2016 csm bariatric workshop presentation · rehabilitaon,of,the,bariatric,paent 2/18/16...

Rehabilita)on of the Bariatric Pa)ent 2/18/16

Property of Swafford, B. and Dwyer, J. Not to be copied without permission 1

REHABILITATION OF THE BARIATRIC PATIENT

APTA Combined Sec8ons Mee8ng 2016 February 18, 3-‐5pm-‐Anaheim, CA

1

Bonnie Bauer Swafford, PT, DPT St. Luke’s Health System Kansas City, MO [email protected]

Jackie Dwyer, PT, DPT Shawnee Mission Medical Center Merriam, KS Rockhurst University Kansas City, MO [email protected]

Objec8ves •  Define overweight and obesity including body mass index and waist circumference

•  Explain current theories in causes and treatment for the overweight and obese pa)ent and summarize the impact to quality of life and health care costs of obesity

•  Discuss weight bias and strategies to improve health care provider/pa)ent interac)ons

Objec8ves •  List equipment that is available for safe movement of bariatric pa)ents

•  Discuss designing a safe and therapeu)c plan of care for rehabilita)on of individuals that are obese

•  Select valid, reliable and meaningful assessment tools for objec)ve documenta)on of improvement of pa)ent func)on

The Joint Commission’s Vision Statement:

All people always experience the safest, highest quality, best-‐value health care across all se]ngs. The Joint Commission’s Mission Statement:

To con)nuously improve healthcare for the public…by evalua)ng health care organiza)ons and inspiring them to excel in providing safe and effec)ve care of the highest quality and value.



United States Obesity Sta8s8cs •  More than 1/3 of American adults are obese •  16% of children ages 6-‐19 are obese •  1 in 8 preschoolers is obese •  Children who are overweight/obese in preschool are 5

)mes more likely to be overweight/obese as adults •  Approximately 325,000 deaths annually are acributable

to obesity

Obesity related condi8ons include:

•  Cardiovascular disease •  Pulmonary disease, obstruc)ve sleep apnea •  Cancer (colon, breast, endometrial, gallbladder) •  Type 2 diabetes •  Arthri)s of hips, knees and low back

BMI: Body Mass Index •  BMI = ( Weight in Pounds / ( Height in inches x Height in inches ) ) x 703

•  BMI=weight (kg)/[height (m)]2

•  It may overes)mate body fat in athletes and others who have a muscular build

•  BMI also may underes)mate body fat in older people and others who have lost muscle

BMI Body Mass Index

18.5–24.9 Normal Weight

25.0–29.9 Overweight

30.0–39.9 Obese

40.0 or greater Extreme Obesity

Waist Circumference

•  Abdominal obesity with most of the fat around the waist rather than hips, is an increased risk for coronary heart disease and type 2 diabetes

•  The risk is higher with a waist size greater than 35 inches for women or greater than 40 inches for men

•  Measure above iliac crests aner breathing out



Health Care Costs •  Medical costs linked to obesity were es)mated to be $147 billion in 2008

•  Annual medical costs for people who are obese were $1,429 higher than those for people of normal weight in 2006

•  Hospital length of stays are longer and with more complica)ons including longer ICU days and more infec)ons

Health Care Costs

•  The total es)mated cost of diagnosed diabetes in 2012 was $245 billion, including $176 billion in direct medical costs and $69 billion in decreased produc)vity

•  Decreased produc)vity includes costs associated with people being absent from work, being less produc)ve while at work, or not being able to work at all because of diabetes

Health Care Costs •  The total cost of arthri8s and related condi)ons was about $128 billion in 2003. $81 billion was for direct medical costs and $47 billion was for indirect costs associated with lost earnings

•  About 80% of pa)ents with OA have some degree of movement limita)on

•  25% cannot perform major ac)vi)es of daily living (ADL's), 11% of adults with knee OA need help with personal care and 14% require help with rou)ne needs

Causes

•  Environment •  Family history and gene)cs

•  Metabolism (the way your body changes food and oxygen into energy)

•  Medica)ons: an)-‐depressants, an)-‐psycho)c, an)convulsants, an)hypertensive (beta blockers)

•  Behavior or habits: inac)vity and smoking

•  DIET: sugar and refined carbohydrates

Metabolism Sa8ety Feedback Mechanisms

•  Aner ea)ng, hormones are released that affect the hypothalamus resul)ng in suppressed appe)te

