On this episode, Dr. Karen Nelson is joined by Karen Dieleman, senior physical therapist at Melrose Center. For many, movement and exercise can become a dangerous extension of their eating disorder behavior. Dr. Karen Nelson and Karen Dieleman will discuss how this behavior can present itself and the steps one can take to have a more balanced relationship with movement and exercise.
On this episode, Dr. Karen Nelson is joined by Karen Dieleman, senior physical therapist at Melrose Center. For many, movement and exercise can become a dangerous extension of their eating disorder behavior. Dr. Karen Nelson and Karen Dieleman will discuss how this behavior can present itself and the steps one can take to have a more balanced relationship with movement and exercise.
For a transcript of this episode click here.
Dr. Karen Nelson 00:02
Eating Disorders thrive in secrecy and shame. It's when we create a safe space for honest conversation that will find the opportunity for healing. Hi there. I'm Dr. Karen Nelson, licensed clinical psychologist at Melrose center, welcoming you to Melrose heals, a conversation about eating disorders, a podcast designed to explore, discuss and understand eating disorders and mental health. On today's episode, I'm joined by Karen D. Lemon, senior Physical Therapist here at Melrose. Karen and I will discuss how movement can impact those struggling from an eating disorder, for many movement can become a dangerous extension of their eating disorder behavior. Karen and I will discuss how this behavior can present itself and steps they can take to have a more balanced relationship with movement. Now, before I begin, I invite you to take a deep breath and join me in this space. Well welcome Karen to the podcast. I'm so happy to have you here with me today. Thank you, Karen. It's an honor to be here. Well, before we get started, I would love it if you could introduce yourself and tell us about your role here at Melrose.
01:17
My name is Karen Dieleman. I am a senior Physical Therapist here at Melrose Center in St. Louis Park.
Dr. Karen Nelson 01:26
Wonderful. Well, let's talk about what makes mal Rose's approach to physical therapy and eating disorders so unique.
01:37
So as a physical therapist, you know, our role really looks at how do we establish and return function to our patient population. At Melrose center, my department is called Park and that stands for physical awareness and rehabilitation center. So the physical therapists at Melrose center really have a unique opportunity to meet our patients where they're at, we evaluates if there are changes that they really want to make, we might be looking at physical impairments, like strength or balance, we might be looking at lifestyle changes, how do we move from one type of activity to another? How do we move away from maybe dysfunctional exercise? And really foundational is, how does the eating disorder symptom use have an impact on our patient's ability to be functional?
Dr. Karen Nelson 02:39
I love that, well, maybe what would be helpful is describing for us when you kind of use those words, functional role, right? So as a physical therapist, maybe helping someone understand what a physical therapist does, who maybe doesn't know what a physical therapist is? Right? Ie me, right? I mean, I make those referrals, but I think it brings up a good point, sometimes we have misperceptions. So at
03:06
Melrose, our physical therapist role is a little bit broader. We sort of step back and and look at a person through a different lens. How does activity fit for you? Right? And what does movement look like for you? How do you find balance with what you do? It's not just exercise, exercise exercise. Because we have a whole spectrum of how we move, right? If if, let's take my example, if I love to garden, well, I need flexibility. I need strength, I need endurance, that passion for what I do, right? I mean, really should shine through. And so you know, talking to people about kind of this variety of movements. And what is that? What does that bring you? Because the intention behind what we do is, is so foundational, I think that's where our, our education, our chance to talk to our patients, and listen to what they have to say, absolutely. I will, I will, I will tell patients that, you know, I have an agenda, of course, there's things that I want to cover. But first off, you know, why are you here? You know, what, what are you hoping to learn from, let's say, our first session together, and that also helps me sort of build a plan of how we're going to work together.
Dr. Karen Nelson 04:48
Well, I love the description that you're sharing. It feels a lot broader right than potentially what some of us might assume. Right? Physical therapy is just about exercise. And I can see that law Probably smile on your face of like, I bet a lot of it's almost like the misnomer, right? And you are describing integration, and almost the complexity of movement, and our body and how that can impact us is what I hear you talking about. Just really cool, then through conversation, you maybe start to have some of those connections about what a patient might need or want.
05:25
Well, and, you know, you reference the referral piece. Usually, one of the first questions I say is, you know, why are you here? You know, what are you? What are you looking to explore? What are you looking to change? You know, as far as maybe your past has shaped some of your thoughts, or your impressions about how I should be working out, or I should be moving. And, you know, at Melrose, we try to leave those shoulds, those Quds those woods out and look at making change. Let's talk
Dr. Karen Nelson 06:06
about the correlation between exercise and eating disorders. I would love it if you could maybe describe how you see those two intersect?
