One Size Does Not Fit All

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March 2002

By Michael Dionne, PT

Michael Dionne, PT, assists a patient from a supine to a long-sitting and short-sitting position in a pattern consistent with her pear-shaped body type.

The diversity of bariatric body types must be addressed in order to safely and effectively treat this often underserved population

Educating clinicians on the safe management of the obese patient is an important facet of health care but one that is often overlooked, which prompted me to develop the program, Dionne's Bariatric Ergonomics©, Transfers and Mobility of the Obese Patient. The program provides a systematic progression of the dependent obese patient. I hope to change the way professionals think about this unique patient population and to demonstrate that restoration of function is possible, even where weakness relative to body mass is dominant. The need for effective structure in pathway and screening tools for safe management of the obese patient population is key. Health care providers need to respect the diversity of body types within the bariatric population and recognize that safe interventions require structure that meets each admission scenario.

Anasarca: The Congested State
Anasarca is a Greek medical term used to describe generalized edema. The term was deemed too general and subsequently was replaced by third space, which more specifically identifies where acutely pathologic fluid volumes or edema dominates, and where medical intervention of edema control is to be directed.

However, in my use of the term, I hope to emphasize that severe generalized edema can have life-threatening consequences, unique for the person of size who is in acute heart failure.

It is key for a bariatric protocol to recognize the critical care state of anasarca. Intervention may include a tate-of-the-art/critical care UL-rated bariatric bed with air surface support; percussion; rotation; dependent full cardio-chair positioning with ability to Trendelenburg the seat pan to achieve cradling postures; Trendelenburg positioning for gravity-assisted boosting, which is especially important for injury prevention for night shift staff; and Gortex or nylon sheets to reduce frictional resistance (shear) and augment moisture dissipation.

During the anasarca state, the primary goal is to recognize and manage acutely changing fluid volumes and support cardiopulmonary function. Restoration of mobility is obviously a secondary and, perhaps, even a deferred goal at this time.

Critical issues may include:

Acute congestive heart failure (CHF) possibly with concurrent respiratory compromise or failure, whereby the secondary effects of pulmonary hypertension with edema may dominate.
Ventilatory pump obstruction uniquely occurs in those who are severely obese secondary to a stressed high-pressure system during acute heart failure. Pathologically, fluid shifts from the vascular space toward peripheral tissues of the chest wall and abdominal tissues. Keep in mind that those who are obese uniquely possess a small skin surface area per body mass. This is evident by the propensity of those of size to sweat significantly more in an attempt to dissipate heat from baseline metabolic activity when compared to the person of average size. With incongruence of dermis thickness and inability of fascia to maintain proximity of excessive internal mass, skin surface results in surface deformity. Where skin surface area has superior ability to approximate tissue, a fissure or inward fold may result with herniation of adjacent less integral tissue bulging outward.

The consequence of small skin surface area to body mass as seen uniquely in the obese population is compounded with the onset of acute heart failure and subsequent global edema resisting chest wall mobility. During the normal kinematic pattern of inspiration, the ribs elevate much like a bucket handle with concurrent inferior diaphragmatic excursion to draw oxygen in. Subsequent relaxation of the ventilatory pump to the starting position occurs on expiration to expel carbon dioxide. The person of size is limited by excessive adipose tissue combined with acute edema in the chest wall tissues that greatly reduces soft tissue compliance and ventilatory pump action.

Additionally, if patients are apple-shaped, they may lose significant diaphragmatic excursion secondary to excessive abdominal fat and/or third-spaced fluid within the abdominal region, such as in right heart failure. This restrictive band of edema surrounding the chest cavity exerts a unique additional burden on ventilation that, combined with loss of gas exchange secondary to pulmonary hypertension, more severely compromises the obese patient already in a state of congestive heart failure.
Oxygen delivery requires constant monitoring through arterial blood gases and pulse oximetry to ensure appropriate saturation and carbon dioxide levels.
Glucose levels may also require constant monitoring as critical illness may compromise self-regulation of glucose levels in this population.
Monitoring for arrhythmia should be obvious as electrolytes may be lost during emergent diuretic activity or compromised respiration may also impact cardiac function.
Heat dissipation. Air mattress support and additional room ventilation may be required to reduce room heat and prevent excessive patient sweating.
Postural edematous deformity or the 7-foot spread, a phrase I coined to describe massive generalized edema that prevents patients from fitting into a 39-inch-wide bed frame. During an extreme congested state, patients may exhibit as much as a 7-foot distance between their ankles. Excessive adipose tissue bulk compounded by severe edema may result in the inability of the patient to flex, adduct, or approximate body segments functionally, preventing activities of daily living (ADL). Even grasp may become restricted and trunk flexion may become extremely intolerable, limiting sitting postures. Massive loss of end range of motion (ROM) globally dominates.
Susceptibility to frictional burn should be obvious in the state of anasarca. Imagine flexing your wrist and rubbing its outer surface across a cotton sheet. The result would be increased susceptibility to frictional burn because of the stretched skin's diminished ability to absorb energy. Pure skin shear is unique for those who are acutely ill and obese. When severely congested, dependent patients of size who are lying in bed may experience skin tears when attempting to reach for the bedside table as they rotate their upper body over a fixed lower body. The skin is simply unable to meet the shear tension loads imposed so it separates or tears.