•  Feeling of fullness and distension cause people to stop ea)ng

•  Esophageal acid reflux causes upset stomach and burning reflux sensa)on



Treatment

•  Diet •  Physical Ac)vity •  Medica)on •  Surgery

Diet

•  Some consider obesity a simple lack of willpower, or the inability to modify dysfunc)onal ea)ng habits

•  Ea)ng behavior is much more complex than pa)ent choice alone

•  Physical ac)vity alone cannot be expected to over-‐come unhealthy ea)ng habits

Obesity per Country Diet Recommenda8ons

•  Calorie balancing; combina)on of decreased caloric intake with increased calorie expenditure (“a calorie is not a calorie”)

•  Por)on control •  Nutri)on educa)on, interpre)ng food labels (ex: added sugar)

•  Managing restaurant and social ea)ng situa)ons

States with Lowest Obesity Rates 2014

Rank State Adult Obesity Rate

1 Colorado 21.3%

2 Hawaii 21.8%

3 District of Columbia 22.9%

4 Massachusecs 23.6%

5 Utah 24.1%

hcp://www.cdc.gov/obesity/data/adult.html



States with Highest Obesity Rates 2014

Rank State Adult Obesity Rate

1 West Virginia 35.1%

2 Mississippi 35.1%

3 Arkansas 34.6%

4 Tennessee 33.7%

5 Kentucky 33.2%

hcp://www.cdc.gov/obesity/data/adult.html

Percent of Adults who engage in NO Leisure-‐Time Physical Ac8vity

The American Physical Therapy Association recognizes that physical therapists and physical therapist assistants play an important role in the promotion of healthy lifestyles, wellness, and injury prevention.

Physical Ac8vity

•  Defined as any body movement that is produced by contrac)on of skeletal muscles that increases energy expenditure

•  It includes tasks like walking the dog and household chores

Physical Ac8vity

•  Products such as pedometers and heart rate monitors may be helpful to monitor the daily physical ac)vity levels

•  A variety of ac)vi)es helps avoid onset of boredom or burnout

•  Enjoyment of physical ac)vity is also a key feature for adherence

•  Invite a friend to exercise with you on a regular basis •  Join an exercise group or class



MET Chart Exercise

•  Defined as a subcategory of physical ac)vity involving planned, structured and repe))ve body movements that are performed to improve or maintain one or more components of physical ac)vity

•  Categories include endurance, strength, balance and flexibility

Exercise Prescrip8on: Endurance

•  Ini)al exercise prescrip)on should emphasize low intensity with a progression in exercise dura)on (up 60 minutes as tolerable) and frequency (5-‐7 days per week), before increases are made in intensity of exercise

•  Exercise intensity should be no greater than 40-‐70% of work capacity (RPE 11-‐13)


•  Consider the age of the pa)ent, musculoskeletal limita)ons and availability of exercise facili)es

•  As licle as 10 minutes of physical ac)vity a day is a good start

•  Ideally, 30 to 60 minutes of moderate physical ac)vity on most days of the week is recommended (> 150 minutes a week)


•  Appropriate intensity may be es)mated by the pa)ent's ability to talk during ac)vity

•  Start at a sustainable intensity level and progress as tolerated

•  Wricen advice to exercise was found to be more effec)ve than just verbal recommenda)on



Exercise Prescrip8on: Strengthening

•  1-‐2 sets of 8-‐12 different exercises that focus on large muscle groups, 2-‐3 days/week

•  Increase 1-‐2 kg/week for arms and 3-‐5kg/week for legs

•  RPE (Rate of Perceived Exer)on):11-‐14 (fairly light to somewhat hard)

•  Slow eccentric

Medica8on •  Pharmacotherapy, when used for six months to one year, along with lifestyle modifica)on including nutri)on and physical ac)vity, produces weight loss in obese adults

•  Medica)ons either alter appe)te or absorp)on of calories

•  Weight lost with medica)ons is more likely to be maintained if medica)ons are able to be con)nued long term

Commonly Prescribed Medica8ons

•  Preven)on of fat absorp)on – Xenical (orlistat)

•  Increased feeling of sa)ety (anorexiant) – Belviq (lorcaserin) – Contrave (buproprion and naltrexone)

Other Considera8ons

•  Behavior management strategies •  Weekly weight checks, food journals •  Rou)ne that focuses on a balanced lifestyle; ea)ng a nutri)onally balanced breakfast soon aner awakening and ea)ng balanced meals at regular intervals

Other Considera8ons •  Non-‐food rewards and posi)ve reinforcements

•  Lifestyle modifica)on includes specific nutri)on recommenda)ons, educa)onal sessions and frequent contact with health care clinicians, such as a die))an

•  Stress management, problem solving •  Assessing for Depression •  Assessing for an Ea)ng Disorder

Roux en Y Gastric Bypass Video



Sleeve Gastrectomy Video Lap Band Video

ReShape Duo Primary Obesity Surgery Endoluminal

POSE

Weight Bias

•  Explicit A]tudes – Conscious – Deliberate – Social and personal values

•  Implicit A]tudes – Unconscious – Spontaneous – Habit

So, ask yourself… ¨  How do I feel when

I see an overweight pa)ent?

