Research Apilotbodyimageintervention programmeforin-patientswitheating disordersinanNHSsetting Patricia Caddy, Barbara Richardson Background: Body image distortion, a distressing problem that precipitates eating disorders, remains a struggle for patients after other symptoms are controlled. Despite a strong physical aspect there is little recognition of physiotherapy intervention. This study aims to assess the effect of a tailored physiotherapy intervention programme for patients with eating disorders in an NHS in-patient unit. Methods: The intervention programme, targeted at known, potentially modifiable factors relevant to body image distortion in 7 patients, used touch, massage, drawing exercises and listening skills. Patients received 8 to 38 sessions determined by length of stay on the unit. Self-drawings were completed at each session and a body shape questionnaire (BSQ-34) and a self-assessment silhouette scale in the first and last sessions. Findings: Self-drawings showed improved comparative proportions of body areas. Initial silhouette scores of more than 5 out of 10 reduced to less than five. There was a reduction in BSQ-34 questionnaire scores for all patients, and to less than half for 3. Conclusions: This pilot study suggests that a tailored programme based on principles of physiotherapy can help to improve body image perception and satisfaction. It draws attention to the potential of physiotherapy intervention programmes in the UK. Keywords: neatingdisordersnphysiotherapyinterventionsntouchmassagenbodyimage Submitted 25 October 2011, sent back for revisions 14 December 2011; accepted for publication following double-blind peer review 20 February 2012 ody image distortion is a distressing argued that a narrow notion of body image should problem that precipitates eating dis- be replaced with the more complex construct of orders and remains a major issue for body experience, which encompasses cognitive Bthe patient after other symptoms are responses (what they think they really look like), controlled (Slade and Russell, 1973). A National affective responses (what they feel they look like) Institute of Clinical Excellence (NICE) Guideline and optative responses (what they want to look (NICE, 2004) proposes eating disorders comprise like) (Probst et al, 1995). Some studies combine a range of syndromes encompassing physical, reports of adolescent and adult case series without psychological, and social features. Anorexia ner- separate analysis (NICE, 2004, p. 34). vosa and bulimia nervosa are frequently chronic The NICE Guideline (NICE, 2004) includes Patricia Caddy conditions with substantial long-term physical physiotherapists in the list of health profession- was Physiotherapy and social sequelae, from which recovery is dif- als who can be involved with patients with eating Manager for the ficult. The NICE Guideline states that about 1 in disorders (ibid. p.12), but despite a strong physical Cambridge locality, Cambridgeshire and 250 females and 1 in 2000 males will experience aspect related to body image, no reference is made Peterborough Foundation anorexia nervosa, generally in adolescence or to physiotherapy intervention programmes. A spe- NHS Trust, UK (now young adulthood and about five times that number cifically adapted form of Cognitive Behavioural retired); and will suffer from bulimia nervosa. Males experi- Therapy (CBT) is recommended as the treat- Barbara Richardson ence many concerns about their bodies similar ment of choice for patients with bulimia nervosa is Reader Emeritus, Faculty of Medicine to females. The concept of body image, often (ibid. p.16) while therapies to be considered for and Health Sciences, termed body dissatisfaction, has two components: the psychological treatment of anorexia nervosa University of East first, body perception, the individual’s estimate also include cognitive analytical therapy (CAT), Anglia, Norwich, UK of their body size; and second, the individual’s interpersonal psycho-therapy (IPT), focal psy- attitude towards their body (Slade and Russell, chodynamic therapy, and family interventions Correspondence to: Patricia Caddy 1973; Rosen, 1996, Skrzypek et al, 2001). Not all focused explicitly on eating disorders (ibid. p.10). E-mail: p.caddy@ patients with eating disorders overestimate their A limited improvement from massage in anorexia ntlworld.com body size (Probst et al, 1998a; 1998b) and it is nervosa symptoms but not weight gain is noted 190 InternationalJournalofTherapyandRehabilitation,April2012,Vol19,No4 Bodyimage.indd 190 23/03/2012 14:57 Research (ibid. p. 103) and the lack of randomized control- condition, particularly body image disorder and led trials (RCTs) comparing exercise or massage inappropriate exercise behaviour. In a professional