This document proposes including physical therapists on the treatment team at Eating Recovery Center of Colorado. Physical therapists could help address medical complications from eating disorders, prevent deconditioning during treatment, and facilitate weight restoration and reduced anxiety/behaviors through exercise. A SWOT analysis and cost analysis are provided to support implementing physical therapy at both inpatient and outpatient levels of care. Measurements of success are also outlined.

1. 1
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.”

12. 12
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

13. 13
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.

14. 14
! 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

15. 15
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

16. 16
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

17. 17
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.

18. 18
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 $17,446
Figure 1: Cost analysis for Denver Health Medical Center based on number of outpatients, and thus
number of hours PT devotes to ERC. Assumed no increase in equipment or staffing needs.
= point at which Friday schedule is full
0
200
400
600
800
1000
1200
1400
1600
1800
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Dollars($)perweek
Number of Outpatients per Week
Break Even Analysis for DHMC
Reimbursement from
ERC
Cost

19. 19
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
Dollars($)
Number of Outpatients
Break Even Analysis for ERC
Reimbursement
Cost

20. 20
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.

21. 21
References
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physical therapy interventions for patients with anorexia and bulemia nervosa.
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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
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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
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athlete-program. Accessed April 2016
12. The Eating Recovery Center-Colorado. Available at:
https://www.eatingrecoverycenter.com/programs/colorado/. Accessed April 2016.
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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
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Exercise in Eating Disorders Treatment: Systematic Review and Proposal of
Guidelines. Med Sci Sports Exerc. 2016
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Within the Treatment and Rehabilitation of Individuals With Eating Disorders:

22. 22
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