¨  How comfortable am I when working with pa)ents of size?

¨  Am I sensi)ve to the needs and concerns of obese individuals?



Key Strategies to Avoid Weight Bias

•  Consider pa)ent’s previous healthcare experiences •  Recognize that obesity is a product of many factors and that sustained weight loss is difficult to maintain

•  Explore all causes of the pa)ent’s presen)ng problems, not just weight

•  Emphasize behavior changes rather that focusing only on weight

•  Recognize that small weight losses can result in important health gains

Dionne’s Bariatric Body Types:

• Apple Ascites • Apple Pannus • Pear Abduc)on • Pear Adduc)on • Gluteal Shelf

Permission granted by Mr. Michael Dionne, PT and Choice Physical Therapy, Inc.

Apple Ascites


Apple Ascites

•  High waist to hip ra)o with forward abdominal region

•  Cardiopulmonary intolerance to flat postures •  Supine to sit via roll to elbow supported side lying technique and progression to si]ng


Apple Pannus


Panniculus Grading

•  Grade 1-‐Covers hairline of mons pubis but not the genitalia

•  Grade 2-‐Extends to cover the genitalia •  Grade 3-‐Extends to cover the upper thighs •  Grade 4-‐Extends to cover the mid thighs •  Grade 5-‐Extends to cover the knees or beyond



Apple Pannus •  High waist to hip ra)o demonstra)ng an inferior abdominal drin

•  To exit bed, flat spin to perpendicular then progress to full si]ng

•  Some use prone or crawling to enter/exit bed •  Log roll to sidelying to sit may cause fall if weight of panniculus slides off bed


Movement Techniques

Sit to stand in a 3 phase sequence: 1.  Preposi)on hips 30-‐40° of abduc)on, 60° of

external rota)on and up to 60° of knee extension 2.  Person translates pelvis forward over base of

support and loads onto forefoot 3.  Knee EXT is achieved and lower extremi)es

adducted to gain upright. Finally trunk extension

Pear Abduc8on


Pear Abduc8on

•  Low waist to hip ra)o

•  Avoidance of log rolling, tend to go from supine to long si]ng then short si]ng

•  Sit to stand via knee extension then trunk extension


Pear Adduc8on


Pear Adduc8on

•  Low waist to hip ra)o but able to achieve full femoral condyle contact

•  May use log rolling or long si]ng technique for supine to sit

•  W/C foot pedals may not fit, may need tracking foot rests




Gluteal Shelf


Gluteal Shelf

•  Persons who demonstrate excessive asymmetrical posteriorly directed )ssue at the level of the gluteal region. May have either high or low waist to hip ra)o

•  Supine may be uncomfortable •  W/C sea)ng may need adapted back support


Ini8al Episode of Supine to Sit •  If pa)ent requires assistance for bed mobility:

–  Posi)on fric)on reducing transfer sheet or air device

–  Flat spin to perpendicular

–  Establish safe bed height and deflate all surfaces

–  Level the pa)ent’s thighs (parallel to floor)

–  Trunk eleva)on to si]ng posi)on


Use of Fric8on Reducing Device


Flat Spin the pa8ent perpendicular to the bed


Establish Deck Height/Level Thighs




Elevate the Trunk Gradually


Dionne’s Egress Test

•  Pa)ent clears hips 1-‐2 inches from bed and returns to seated posi)on. Two reps of sit to stand are then performed. If successful,

•  Pa)ent stands and marches in place 3 repe))ons. If successful,

•  Pa)ent steps forward and back with one leg then the other


Dionne’s Egress Test

•  The test is stopped at any point where the pa)ent cannot perform the task safely.

•  The pa)ent is always directly in front of the bedside so returning to seated posi)on is possible.

•  Passing the Egress test does not mean that the pa)ent is independent, only that safe means to egress from the bed have been determined.

•  Mechanical conveyance is appropriate if the pa)ent cannot perform the steps of the Egress test.


