ACUTE Center for Eating Disorders

Denver Health’s unique program and the role of therapy in treatment

Megan Smith, SPTUniversity of Colorado—Anschutz Medical Campus

THE PROGRAM Acute Comprehensive Urgent Treatment for

Eating disorders Founded 2008 by Dr. Philip S. Mehler

First step in treatment for very ill patients Goal: Medical stability Prepare patients for inpatient or residential

treatment program Strength and ability to participate Consuming goal calories Normal labs—electrolyte balance Detox from purging mechanism, or alcohol/drug use

Typical LOS: 2-3 weeks3

THE TEAM Internal medicine MDs Dietician Nurses Psychologist Psychiatrist PT, OT, SLP Social work

Photos courtesy of Denver Health ACUTE website http://www.denverhealth.org/medical-services/acute-eating-disorders/our-team/internal-medicine-physicians

THE PATIENTS 50-70% of ideal body weight (IBW) BMI 12-14 (normal 18.5-25) Severe muscle atrophy Often have co-existing psychological

disorderAnxiety, depression, schizoaffective, bipolar

disorder, BPD

ED MEDICAL COMPLICATIONS Stomach/GI impairments Osteoporosis- irreversible Heart muscle weakness Cardiac arrhythmias and arrest Hypotension Hyperthermia Severe anemia Teeth, mouth and throat problems Severe electrolyte imbalances

Cardiac complications Memory loss and cognitive impairment

Refeeding syndrome: weakness, inability to breathe, seizures, mental confusion, cardiac arrest, coma, death Gradual caloric gains ACUTE prevents and treats associated complications

REFEEDING SYNDROME

ACUTE clinical research on risk factors for refeeding syndromehttp://www.denverhealth.org/medical-services/acute-eating-disorders/conditions-we-treat/refeeding-syndrome

NEXT STEPS Inpatient treatment

24 hr care, length of stay based on medical needs Psychotherapy—CBT, DBT Group meal time with dietician support Nutrition education, PT, OT, art therapy Daily visits from MD Transition pt. to residential program Goal: restore weight, stop symptoms, manage emotions, coping skills

Partial day program 8 hours/day, 3-5 days per week Psychotherapy, PT, OT, nutrition education MD visit, psychiatry, family therapy weekly Supervised group outings (restaurant, grocery shopping)

Intensive outpatient program (evening) 3 hours/day Supervised group meal Weekly psychotherapy, family therapy, MD visit and psychiatry

Outpatient program Frequency based on individual needs One on one with psychologist, dietician and medical doctor

Residential treatment Longer term treatment Live at facility 24 hrs/day Stay based on treatment needs Psychotherapy, PT, OT, education, nutrition, exercise Meal time, with dietician support Visit with MD weekly

Information provided by Park Nicollet, Melrose Center website (4)Photos by Eating Recovery Center, Denverhttp://www.eatingrecoverycenter.com/eating-disorder-facilities/behavioral-hospital-for-adults/

Many programs include exercise as part of comprehensive treatment Improved strength, flexibility, balance Educate and promote healthy, moderate exercise in the

future Incentive for patient Stress reduction, mood improvement Body awareness and appreciation Introduce different means of exercise Increased compliance with treatment program

Note: Most gains made in inpatient/outpatient once medically stable

PT/OT AND EATING DISORDERS

EVIDENCE FOR ACTIVITY Limited studies, limited sample sizes, no standard criteria or protocol Exercise Interventions for Women with Anorexia Nervosa: Review of the Literature1

Summary: Positive correlation between physical activity and weight restoration for patients with AN

Calogero & Pedrotty. 254 medically stable pts. 60 min sessions, 4x/week Posture, yoga, stretching, pilates, strength, balance, exercise balls, aerobic activity Women with AN gained 33% more weight Decreased score for obligatory attitude toward exercise

Thien et al Graded exercise program based on % IBW. Pts progress through levels as BW increases Both control and exercise group increased BMI, body fat (limited sample size)

Golden Moderate weight-bearing exercise for AN pts. Avoid excessive exercise that interferes with weight gain

Tokumura et al. Exercise group increased BMI and exercise capacity

Weight-bearing exercise does not prevent osteoporosis or increase BMD in individuals with AN

Beaumont et al suggest criteria for participation, similar to ACUTE’s criteria

Randomized Control Trial of Yoga in the Treatment of Eating Disorders2

8 week program of standard care + yoga vs. standard care. Yoga group: greater decrease in ED symptoms, decreased preoccupation

with food. No negative impact on BMI Increased self-awareness and self-soothing

THERAPY’S ROLE AT ACUTE Increase strength and stability to

enable participation in treatment program Postural muscles ADLs and transfers Gait and endurance Major muscle group training Swallowing technique/strengthening Safety