The tears present typically as diagonal linear ulcerations less than one inch in length and usually number in a chain several ulcerations within a skin fold.

The patient of size who is severely edematous may experience higher pressure in the lower body tissues forcing serous fluid and possibly blood through skin pores. Particularly in the lower leg with dependent positioning, fluid pooling, secondary to effects of gravity, increases this patient's risk for sepsis.
Bladder issues can be managed with catheter placement, though in extraordinary situations it may require extensive search with a scope to obtain access. Bowel care is perhaps the greatest challenge. The acute state presents with few options. Several practitioners may be required to logroll the patient to effect pericare. Sometimes lifts or an air mattress with surface rotation may be employed to assist in rolling. Because of anatomical variances, fecal incontinence applications usually do not work well in the bariatric population.
Many patients who are in the critical care environment often demonstrate anxiety and express difficulty coping with dramatic loss of function in their lives.

Recognition of the transition to the subcritical phase is key in the bariatric protocol. The progression may be successful transition from dependent ventilation (IMV, SIMV, or pressure support) to ventilatory weaning. The patient begins to take physical responsibility in ADL performance. Bariatric protocols need to match this transition in equipment prescription. The patient should be transferred from a critical care bed to a rehabilitation-based bariatric bed. The rehabilitation bed should include some of the following options: intermittent air mattress or viscoelastic support surface; adequate high low function; Trendelenburg function for gravity-assisted boosting; side exit to accommodate patients who are short or who present with immobile abdominal wall, and foot exit for those who require substitution patterns in the postoperative abdominal or thoracic surgery scenarios; and enough portability that evacuation policies can be followed and transportation to diagnostic, rehabilitation, or other parts of the hospital is possible.

The nine critical issues identified in the state of anasarca should begin to subside. Ventilatory pump function and CHF resolve as the grossly edematous state subsides, allowing the patient to achieve functional ventilation. Glucose, blood gases, and electrolyte levels become stable; there is reduced risk of cardiac arrhythmia and subsequent weaning from telemetry is possible. Scheduled laboratory studies are done only when needed. The patient may reduce air mattress dependency to intermittent use as once maximally stretched skin becomes more mobile and less susceptible to shear and frictional burn. The postural edematous deformity or 7-foot spread may subside enough to allow for mobility and positioning.

In the critical care state, the patients were subject to constant care and interventions. Once stabilized, some individuals find themselves placed in a room away from the staff and there is a risk of isolation. A facility that lacks bariatric equipment, effective pathways, scheduled mechanical mobilization, or structure may subject a patient to prolonged length of stay and months may pass without attempts at progression.

Apple Ascites Distribution
A high waist to hip ratio is indicative of apple distribution obesity. Upon examination of this patient, we may find a diagnosis of pickwickian syndrome or hypoventilation syndrome. The patient may be at a known carbon dioxide retention risk with significant difficulty tolerating flat supine and prone postures. He finds himself using several pillows under the head of his bed to achieve semi-Fowler positioning to augment breathing. He has very poor endurance to activity limited by shortness of breath upon exertion. On physical inspection, his presentation demonstrates postural adaptations to chronic difficult breathing over recent years including: hypertrophy of accessory muscles of respiration; convexity of the cervical region; jugular vein distention; oxygen saturation is adequate but remains in the lower 90%; history of limited ambulation or wheelchair propulsion secondary to endurance restrictions; elevated clavicles and seeking of postures to stabilize upper extremities on external surfaces for additional respiratory support; immobile umbilicus tending not to deviate, obstructing flexed trunk postures; palpation of abdominal wall may reflect a rigid and relatively immobile surface; lower leg cellulitis may be apparent; and the apex of the abdominal wall tends to be anterior with limited abdominal drift near the belt line observed in standing.

Observed mobility patterns demonstrate a supine to sit technique via supine on elbows flat spin on the bed until perpendicular and elevation of the trunk by virtue of the patient moving his hips near the edge of the bed and using his lower body to counterbalance the upper body while pushing his trunk to upright. For this reason, this patient may require a wider bed for mobility.

The apple ascites patient seems to be very limited in techniques because of his immobile abdominal mass and difficulty breathing in dependent postures. Some patients of this group may tolerate rolling though they tend to avoid flat postures needed for a pure log roll. The classification of apple ascites provides a clinical description of patients who, like those dominated by right-sided heart failure, often demonstrate a rigid abdominal wall, and nearly all of the observed limitations stated above. While I recognize that not all patients who are obese and fit this description have ascites, I am combining apple and ascites to recognize the clinical presentation for patients who present with mobility-based challenges and intolerance requiring unique intervention and equipment prescription.