Specialty Equipment in Bariatric Care

Stryker Bari 10A 1000 lb. capacity Expandable width 36”-‐48” Expandable length 80”-‐88” Deck height 18.75”-‐33.75”

Bariatric Beds con8nued

Gendron Maxi Rest 1000 lb. capacity 36/39/48/54” widths x 80-‐88” length


Hill-‐Rom Tri-‐Flex 1000lb. Capacity Width 39”-‐48” Length 86” Deck Height 14”-‐28” 5 posi8ons including cardiac chair




Sizewise Lowboy 850 lb. weight capacity 35”-‐48” width, 82” length Deck Height 7.5”-‐30.75” Lower siderails rotate away from pa8ent to the foot of bed for egress


Sizewise Bari Rehab Plagorm 2 1000 lb. weight capacity 39”-‐48” width, 80-‐86” length Deck Height 15”-‐30” Chair mode Removable Siderails


UHS Vital Go Total Lih Bed 450 or 650 pound capacity Footboard is a forceplate to determine weight bearing Bed is a 8lt table and chair

Surfaces

Hill-‐Rom (UHS) Accumax Quantum Conver8ble Bariatric Pressure Relief Malress with side bolster. 38W x 86L X 6D. 800 lb capacity, low pressure with a series of horizontally orientated air sectors

Surfaces

Sizewise Big Turn 1000 lb. capacity Full body rota8on with low air loss and pulsa8on therapies.

Ceiling Mounted Lihs

Medcare 1000 lb. capacity Allows lihing from floor hcp://www.medcarelins.com/videos /index.php?v=bariatricceilinglinone #bariatricceilinglinone

Arjohuntleigh Maxi Sky 600 or 1000 lb. capacity



Portable Lih Devices

Apex Dynamics 600 lb. capacity

Portable Lih Devices

Hill-‐Rom Viking XL 660 lb. weight capacity

Air Transfer Devices

Arjohuntleigh MaxiAir 1200 lb. capacity

AirPal 1000lb capacity

Bariatric Toile8ng Equipment

AliMed Bedpan 650 lb. capacity

AliMed Commode 650 lb/ weight capacity

Bariatric Bathroom Equipment

AliMed Shower Commode Chair 700 lb. capacity Alimed Shower Gurney

900 lb. capacity

Bariatric Mobility Equipment

Barton Medical Posi8on and Transfer System, Palerson Medical Stretcher, mobile chair, sea8ng 700 and 1000 lb capacity 0-‐70 degree back angle



Stretchair 1000lb. Weight capacity

Sizewise Shulle 650 and 1000lb. Weight capaci8es

EZ Stander 800 lb capacity

LiteGait 500lb. capacity

SoloStep 500lb. capacity

AliMed Heavy Duty Transfer Board 650lb. Weight capacity

Hausmann Industries Bariatric Electric Mat Plagorm 20-‐30” height 750 lb capacity

Sizewise SW advantage 850 lb. capacity

Bariatric Gait Devices

Midland Electric Parallel Bars 500 lb. capacity

Alimed Walker 1000 lb. capacity

Sizewise walker 750 lb. capacity

Medline 500 lb. capacity



500 lb. capacity for all of these devices

Case Report

REHABILITATION OF A BARIATRIC PATIENT WITH HEMIPARESIS

Pa8ent History

•  RB is a 48-‐year-‐old right-‐handed man who started developing complex par)al seizures in 2007

•  It was ge]ng worse and he was found to have a low-‐grade glioma in the right parietal area

•  He underwent a surgical resec)on/craniotomy and postopera)vely had a middle intraparenchymal hemorrhage

Past Medical History

•  Morbid obesity’ weight 550 pounds, height 6’, 5” •  BMI: 65.2 •  Hypertension •  Arthri)s

Medica8ons

•  Keppra (an)-‐seizure) •  Trileptal (an)-‐seizure) •  Dil)azem (an)-‐hypertensive) •  Coreg (an)-‐hypertensive) •  Lisinopril hydrochlorothiazide (an)-‐hypertensive)

Prior Level of Func8on

•  Lives independently in a mobile home with 5 steps and one rail entry

•  Works full )me as a machine shop inspector and accountant

•  Uses no assis)ve devices, drives and has a dog •  Does not drink or smoke •  His mother and 1 sister live locally



Pa8ent Hospitaliza8on and Recovery

•  Acute care (ICU and neurology unit) for 13 days

•  Inpa)ent rehabilita)on for 4 weeks

Acute Evalua8on

•  Flaccid len upper and lower extremity •  5/5 strength right upper and lower extremity •  2-‐3 beat wrist and ankle clonus on len •  Intact sensa)on, vision and cogni)on •  No lung, heart nor kidney problems postopera)vely