06:16
Yeah, so we talked about the role exercise plays with each patient. And, you know, there's a concept of dysfunctional exercise. What does that look like, for some patients, the intention behind their exercise, could be very negative. And it could be five minutes of exercise with a very negative intention, could make it a dysfunctional part of their life. You know, the flip side of that, of course, is you could have someone who exercises for five hours, it's part of their job, if they're a professional athlete, let's say, but they support it. They do cross training, they have nutrition support, they have sports psychologists, right, they have a lot of these other pieces. And that five hours might be fine for them. So, you know, we figure out where does our patient fit within that dynamic? For patients that over exercise? You know, what, what might we see? You know, a few things that come to my mind, if their exercises getting in the way of their daily activities, their daily life, their social pieces? No, no, no, I can't go out, because I have to go to the gym after work. Right. Now, for some people, they get a negative reinforcement with that. Oh, you're so dedicated. Oh, that's terrific. Good point. Good point. And, and that can fuel that more dysfunctional piece. You know, if you exercise through illness, or through injury, that's another kind of red flag that looks at this over exercise piece. If there are negative medical consequences, if there are negative mental health consequences, right. Those are other red flags, that the role that exercise plays for that person isn't in their best health interests? Absolutely. I'm really careful not to use the word healthy. Yes. Because there's a good or bad, right, just like we have with food some people have, this is an okay, good food, this is an own that good for this is a bad food, right. And some people have that connotation as well. With exercise. Oh, yeah. No, that's, that's, I can never do that.
Dr. Karen Nelson 08:59
I think I love that you're talking about the idea of a potentially dysfunctional or intense relationship with movement or exercise. You know, as I hear you describe that what comes up for me is potentially, maybe our clients are feeling a lot of internal pressure to exercise or the eating disorder might be sending them the message, like, you were saying, I have to work out at any cost, right? No matter what, even if I'm sick, even if I haven't fueled my body, even if I've already worked out for an appropriate of my amount of time. I'm going to continue to work out. Does that show up or tell me about what you might notice? Yeah.
09:45
We'll see patients that no, i My plan is to go to the gym, and I'm just going to do a class let's say and then the class finishes and they don't feel I If they worked hard enough, while conveniently, the cardio room is right around the corner, and then they get onto a piece of equipment. And, oh, you know, I look at this fancy dancy little gadget on my wrist, and my circles haven't closed, and I haven't had enough steps, and therefore I need to, you know, and then we see kind of this escalation of their activity, and it's in, it feels like it's not in their control. Ironically, from their eating disorder, they feel like, if I just do this, then the rest of my day will be okay. Or, oh, because I had to eat breakfast and lunch, I need to make sure I go to the gym and burn off those calories. Right? So I have to compensate for what I've just done. So, you know, our dysfunctional exercise can have a compensatory component, it can have a compulsive component. Absolutely. And, and typically, those lend our patients or lead our patients down a path, that's, that's a difficult road for them,
Dr. Karen Nelson 11:17
for sure. Well, the eating disorder often is about rules. And many of our patients talk about, I love that you bring it up, right? If I just do this, then I'll feel better, or the eating disorder often is in the business of sending us messages that I may need to attain a certain type of body. And so many of my patients share with me, this perception, if I just get that body, which may be through excessive exercise, a lot of eating disorder behavior, really in a destructive way, then I'll be happy. And hello, we just met the myth of the eating disorder, right? Like, oh, there she is, this belief. If I just get fill in the blank, then I'll be happy, then I'll feel good about myself. And we potentially may be spending a lot of risky hours at the gym or exercising, attempting to attain that,
12:16
what I hear a frequent conversation from a patient will say, Well, I was feeling so anxious. So I had to go out and I had to move and I had to walk. Oh, okay. So let's talk about that. How did it feel when you're doing it? Well, you know, it's thinking about, you know, this is just going to help my anxiety and, and I came back and, and how did you feel then? Well, it helped, like, I wasn't as anxious. Oh, okay. So then when you had to go back out later, and again, the third time of the day and the fourth time of the day? Is it really managing your anxiety? Like, I would really question that. And, certainly, exercise can be one of those tools to manage some of our mental health. But can't be the only thing. Beautiful point, if we derive that sensation of movement, it will help us with our anxiety. Can we sit in a rocking chair, out on the porch? Can we swing in the hammock, you know, at the park, right, because there's movement there? If that's what's helping us, then those are the other pieces that we also need to practice. There's a really terrific connection between our breath work and calming. Yes. And, you know, I'm a physical therapist, so I'm super grounded in the science piece. And we go through this training that Melrose did with us a number of years ago called mind and body. And I was a skeptic. Tell me Yes, I was.