with psychological interventions for treatment of newsletter, Duckworth (2000) highlights the lack people with bulimia nervosa (ibid. p. 147). The of medical and public appreciation of physiothera- guidelines state that although physical therapies pists working in the recovery process of eating are used in some European countries e.g. Belgium disorders and points to less than 50 units available and Norway (ibid. p. 101), with a long tradition of for patient access in the NHS and the private sec- integrating physical therapies into psychological tor, many of which with long waiting lists being therapy, this is not the tradition in the UK. without physiotherapy. She calls for wider access The aim of this study was to assess the effect to outpatient departments to enable earlier inter- of a tailored physiotherapy programme. A lit- vention. Tonkin (2000) further argues that physi- erature search of relevant data bases: CINAHL, otherapists are well placed to help young people AMED, PsychINFO, EMBASE carried out for address body image and to play a key role in rein- physiotherapy studies reported in English, using forcing healthier lifestyle messages. combinations of key words: Body image, inter- Until a more substantial evidence base is estab- ventions, Anorexia Nervosa, Bulimia Nervosa, lished it is unlikely that physiotherapy can form Eating Disorder, and physiotherapy, substantiates part of the routine practice of eating disorder the paucity of evidence of physiotherapy inter- services in the UK. However, as suggested by the ventions in general and in UK health care in par- NICE Guideline (2004) the absence of empiri- ticular. Few relevant studies were identified. For cal evidence for the effectiveness of a particular example, in the United States the focus is on phys- intervention is not the same as evidence for inef- iotherapy responsibility in recognizing, treating fectiveness. Eating disorders present complex and preventing the female athlete triad, in rela- challenges and treatment tends to be long-term tion to eating disorders. In this syndrome the low with the possibility of frequent relapses. The set- energy availability that leads to menstrual dys- ting, finding the right person to work with who function and compromised bone health can result has expert knowledge and particular qualities, who from an insufficient calorific intake (Pantano, will accept and understand the person as ‘an indi- 2009). Reporting in the Swedish language Berg vidual with a unique experience’ rather than as et al, (2005) stress the role of communication ‘a case of pathology’, is thought to be critical to in the therapeutic process, and Mattsson (1998) treatment success (NICE, 2004 p. 39). theorises body awareness to be a key element of This paper is aimed at assessing the effect of physiotherapeutic practice in work with patients a tailored physiotherapy programme. It proposes with eating disorders. Thornberg and Mattsson physiotherapy can play a unique and explicit role (2010) used assessment scales to look at the in the treatment of eating disorders within the concordance of a physiotherapist’s observation multidisciplinary team, using physical strategies with 87 patients’ own reports of bodily expres- to help patients overcome their symptoms and to sion. Although the PT observations did not always accept their changing body shape. The concept of concur, the study prompts further examination a physiotherapy intervention programme was gen- of appropriate methodology and physiotherapy erated by the first author (PC), during many years research in this area of health. They suggest Basic of experience working with patients in this area. Body Awareness Therapy (BBAT) (Roxendal, Patients reported positively to not only benefit from 1985 cited in Thornberg and Mattsson, 2010), a massage for the relief of muscle tension and anxi- treatment modality within psychiatric and psy- ety, but also improvement in their body awareness. chosomatic physiotherapy, developed for patients with longstanding complex illnesses including Methods patients with eating disorder, is an established treatment in many countries, although this is not Following advice from the local ethics committee evidenced in this literature search. In the UK, in 2009 an opportunistic sample of seven patients Mandy and Broadbridge (1998) conducted a ques- with eating disorders post-discharge were invited tionnaire survey of 159 members of Chartered in writing to allow their personal data to be ana- Physiotherapists in Mental Health to ascertain lysed. They each signed a consent form. Six were their involvement in anorexia nervosa. Of the 115 female and one male. The intervention programme responses, just under half had treated patients with was targeted at known, potentially