Acute Treatment

•  Ac)ve range of mo)on exercises on right side and passive range of mo)on to len side with facilita)on to assist in movement

•  Progressed to mobility and required maximum assistance of 2-‐3 people to roll and go supine to and from si]ng

Acute Treatment

•  Si]ng edge of bed for 10-‐15 minutes with minimal assistance

•  Pa)ent was transferred into a chair dependently with a ceiling mounted lin

Maxi Sky 600

Arjohuntleigh

Bariatric Challenges

•  Extensive collabora)on with pa)ent, nursing and therapy staff was required for safe transfers and progressive mobility program

•  Specialized equipment included a bariatric bed, commode, transfer board, Geri chair, wheelchair, Air Pal and a Hoyer (sling) lin



Rehabilita8on Evalua8on

•  Rolls to len with minimal assistance, to right with maximum assistance

•  Maximum assist of 2 to go sit to supine; help to get legs on mat

•  Maximum assist of 2 to go supine to sit; help with legs and trunk

Rehabilita8on Evalua8on

•  Len strength 2/5 proximally and 3-‐/5 ankle and hand

•  Able to sit edge of mat/bed with minimal to stand by assistance and some support of right upper extremity

•  Transfers from bed to Geri chair with Air Pal and assist of 4-‐5 staff

“Geri Chair”

Maxi Air, Arjohuntleigh 1200 lbs

Rehabilita8on Treatment: Week 1

•  Dependent transfers from Geri chair to mat with Air Pal

•  Worked on upright tolerance, si]ng balance; sta)c and dynamic

•  Rolling with tac)le/contact guard assist to len, moderate assistance to right


•  Ac)ve and assisted exercises in seated and supine posi)on

•  Sit to stand from elevated mat with moderate assist of 2 and walker (len hand on walker to stand up, other pushing on mat)

•  Standing balance with 2 hands on walker, marching in place

Dura)on: 30-‐45 min of PT bid, 5x/wk, 45 min daily on Saturday and Sunday



“Hoyer Lin”


•  Con)nued si]ng unsupported ac)vi)es; increasing dynamic/weight shin

•  Bed mobility minimal to moderate assistance of 1

•  Mat to/from wheelchair with sliding board going to len, moderate to maximum assist of 2


•  Progressive exercises to include less assistance and light resistance

•  Stand from wheelchair (with 2 cushions) moderate/maximal assistance of 1-‐2

•  Gait with roller walker 25 n and assist for walker management and support of len upper extremity and wheelchair follow


•  Bed mobility minimal to stand by assist (rolling to right)

•  Transfers moderate assist wheelchair to and from mat with roller walker

•  Exercises included ac)ve seated, supine, standing in parallel bars increasing repe))ons and some use of theraband and weights


•  Walking 150 feet with minimal assistance and roller walker and wheelchair follow including turning; )le and carpeted surfaces

•  Started step-‐ups on 4” curb in parallel bars •  Standing balance reaches/cones with one hand on walker

600 lbs Parallel Bars




•  Bed mobility modified independent •  Walking with wide base quad cane progressing to single point cane on level surfaces and inclines

•  Progressed to stairs with 2 rails then 1 rail and cane; “step to” technique

Outcomes

FIM Eval Week 1 Week 2 Week 3 DSG

Transfer 1 1 3 4 6

Gait 0 0 3 5 6

Stairs 0 0 0 2 6

0= did not perform ac)vity 1= total assistance; pa)ent expends less than 25% of the effort 2= maximum assistance; pa)ent expends less than 25-‐50% of the effort 3= moderate assistance; pa)ent expends 50-‐75% of the effort 4= minimum assistance; pa)ent expends 75% or more of the effort 5= supervision; pa)ent requires no physical assistance; cuing/stand by assist 6= modified independent; pa)ent requires assis)ve device or takes more )me 7= independent