Dr. Karen Nelson 14:07
Wait is Mind and Body Code for kind of mindfulness? Easing? Yes. Yeah. I got a no
14:13
and and I was like, Oh, right. Uh huh. Yep. You know, I'm laying there and I'm laying on a bolster, and I got my feet up and, and I'm breathing and my mind is still racing, because I'm still thinking about, do my socks match, or, you know, or whatever it is. And, gosh, if it didn't start to sink in, for more, I practiced it. That's right. And in then I learned, oh, there's a whole science behind when you take a deep breath and what your diaphragm does, and until then I'm like, Well, this is why it works. That's right. And then I thought a little bit more and I'm like, No, it works because I'm practicing it, love it. And like if I can feel figure out within a five seconds, exhale, how to decrease the tension for myself. Wow, like, okay, okay, now I'm fully behind like, that's right, our patients need to learn this,
Dr. Karen Nelson 15:15
for sure. We actually just did an episode on mindfulness. And I lead people through a mindfulness experience, because you're right, there is a lot of evidence, actually, it's one of the evidence based treatment for anxiety disorders is breathwork. Just fancy words for deep breathing. Yeah, and it can feel minimizing, especially if someone is experiencing a lot of anxiety to be told, Well, you just need to breathe. And then we need to experience it with a facilitator, right with our therapist with my physical therapist, that can be a beautiful entry. As we were kind of talking, I think sometimes there is maybe initially that misperception that physical therapy is strictly about exercise. And if we think about this topic of exercise, to put it mildly, there is often a complicated relationship, often with our patients who are potentially struggling or are struggling with an eating disorder, and their either history or perception of movement and exercise. And so I would love it, if you could maybe share with us, Karen, exercise is typically said to be good for you. So can it be harmful?
16:33
Yes, very definitely. The first thing that struck me with your question was, when we talk about exercise, we also talk about rest. Rest days, what does that look like? And you're like, well, as a physical therapist, aren't you? Like, oh, 17 reps, 18 reps? 19 reps? And yeah, that's a part of it. But the balance between how does your body recover? How does your body repair those happen on our on our rest days? We also talk about kind of the intangibles for exercise. Because yes, exercise does give us a lot of positive mental health benefits, as well as physical health benefits. But there's also kind of a mind body spirit peace. rest days allow some of that to happen. We talk about grounding, we talk about intentions with our exercise.
Dr. Karen Nelson 17:34
Maybe if we focus our attention a little bit on specifically, risks for women, as they are potentially engaging with over exercise, are there any specific risks for women who may be are exercising in in a too intense way?
17:51
We have to consider how you fuel yourself first, right? Because intensity with exercise is only a piece of this. You know, certainly there are the hit workouts, the training for, you know, a variety of hold a bike ride across Iowa, and you know, those sorts of things. So, I, I look at it again, with this bigger view. If we're not fueling ourself, and for men and women, we see similar pieces. You know, we might see slower heart rates, right. Hi, I get a really great argument from a lot of patients. Well, it's true when you engage in aerobic exercise, right, that cardiovascular training definitely has a lowering impact on your heart rate, right? And I say yes. And I will believe that for you, when you're fueling yourself, and your heart rate stays the same. Right now, the only thing I have to go on is, is you're not fueling yourself adequately, because you're hearing treatment, and you have a low heart rate. So let's, let's see what else we can do in that regard. So we might see changes in vitals. We might see like I said, loss of muscle mass. We might see an impact over time and duration on your bone density. And certainly as a physical therapist, loss of muscle mass and loss of bone density are really big concerns for me. And how can we adjust or adapt? Our bodies are super amazing because they do that frequently. To the positive and to the negative for women, we might see a loss in their menstrual cycle. And you know, there's a lot of research out there that supports not having a regular cycle can lead to osteopenia or osteoporosis, when we don't have that estrogen that protects us and protects our bones, particularly for our younger patients, you know, are adolescents where they're building their bone density? Man, that's really important that they get that that regular cycle back. Certainly with men, hormone, low hormones for testosterone, definitely have an impact as well, if we don't have adequate testosterone, you know, you cannot maintain or build any muscle. Right? Again, loss of muscle for me, like, I'm concerned about that.