Nutrition = main contributor to improved strength, balance, endurance, function

PT/OT/SLP is complimentary

PT EVALUATION Bed mobility, transfers, ambulation, gait

velocity Gross ROM and strength (observed via functional

mobility) 5 times STS (depending on level of function)

>12 sec requires further assessment of fall risk Skin integrity Balance

Tinetti POMA (functional, but some limitations) Four Square Step Test Dynamic Gait Index (requires stairs)

<19 increased fall risk

ACUTE mobility program

ACUTE mobility program

>2000kcals + consistent weight gain

30 min. 2-3x/ weekFunctional mobility assessment

5xSTS, gait velocity, stairsBalance

Tinetti, 4 square step test, Berg/DGI, functional balance activitiesStrengthening/ conditioning

Light theraband exercises- major muscles groups- during PT only

CONSIDERATIONS Many patients are over-exercisers, or were

physically active before treatment EE: 6 hours/week or more of moderate to vigorous

exercise1

Typical adult recommendation: 2.5 hrs/week of moderate intensity + strength training major muscle groups 2x week

Compulsive exercising and obligatory, compensatory activity Educate on balance

Activity is good, in moderation, and requires fuel Respect for the body and its capabilities at each stage of

recovery Activity, and therapy, are one piece of the puzzle

ESTIMATED EXPENDITURE5

*Very gross estimate. Based on avg age 30, weight 75lbs (35kg), height 5’4”

Activity kCal. Calisthenics—moderate, 10 min. 26 Stretching—10 min. 22 Walking 0.90m/s (3mph) x 10 min 16 Sit-ups/core stabilization x 5 min. 13 Stairs—2 min (Up/down) 9 Standing 20 min 13Theraband activity (10 min) UE: 36kg (80lb) x 3 METs x 10min = 17.2 LE: 36kg x 3.6 METs x 10 min. = 20.7

30 minute PT or OT session is most likely <75 kCal. Ex: 10 min walk, stairs to 6th floor, theraband exercises LE, core strength=

~60kCal.

TIPS FOR WORKING ON ACUTE Treating these patients can be scary, but.. Assess and treat functional mobility

like other medical patients with deficits Atrophy and mild to severe weakness Postural control Balance ADL’s Sit to stand Monitor vitals

With consideration for psychological/emotional condition

TIPS FOR WORKING ON ACUTE Get to know the patient, beyond their ED Not all patients or ED’s are the same

Different stages in disease and recovery, forms of ED, psych issues

Patients can be emotional and sensitive—avoid triggers

Meal and snack time can be very stressful Many patients are high-achieving and want to

please Both a pro and con

Monitor: Vitals (HR, BP), fatigue, LOB

Stay positive and empatheticActive listening

Some patients feel forced or trappedEmphasize that the ACUTE team is on their

side Decline to discuss meals, pt’s weight, calorie

intake etc. and refer to appropriate providerStay focused on PT/OT goals

Be honest and direct with patientsBe aware of manipulative tendencies

It’s hard for anyone to know the “right thing” to say.

Experience helps

BIBLIOGRAPHY1. Zunker C, Mitchell JE, Wonderlich SA. Exercise interventions for

women with anorexia nervosa: A review of the literature. Int J Eat Disord. 2011;44:579-584. doi:10.1002/eat.20862.

http://onlinelibrary.wiley.com.hsl-ezproxy.ucdenver.edu/doi/10.1002/eat.20862/epdf2. Carei TR, Fyfe-Johnson AL, Breuner CC, Brown MA. Randomized

controlled clinical trial of yoga in the treatment of eating disorders. J Adolesc Health. 2010;46:346-351. doi:10.1016/j.jadohealth.2009.08.007. http://www.ncbi.nlm.nih.gov/pubmed/20307823

3. ACUTE center for Eating Disorders at Denver Healthhttp://www.denverhealth.org/medical-services/acute-eating-disorders4. Park Nicollet, Melrose Center (St. Louis Park, MN) website

http://www.parknicollet.com/SpecialtyCenters/Melrose-Center/Residential-Treatment

5. Caloric expenditure calculator https://www.healthstatus.com/calculate/cbc

*A special thank you to Michelle Laging and Christina Alvord

for showing me the ACUTE program in action*