Outcomes KU Balance Eval Week 1 Week 2 Week 3 DSG

Si]ng 1+ 3 4 5 5

Standing 0 1+ 2+ 3 4

0 Pa)ent performs 25% or less of si]ng ac)vity. (Maximum assist). 1 Pa)ent supports self with upper extremi)es but requires therapist assistance. Pa)ent performs 25-‐50% of effort. (Moderate assist). 1+ Pa)ent supports self with upper extremi)es but requires therapist assistance. Pa)ent performs >50% of effort. (Minimal effort). 2 Pa)ent supports self independently with both upper extremi)es. 2+ Pa)ent supports self independently with 1 upper extremity. 3 Pa)ent sits without upper extremity support for up to 30 seconds. 3+ Pa)ent sits without upper extremity support for 30 seconds or greater. 4 Pa)ent moves and returns trunkal midpoint 1-‐2 inches in one plane. 4+ Pa)ent moves and returns trunkal midpoint 1-‐2 inches in mul)ple planes. 5 Pa)ent moves and returns trunkal midpoint in all planes greater than 2 inches. e.g. able to grasp and move object, react to unan)cipated challenges, such as external force, catching a ball or hi]ng a balloon.

Kansas University Siqng Balance Scale

0 Pa)ent performs 25% or less of standing ac)vity. (Maximum assist). 1 Pa)ent supports self with upper extremi)es but requires therapist assistance. Pa)ent performs 25-‐50% of effort. (Moderate assist). 1+ Pa)ent supports self with upper extremi)es but requires therapist assistance. Pa)ent performs >50% of effort. (Minimal effort). 2 Pa)ent supports self independently with both upper extremi)es. (i.e. walker, parallel bars, crutches). 2+ Pa)ent supports self independently with 1 upper extremity. (i.e. cane, parallel bar, 1 crutch). 3 Pa)ent stands independently without upper extremity support for up to 30 seconds. 3+ Pa)ent stands independently without upper extremity support for up to 30 seconds or greater. 4 Pa)ent independently moves and returns center of gravity 1-‐2 inches in one plane. 4+ Pa)ent independently moves and returns center of gravity 1-‐2 inches in mul)ple planes. 5 Pa)ent independently moves and returns center of gravity in all planes greater than 2 inches. e.g. able to grasp and move object, throw ball.

Kansas University Standing Balance Scale Outcomes

KUH Func8onal Scale

Eval Week 1 Week 2 Week 3 DSG

Bed Mobility

2 3 4 5 6

Transfer 1 2 3 5 6 Gait Assist 0 3 4 5 6 Gait Distance

0 2 5 6 7



KUH Func8onal Outcome Scale 1. Bed mobility 7= Complete independence 6= Modified independence; safety considera)ons, use of assis)ve device as bed rail, head of bed elevated, use of overhead trapeze or takes longer to perform ac)vity 5= Supervision; set-‐up or cuing needed 4= Minimal assistance; pa)ent performs 75% of ac)vity 3= Moderate assistance; pa)ent performs 50-‐74% of ac)vity 2= Maximum assistance; pa)ent performs 25-‐49% of ac)vity 1= Total assistance; pa)ent performs less than 25% of ac)vity 0= Cannot assess or ac)vity not appropriate 2. Transfers; bed to chair 7= Complete independence 6= Modified independence; safety considera)ons, use of assis)ve device or takes longer to perform ac)vity 5= Supervision; set-‐up or cuing needed 4= Minimal assistance; pa)ent performs 75% of ac)vity 3= Moderate assistance; pa)ent performs 50-‐74% of ac)vity 2= Maximum assistance; pa)ent performs 25-‐49% of ac)vity 1= Total assistance; pa)ent performs less than 25% of ac)vity 0= Cannot assess or ac)vity not appropriate

KUH Func8onal Outcome Scale 3. Gait; walking on level surfaces 7= Complete independence 6= Modified independence; safety considera)ons, use of assis)ve device or takes longer to perform ac)vity 5= Supervision; set-‐up or cuing needed 4= Minimal assistance; pa)ent performs 75% of ac)vity 3= Moderate assistance; pa)ent performs 50-‐74% of ac)vity 2= Maximum assistance; pa)ent performs 25-‐49% of ac)vity 1= Total assistance; pa)ent performs less than 25% of ac)vity 0= Cannot assess or ac)vity not appropriate 4. Walking distances 7= > 201 feet 6= 151-‐200 feet 5= 101-‐150 feet 4= 51-‐100 feet 3= 31-‐50 feet 2= 11-‐30 feet 1= 1-‐10 feet 0= Cannot assess or ac)vity not appropriate

Outcomes

•  KU si]ng and standing balance improved 8 points

•  FIM mobility score improved 17 points •  KUH Acute care outcome improved 22 points

Outcomes

•  On discharge RB was walking independently with a cane

•  Con)nued outpa)ent physical therapy was recommended for high-‐level balance and mobility ac)vi)es without the cane

Other Considera8ons: Equipment Choices

•  Func)onal purposes: mobility, toile)ng •  Ceiling mounted

•  Free standing/mobile

Other Considera8ons

•  Staff safety

•  Staff training •  Choice of tests/measures (TUG, Tine], Berg, 5x sit to stand, Walking speed, 6 minute walk test)



You’re a rock star, RB!