Dr. Karen Nelson 20:49
So we know we've been talking about a lot of potential side effects that can happen with the engagement of the eating disorder and over exercise. Let's talk about what again, when if we logically know that there are potential risks of engagement with over exercise? Why might it be so hard to stop?
21:12
Well, some of that comes from our brain. What have we established? We've established a pattern. And, you know, how do we break patterns? Day in, day out? There's brand, I'm not brand new research, but I always used to think, oh, it's like a 21. Day to change.
Dr. Karen Nelson 21:34
Oh, I've everyone's heard that. Right. All these magic days? Yeah, change? What do you know, tell us,
21:39
there was a, there was an article in Oh, I'm gonna lose the journal that it was in doesn't matter. That said, 66 days, wow, to create a new habit to create a new pattern. So that means every day, I have to think I have to put some intention behind. What's my what's my plan for this? How do I follow through? If I have an urge to change that plan? What skills do I use? Now if I'm engaging in restrictive, eating or purging? My brain doesn't have the energy to do that. So it is really hard to make those changes, I might think tomorrow, that's right. Tomorrow, I'm going to make this change. I'm going to do this differently tomorrow. But my purging today or my restrictive eating today has a negative impact on me getting up in the morning. And oh, well, I did this yesterday. I'm just going to keep going today. Right? And so it becomes very hard to break that cycle. Can it be done? Or 100%? Yes, yes, yes, yes, definitely can. And it takes support, right, it takes the support people in our lives to help. Now that might be your treatment team. That might be your spouse, your parents, your friend that you call once a week to be able to make some of those changes. But it definitely starts with willingness on the patient's part. So yeah, I think that you can make some of these changes. So I think
Dr. Karen Nelson 23:23
we often talk in therapy about the function of the eating disorder, and over exercise may present a certain level of function, right? It may be a way to, quote feel in control, to use that as maybe almost like a purge behavior or compensatory behavior is kind of a fancy word for that. So acknowledging that, potentially, I'm engaging with exercise or over exercise in an attempt to maybe manage other emotion,
23:55
right? Or to avoid Oh, perfect, avoid feeling any of those those emotions, right? Because I can get on my equipment, plugin tune out, and then I don't have to feel. All right, well, what does it feel like when you move? Well, I don't know. What do you mean? Like, what does it feel like? You know, let's take a step back. That's right. You know, let's figure out how do we use some of the skills that we may learn from our therapists appointments? And how do we apply them to our exercise? How do we apply them to making change?
Dr. Karen Nelson 24:31
What benefit does physical therapy bring to the eating disorder recovery process?
24:36
Well, if we think about kind of what our what our role is, it's about function. I really want you to be a part of your life. Like I don't want you to be a bystander in your life. If I don't have enough energy if I don't have enough fuel, to support my body at work, as a daughter as a sister as a friend as a volunteer, or if there's a faith part of me. Okay, we got to figure out that fuel piece, right? If exercise is a component, okay, maybe we need to look at more balance in what you do. Right? It's not necessarily about No, you because I don't feel like telling somebody, you can't do anything. No one's gonna come back. Right? Right. They'll
Dr. Karen Nelson 25:28
be like, Oh, no, she is a Karen. She's so me.
25:32
But maybe we can't do cardio. But, gosh, there's a whole lot of other things that you can do. Right. So as a physical therapist, let's explore those pieces. Well, and
Dr. Karen Nelson 25:45
that feels comforting to me to know that it's not about finding the perfect exercise plan or like you said, I have to do 10 Push Ups a day for this many. It's about curiosity. And balance is really what I hear you talking about.
