $65,520

Difference $17,446

Figure 1: Cost analysis for Denver Health Medical Center based on number of outpatients, and thus number of hours PT devotes to ERC. Assumed no increase in equipment or staffing needs.

= point at which Friday schedule is full

0

200

400

600

800

1000

1200

1400

1600

1800

14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Dol

lars

($) p

er w

eek

Number of Outpatients per Week

Break Even Analysis for DHMC

Reimbursement from ERC

Cost

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Table 4. Budget for the Eating Recovery Center-CO Item Cost Per week

(21 hours) Per year Total

Billing set up $500 Office set up $500 Treadmill $400 TOTAL $1400 Variable costs Payment to DHMC

$60/ hour $1260 $65,520

Reimbursement

Outpatient $75/patient $1050 $54,600 Difference $ -210 $ -10,920

Figure 2. Cost analysis for the Eating Recovery Center based on increase in outpatient appointments, subsequent increase in payment to DHMC for hours, increased reimbursement, and no change in equipment or staffing needs

= point at which Friday PT schedule is full

0

500

1000

1500

2000

2500

14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Dol

lars

($)

Number of Outpatients

Break Even Analysis for ERC

Reimbursement

Cost

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Measurements of success Patient Survey The first measure of success for this program will be subjective measures from patients. Two of the measures listed below have been highlighted in previous studies with this population. They will measure the psychological aspects of a patient’s condition to see if PT aids in improving body awareness and eating disorder behaviors as suggested earlier. The third measure is a survey administered to patients after discharge from their respective program. It will specifically address how the patient feels physical therapy did or did not affect their treatment or return to activity.

! Body Awareness Rating Scale ! Eating Disorders Inventory or Eating Attitudes Test18 ! Patient survey for physical therapy program

BMI tracking Data on patients’ BMI values will be compiled and graphed for the inpatient

setting. Each graph will represent 2 weeks of data. Data will be retrospectively collected from the previous 3 months for comparison. Each graph will be analyzed for trends in the rate of BMI increase. At the 3-month assessment of this program, the data will be examined to see if there is any change BMI progression with the inclusion of physical therapy in treatment. The goal of this measure is to assure that physical therapy does not impede goals of weight restoration. Length of Stay/Readmission Rates

These measures may already be documented, but they will be examined at the 3-month assessment to look for any differences before and after implementation of the physical therapy program. There are numerous factors that contribute to length of stay or readmission, and it may be difficult to attribute any changes to physical therapy. But it will be something to consider and worth examining. Outpatient

The number of outpatient appointments filled per week will be tracked and graphed. This measure is crucial for assessing success of the outpatient physical therapy program. It reflects patients who choose to continue PT follow-ups after receiving care in partial-day programs or inpatient. It also reflects the success of marketing to primary care physicians and coaches who may refer patients or athletes to this program. Finally, this measure will determine when it is appropriate to increase the number of outpatient appointments offered per week, expanding the program and increasing reimbursement for the ERC.

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References

1. Vancampfort D, Vanderlinden J, De Hert M, et al. A systematic review of physical therapy interventions for patients with anorexia and bulemia nervosa. Disabil Rehabil. 2014;36:628-634. doi:10.3109/09638288.2013.808271.

2. Kaye, Walter MD. Mortality and Eating Disorders. National Eating Disorders Association website. https://www.nationaleatingdisorders.org/mortality-and-eating-disorders

3. Davis C, Kaptein S. Anorexia nervosa with excessive exercise: A phenotype with close links to obsessive-compulsive disorder. Psychiatry Res. 2006

4. Le Grange D, Swanson SA, Crow SJ, Merikangas KR. Eating disorder not otherwise specified presentation in the US population. Int J Eat Disord. 2012

5. Fairburn CG, Bohn K. Eating disorder NOS (EDNOS): an example of the troublesome “not otherwise specified” (NOS) category in DSM-IV. Behaviour Research and Therapy. 2005

6. Kratina, Karin, PhD, RD, LD/N. Orthorexia Nervosa. NEDA website. https://www.nationaleatingdisorders.org/orthorexia-nervosa Accessed May 2, 2016.

7. Laging, Michelle. Severe Malnutrition and the Role of Physical Therapy in an Inpatient Setting. Lecture at CU DPT program, May 3, 2016

8. Dotti JC. Eating disorders, fertility, and pregnancy: Relationships and complications. J Perinat Neonatal Nurs. 200. 15:36-48

9. Casiero D, Frishman WH. Cardiovascular complications of eating disorders. Cardiol Rev. 2009;14:227-231.

10. Rauh MJ, Barrack M, Nichols JF. Associations between the female athlete triad and injury among high school runners. Int J Sport Phys Ther. 2014. 9:948-958.

11. Eating Disorder Center-Denver. Available at: http://www.edcdenver.com/elite-athlete-program. Accessed April 2016

12. The Eating Recovery Center-Colorado. Available at: https://www.eatingrecoverycenter.com/programs/colorado/. Accessed April 2016.

13. Davis C, Katzman DK, Kaptein S, et al. The prevalence of high-level exercise in the eating disorders: Etiological implications. Compr Psychiatry. 1997

14. Hausenblas HA, Cook BJ, Chittester NI. Can Exercise Treat Eating Disorders? Exerc Sport Sci Rev. 2008

15. Sparkpeople, Calories Burned. Available at: http://www.sparkpeople.com/resource/calories_burned.asp?exercise=507. Accessed April 2016

16. Josefsson T, Lindwall M, Archer T, Institutionen för idrottsvetenskap (ID), Fakulteten för samhällsvetenskap (FSV), Linnéuniversitetet. Physical exercise intervention in depressive disorders: Meta‐analysis and systematic review. Scandinavian Journal of Medicine & Science in Sports. 2014

17. Cook B, Wonderlich SA, Mitchell J, Thompson R, Sherman R, McCallum K. Exercise in Eating Disorders Treatment: Systematic Review and Proposal of Guidelines. Med Sci Sports Exerc. 2016

18. Soundy A, Stubbs B, Probst M, et al. Considering the Role of Physical Therapists Within the Treatment and Rehabilitation of Individuals With Eating Disorders:

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An International Survey of Expert Clinicians. Physiotherapy Research International. 2015.

19. Goode E. Centers to Treat Eating Disorders Are Growing, and Raising Concerns. The New York Times 2016. Available at: http://www.nytimes.com/2016/03/15/health/eating-disorders-anorexia-bulimia-treatment-centers.html. Accessed May 3, 2016

20. Class Notes, Medical Conditions III. By Dan Malone, PT, DPT, CCS. Spring 2016

21. Neaton, Lois, PT. Physical Therapist at Melrose Center, St. Louis Park, MN. Email communications, April/May 2016.

22. Richards, Leigh. “Cost of Employee Benefits for an Employer.” Available at: http://smallbusiness.chron.com/cost-employee-benefits-employer-2694.html Accessed May 1, 2016

23. Stone, David. Cost-per-page analysis. Available at: http://www.pcmag.com/article2/0,2817,1625352,00.asp. Accessed April 28, 2016