Case Scenarios

#1. Mr. Jones is admiced to your hospital with a right distal femur fracture secondary to a fall at home. His current weight is 550 lbs. An ORIF was completed yesterday and post-‐op referral is for PT for mobiliza)on with non-‐weight bearing on the R LE for 8 weeks. You enter the room for your evalua)on and the nurse states that he must go for a chest x-‐ray now. He is not familiar with the lin equipment and wants your advice for the best way to get this pa)ent to x-‐ray.

Case Scenarios

#2. Ms. Smith just had gastric bypass surgery yesterday and was doing well si]ng on the bedside but became faint while trying to walk to the bathroom with the CNA and is now on the floor. You have been called to assist because the pa)ent weights 400lbs. You enter the room and find 10 staff members trying to problem solve as they talk over the pa)ent. She reports that she doesn’t hurt anywhere and the physician already cleared her from obvious injury.

Case Scenarios

#3. Mr. Conner has been bed bound in his home for the past 5 years secondary to morbid obesity. He has been admiced to the hospital with pneumonia and acute respiratory failure requiring ven)lator. He weighs 700lbs. You are consulted and the physician writes “PT to get pa)ent out of bed”. What equipment and treatment op)ons will you choose and educate other staff to use to improve this gentleman’s situa)on?

Case Scenarios

#4. Ms. Gentry tolerated being upright in bed (chair mode) for one hour yesterday and sat in Shucle for one hour today. She is excited to try walking and the physician wrote for “PT for walker training”. The pa)ent hasn’t walked for 2 months due to bilateral LE celluli)s and non-‐healing ulcers on her legs. Her body weight is 375 pounds. Describe your plan for today’s treatment.

Special Thanks

•  Michael Dionne, PT •  Mark Dwyer, PT, MHA, FACHE •  Lorra Embers, PT, MSHA, FACHE •  Amy Foley, PT, DPT, MA •  Stephen Tepper PT, PhD •  Brian Brane, Sizewise •  Panera Restaurant for free wi-‐fi and healthy food!



References Ladabaum U, Mannalithara A, Myer P, Singh GObesity, abdominal obesity, physical ac)vity, and caloric intake in US adults: 1988 to 2010. American Journal of Medicine, 2014; 127 (8)717-‐727 Lucan SC, DiNicolantonio J. How calorie-‐focused thinking about obesity and related diseases may mislead and harm public health. An alterna)ve, Public Health Nutri)on, 2015; 18 (4) 571-‐581 Consumer Reports, Welcome to Snack Na)on, September 2015, p. 45 Puhl RM, Brownell KD. Confron)ng and coping with weight s)gma: an inves)ga)on of overweight and obese adults. Obesity, 2006; 14(10) 1802-‐15 Mihalko W, Bergin P, Kelly F, Canale ST. Obesity, orthopaedics and outcomes, Journal of the American Academy of Orthopaedic Surgeons, 2014; 22, (11), 683-‐690 Aminian A, Brethauer SA, Kirwan JP, Kashyap SR, Burguera B, Schauer PR. How safe is metabolic/diabetes surgery? Diabetes, Obesity and Metabolism; 2015; 17, (2), 198–201 Hinkle C, Buchanan A, Paz J. Physical Therapy management of pa)ents’ status post-‐bariatric surgery in acute care, Journal of Acute Care Physical Therapy, 2013; 4 (2), 45-‐64