26:00
And social media has not really been kind in this vein. Because there's lots of things that are represented in social media that aren't always factual, let's say, images that aren't always factual. And, yeah, if I were to tell you stand up paddleboarding is the only exercise that counts, and you have to do it and you're like, I don't live near a lake. And I don't have $1,000 paddleboard and no what, right I mean, there is not a one size fits all,
Dr. Karen Nelson 26:41
bringing up that idea of that sometimes there may be barriers to movement, or, or barriers to exercise. Any insight on how you do have those conversations about potential, like motivation for movement, or how we might incorporate movement back into our routine. have barriers
27:00
and limitations. Those are frequently things we talk about, with everybody. What do you like to do? What brings you joy? What builds you up? Right? Because what builds us up? In here in our heart and in our spirit? Right? Those are the pieces that I want to explore more? Well, I really love to so terrific, like, how much time do you spend sewing? Well, I could sit and get lost in sewing for two hours. I'm like, Oh my gosh, that sounds amazing. How about you set a timer at an hour mark. And then you get up and you go downstairs and you go outside and you breathe the fresh air? Right? And then you come back in and you sit back down? And then you sew for another hour? Oh, well, maybe I could try that. Right? I mean, finding things that you do. But then also, how can we incorporate just other pieces of movement in there? And no, I'm not saying go out and run around the block 17 times. I mean, if I really love to, so I'm not going to stop and run around the block for 17 times. But I got to figure that out. Right? What makes you you What do you like? And then how can we pair that? You know, maybe, maybe you plan to get together with a friend, grab a coffee, and walk down and walk around. We've got awesome lakes in Minnesota, we're super blessed. Right? And you know, maybe you go down and you walk partway around the lake and come back. I love coffee in hand. social peace is such an important factor that's right to keep fighting against that isolation. I frequently will remind patients, right that two really great friends of your eating disorder are isolation and fatigue.
Dr. Karen Nelson 29:04
Well, what do you think about or what can make it hard for patients to find balance in exercise?
29:12
Thinking that only one thing matters. Right that misconception you know? Well, yeah, running is the only thing that matters. Okay. Well, do you stretch when you're done? No. Okay. Well, maybe we can incorporate some balance there. You know, figuring out
Dr. Karen Nelson 29:36
not being so rigid is I think what I hear you say yes, yes. Yes. Totally. All that rigidity, which is often the business of the eating disorder, it all or nuns, everything. Oh, diagonally. Absolutely. Recovery isn't about all or none either. It's about practice. That's what I really I love that, that you can really name that even for a patient right? That we it's through exploration. and trial, right of like, oh, well this thing worked. Or maybe I do need to tap back into some mindfulness practice as I am verging back down that path of some more intensity
30:13
while carrying on I think, if you think about just the course of life in in many avenues, right? I mean, we have these ebbs and flows within our job, within our schooling within our kids, you know, with, within maybe how we practice our faith or gosh, I mean, so very many areas. But what we want, or we hope to really get across is, is balance. And yeah, physical balance. Can you stand on one leg? Sorry, that's the physical therapist and Right, right, but balance across how we think how we fuel ourselves how we
Dr. Karen Nelson 30:54
move? Well, and I think it's important for us to be clear about it is possible to move back into a place of a healthy relationship with trial and effort and support and guidance that we can get back there. Yeah, to a place of a healthy relationship with movement that feels hopeful,
31:14
it takes effort. I mean, you know, just that brain practice,
Dr. Karen Nelson 31:18
I love that. What does a healthy relationship with exercise look like?
31:24
Oh, gosh, well, how do you define healthy? How do you define exercise? Sorry, I'm gonna turn the tables on you love it. Because careful when we define it that way, and that's kind of one of our pieces, you know, healthy exercise is healthy. Definitely. It can lead us down or lead us down that road of being unhealthy. Right. I keep coming back to balance, right. There's, there's not a one size fits all. Yes, there's a whole bunch of guidelines out there of reduce your risk, Oh, I get a lot of this one, like reduce your risk for cardiovascular disease, cancer, right? There's the component of 150 minutes a week of moderate intensity of exercise. If you're coming to me, as someone who doesn't do anything, and I'm telling you, you need to find 150 minutes in your week to be active. Holy cow, you're not coming back. Yeah, right. Or if you're coming to me, and you've got 300 minutes of exercise in your week, and I'm like, 150 minutes, and you'll be like, Yeah, I'm not coming back.
Dr. Karen Nelson 32:42
Is there anything I didn't ask you today, Karen, that you'd like to tell our listeners,
32:48
find what builds you up? Find what brings you joy? Have have a variety in what you do. You know, this intentional peace. This mindfulness piece, I think is really kind of foundational to having a balance on how we think, how we feel how we move. I guess I've summed it all up.
Dr. Karen Nelson 33:18
Beautifully. Well, thank you so much for being with me today. It's been just a joy talking with you. It's been
33:24
my pleasure. Thanks for inviting me.
Dr. Karen Nelson 33:28
That's it for today. Thanks for joining me, we've covered a lot. So I encourage you to let it settle and filter in. And as I tell my patients at the end of every session, take notice. Pay attention, and we'll take it as it comes. I'll talk to you next time. Melrose heels a conversation about eating disorders was made possible by generous donations to the park Nicolet foundation