Apple Pannus Distribution
A high waist to hip ratio and an apple distribution body type signify the apple pannus patient. These patients present with dominant pannus (inferior abdominal drift) and, when stabilized, they begin to tolerate flat postures. Depending on how much the patient's pannus is able to drift inferiorly from the diaphragm in supine, the patient tolerance to flat supine may be variable. Should the pannus resist diaphragmatic excursion in the supine posture, the apple pannus patient simply rotates to flat-side lying and does not usually require semi-Fowler positioning. Flat posture in supine or side lying; is not tolerated well in the apple ascites scenario because of loss of both chest wall compliance and diaphragmatic excursion.

The apple ascites patient demonstrates an immobile chest and abdominal wall restricting ventilatory pump activity in either supine or side-lying postures. The person of apple pannus distribution has a somewhat mobile pannus in which the patient is often seen actually placing the pannus on some pillows for support while in flat side-lying; he can mobilize his umbilicus up to 12 inches or more, side to side. Postural adaptations may present as follows: dominant pannus with lumbar lordosis; concavity of the cervical region or lacking accessory muscle hypertrophy or elevated clavicles; history may reveal significant tolerance to distance ambulation; palpation demonstrates a significantly mobile umbilicus and mobile tissue about the chest wall; and hypercallus may form on the plantar surfaces of both feet and where the inferior surface of the pannus rubs the patient's thighs during gait (because these patients are able to ambulate or propel a wheelchair greater distances, they are more likely to develop hypercallus formation on weight-bearing surfaces given the significant loads); and the apex of the abdominal wall is located on the inferior surface, which may drift significantly below the belt line when standing.

Observed mobility patterns demonstrate a diverse number of techniques achieving supine to sit. Some patients of apple pannus distribution use a supine flat spin to perpendicular and sit up to the edge of the bed. It is surprising that a significant number of patients over 500 pounds use some form of prone progression entry or egress from bed. Prone entry techniques may include a prone flat spin on the bed or a four point (hands and knee posture) entry. The four point entry is actually very common in patients with a mobile abdominal wall up to 500 pounds. I have had two patients beyond 850 pounds who each turned from supine to prone then performed a flat spin on the bed while on their stomachs and dropped their legs over the side of the bed in an abducted extended leg posture. They both then benchpressed their trunks into standing and adducted their legs to achieve full upright standing. In doing so, they do not have to thrust upward from a sitting posture where their knees would be flexed beyond peak knee extension torque located in the average person at 60° of knee extension.

Pear Abducted Distribution
The pear abducted distribution patient has a very low waist to hip ratio. These patients present with the majority of tissue bulk below the belt line and their femurs are in an abducted posture because the majority of tissue bulk is medially located about the thighs and prevents the knees from making contact or midline posture. These patients may quickly accommodate to supine tolerance. Their ability to breath is easily accomplished without ventilatory obstruction, as the excessive tissue bulk is located in the lower body.

Pericare issues dominate this population as urine spills, skin rubbing, and excessive moisture buildup contribute to a host of risk factors for urinary tract, yeast, and fungal infections.

Observed mobility patterns demonstrate difficulty with rolling secondary to extreme abducted lower extremity posture. Rolling is generally an inefficient movement pattern since lifting a heavy leg requires strength possibly not available relative to body mass. Most persons of pear abducted distribution move supine to long sitting or semi-long sitting (sitting with legs in front) and finally to short sitting over the edge of the bed. Equipment implications may require a narrow lower bed and a wider wheelchair.

Pear Adduction & Gluteal Region
Two other body types I discuss in the program include pear adducted shape and bulbous gluteal region body types. The person with pear adducted distribution has the majority of tissue bulk below the belt line and, hence, a low waist to hip ratio. They typically present with the majority of tissue bulk on the lateral aspect of their thighs. They can fully adduct their knees until femur condyles make contact. Because of the lateral placement of adipose tissue, the patient has easy access to pericare and hygiene is easily managed.

Observed mobility patterns include supine to long or semi-long sitting and, finally, short sitting posture. The pear adducted distribution allows for logrolling, as the tissue bulk is usually mobile.

Some persons of size in sitting demonstrate a shelf of excessive tissue protruding posterior-ward from the plane of their pelvis. They may be limited in sitting and supine posture secondary to postural-related pain avoiding. In supine, excessive tissue bulk on the posterior aspect of the pelvis pushes patients' hips upward, relative to the plane of their trunk. Equipment options may include air mattress support, which allows the heavier hips to sink into the mattress and the lighter trunk to become approximated in line with the hips. In wheelchairs, special adaptation may be required to accommodate this deformity.

Having more than 16 years of experience with bariatric patients, I believe there is significant diversity in the bariatric population that requires specific equipment adaptation. Bariatric pathways, protocols, appropriate equipment prescription, nursing screening, and egress tools are integral to safely guide clinicians in the care of this unique population. Bariatric rehab can be safe and rewarding.

Michael Dionne, PT, is a therapist at Northeast Georgia Medical Center, Gainesville, Ga, and the founder of www.bariatricrehab.com. He is the recipient of the Mary Pat Murray Award for Clinical Excellence for his work in bariatric rehabilitation.

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March 2002