Halbert J, Pearce R, Burgess T, Zock R. Advantages of using ceiling mounted lins in acute stroke rehabilita)on, Journal of Acute Care Physical Therapy, 2013; 4, (2), 73-‐83 Smith B. A pilot study evalua)ng physical therapist-‐nurse inter-‐rater reliability of Dionne’s Egress Test [TM] in morbidly obese pa)ents. AcuteCare Perspec)ves. 2008; 17, (4), 1,4-‐7 Arnold M, Radawiec S, Campo M, Wright L. Changes in Func)onal Independence Measure Ra)ngs Associated with a Safe Pa)ent Handling and Movement Program. Rehabilita)on Nursing 2011; 36, (4), 138–144 Kluding P, Swafford B, Cagle P, Gajewski B. Reliability, Responsiveness and Validity of the Kansas University Standing Balance Scale Journal of Geriatric Physical Therapy,2006; 29, (3) Swafford, B. Validity of Kansas University Hospital Physical Therapy Acute Care Func)onal Outcomes Tool AcuteCare Perspec)ves, Fall 2008 Fitch A, Everling L, Fox C, Goldberg J, Heim C, Johnson K, Kaufman T, Kennedy E, Kestenbaun C, Lano M, Leslie D, Newell T, O’Connor P, Slusarek B, Spaniol A, Stovitz S, Webb B. Ins)tute for Clinical Systems Improvement. Preven)on and Management of Obesity for Adults. Updated May 2013. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-‐2000. JAMA 288:1723-‐7. 2002. Hedley, AA, Ogden, CL, Johnson, CL, Carroll, MD, Cur)n, LR, Flegal, KM. Overweight and obesity among US children, adolescents, and adults, 1999-‐ 2002. JAMA 291:2847.2850. White, DK et all. Daily Walking and the Risk of Incident Func)onal Limita)on in Knee Osteoarthri)s: An Observa)onal Study. Arthri)s Care and Research 66(9) 2014

ACSM’s guidelines for exercise tes)ng and prescrip)on. 7th ed. Bal)more: Williams & Wilkins; 2005 and ACSM posi)on stand on exercise and type 2 diabetes. Med Sci Sports Exer 2000:32(7):1345-‐1360. Kelly. SA (2008) Systematic review of multicomponent interventions with overweight middle adolescent: implications for clinical practice. Worldviews Evidence Based Nursing. 5(3): 113-35 Dionne, M (2006) Among Giants: Courageous Stories of Those Who Are Obese and Those Who Care for Them.

Resources •  Obesity rates by state:

www.cdc.gov/obesity/data/adult/html •  How America Eats:

www.hartman-‐group.com •  Ins)tute for Clinical Systems Improvement, Preven)on and

Management of Obesity for Adults www.ici.org

•  Move Forward: Physical Therapist’s Guide to Obesity www.moveforwardpt.com

•  Project Implicit: Implicit A]tude Test implicit.harvard.edu •  Weight Bias: www.yaleruddcenter.org/weightbias

Company Resources for Bariatric Equipment

•  www.sizewise.net •  www.stryker.com •  www.gendroninc.com •  www.hill-‐rom.com •  www.uhs.com •  www.arjohuntleigh.us •  www.medcarelins.com •  www.apexdynamics.com

•  www.airpal.com •  www.alimed.com •  www.pacersonmedical.com •  www.easystand.com •  www.solostep.com •  www.litegait.com •  www.hausmann.com •  www.medline.com

Bariatric Beds

Bariatric Bed Weight Capacity

Deck Height

Length/Width Features

Stryker Bari 10A 1000 lb. 18.7-‐33.7” 80-‐88”/36-‐48”

Gendron Maxi Rest

1000 lb. 15.75-‐32.5” 80-‐88”/36-‐54”

Hill-‐Rom Tri-‐Flex 1000 lb. 14-‐28” 86”/39-‐48” 5 posi)ons including cardiac chair

Sizewise Lowboy 850 lb. 7.5-‐30.75” 82”/35-‐48” Siderails rotate away from pa)ent to foot of bed

Sizewise Bari Rehab Pla�orm 2

1000 lb. 15-‐30” 80-‐86”/39-‐48” Chair mode Removable siderails

UHS Vital Go Total Lin

450lb. 650lb.

18.25-‐ 29.75”

Chair mode Tilt table Forceplate measures weight bearing



Bariatric Beds

Bariatric Bed Weight Capacity

Deck Height

Length/Width Features

Stryker Bari 10A 1000 lb. 18.7-‐33.7” 80-‐88”/36-‐48”

Gendron Maxi Rest

1000 lb. 15.75-‐32.5” 80-‐88”/36-‐54”

Hill-‐Rom Tri-‐Flex 1000 lb. 14-‐28” 86”/39-‐48” 5 posi)ons including cardiac chair

Sizewise Lowboy 850 lb. 7.5-‐30.75” 82”/35-‐48” Siderails rotate away from pa)ent to foot of bed

Sizewise Bari Rehab Pla�orm 2

1000 lb. 15-‐30” 80-‐86”/39-‐48” Chair mode Removable siderails

UHS Vital Go Total Lin

450lb. 650lb.

18.25-‐ 29.75”

Chair mode Tilt table Forceplate measures weight bearing

2016 csm bariatric workshop presentation · rehabilitaon,of,the,bariatric,paent 2/18/16...

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