January 2002

Rehab and the Bariatric Patient

By Carol Daus

Rehab and the Bariatric Patient
Having the correct equipment and a well-trained staff offers bariatric patients the best possible chance to achieve rehabilitation goals.

The bariatric patient population has grown dramatically during the past few decades, causing hospitals and rehabilitation facilities to develop strategies for treating obese patients. According to the Englewood, Colo-based American Society of Bariatric Physicians, the prevalence of obesity increased from 12% of the US population in 1991 to 17.9% in 1998 and this rate continues to rise.

Recognizing this growing population, Madonna Rehabilitation Hospital in Lincoln, Neb, several years ago developed strategies for treating severely obese patients. "As we began to see an increasing number of these patients," notes Judy Clementson, PhD, a licensed psychologist at Madonna, "it became clear that there was a need for increased staff training and specialization to better meet their needs." Although many of the obese patients who are treated at Madonna are in the 300-pound category, it still occasionally receives patients who weigh more than 700 pounds. As Clementson points out, patients who suffer profoundly from immobility due to severe obesity often require specific mobilization techniques, self-care issues, specialized rehabilitation equipment, cardiorespiratory precautions, and pressure relief.

Training Is First Step
The first step Madonna took to better serve this population was to introduce an extensive training program for rehabilitation staff and nurses to help sensitize them to the psychosocial issues of weight discrimination. "It's really one of the last forms of discrimination that is still sanctioned in our society," stresses Clementson. Clementson cites a study that asked individuals with disabilities if they had a choice and could trade their disability for another disability, whether they would make this decision. "Virtually everyone-whether they were diabetic, had an amputation, or were blind-chose to keep their disability, except for obese people who chose any other disability rather than staying obese."

To complicate matters, most rehabilitation workers are young and fit, which often makes it difficult for them to relate to this population. According to Sharon Balters, LMNT, RD, PhD, manager of medical nutrition therapy, there is a misconception among many medical professionals that the simple solution for most obese patients would be to lose weight. "Obese people really don't eat as much as people think, and after they have become obese, it's extraordinarily difficult for them to lose weight," says Balters. "You don't need as many calories to keep fat tissue alive versus lean tissue." Since many of Madonna's rehabilitation employees were uninformed about nutrition and obesity, a major focus of the training effort was to educate caregivers about these issues.

Throughout the training, the entire multidisciplinary team-which consisted of physical, occupational, and recreational therapists; psychologists; nutritionists; case managers; respiratory therapists; and nurses-were taught to treat this population as one with special needs. In some instances, depending on the degree of obesity, a patient's treatment plan would be tailored to meet these needs. For instance, therapy goals need to be realistic, achievable, and less ambitious than for other patients without this complication. "Some years ago we made the mistake with certain obese patients of not adjusting the standards and as a result these individuals found things to be overwhelming," says Clementson.

The Fear Factor
Laura Grunke, PT, a Madonna physical therapist who works with bariatric patients, notes that one of the biggest concerns for these patients is the fear of falling. Many obese patients have had humiliating experiences where, after a fall, a fire engine or ambulance was called out to help pick them up. Unfortunately, this fear of falling or even moving causes many of these patients to remain as inactive as possible. "This is a serious problem because deconditioning will then set in," explains Grunke. To prevent this occurrence, Grunke says in most cases rehabilitation efforts closely resemble those that would be performed for nonobese patients. "We work closely with them on achieving balance and helping them learn where their center of balance is," says Grunke. "This is a challenge for many obese patients: they usually do not want to lean forward because of their fear of falling, yet by doing this they will be able to become mobile."

Grunke also advises caregivers of obese patients to help them stand by pulling them forward rather than by pulling up, which can frighten them because of their fear of falling. Pulling them forward also allows them to use their own muscles. "This is different from other patients since most people don't have to lean forward to get their momentum going," says Grunke. "You might still need several people to assist them, but it works much better than trying to lift a heavy person straight up."

When bariatric patients are able to walk, Grunke stresses that it is very important to monitor their progress and at the same time teach them how to monitor their own activity levels, take their pulse, and use certain scales. "We work closely with them to help them understand what their heart rate should be for activities and endurance training."

Grunke also makes sure that obese patients learn how to get up and down from the floor. "This is a big cause of stress for this population, but once they learn that they can get up with the help of one or two people, they feel much more confident," she says.

Clementson adds that many bariatric patients who are admitted for rehabilitation have severe obstructive sleep apnea, which limits their stamina and often makes them lethargic during the day. In many cases, the sleep apnea had never been diagnosed before they were admitted to Madonna. "For those who can tolerate bilevel or continuous positive airway pressure treatment at night, we find it makes a big difference in their ability to participate effectively in therapy," says Clementson.

Increasing Independence
Occupational therapists play an important role in treating obese patients by helping them learn how to conserve their energy. Although this may appear counterintuitive, the fact is that energy conservation enables a heavier person to achieve higher levels of independence. Occupational therapists also work with nurses to teach these patients about proper hygiene. Since there are more folds of skin in obese patients, these areas are more susceptible to infections, fungus, and wounds. Body odor and chafing from clothing can also be a problem.

According to Clementson, another issue that staff needed to be educated about was a defense mechanism used by many bariatric patients: denial of certain emotional issues such as social isolation and withdrawal. Some patients also may withdraw from interaction with staff, possibly becoming anxious, fearful, or depressed, or may even misplace anger toward the staff. "While patients are here, we can address these issues with the help of our psychologist and recreational therapist," says Clementson.

Patient compliance has not been difficult with this population mainly because Madonna has adequately trained its staff to work with bariatric patients. But at the same time, she is quick to point out that since many obese patients have been told what to do by many different people (both medical professionals and family members), they can be initially resistant to rehabilitation efforts. "We can move through this situation by communicating with them closely on what their individual goals are," says Clementson.

Equipment
Although some rehab professionals worry about self-injuries when transferring or working with obese patients, Grunke is proud to report that there have been no injuries among the rehabilitation staff. She credits the use of specialized equipment in ensuring this safety record. To meet the needs of this growing population, Madonna several years ago began acquiring specialized beds, lifts, wheelchairs, commodes, and scales. Special accommodations were also made so that these patients had larger rooms with wider doors to house the equipment. Staff also learned quickly that additional supplies needed to be stocked for this population. For example, the standard size blood pressure cuff should not be used on a person with an arm bigger around than 14 inches because it will give a false high reading. As a result, larger-sized blood pressure cuffs were purchased along with larger patient gowns.

Balters explains that one of the advantages of focusing on the needs of this population is that physicians and other local providers began to recognize Madonna's expertise in this area. "There are still many nursing homes that will not accept any patients who weigh more than 350 pounds," says Balters. To this date, many facilities still lack the necessary equipment for bariatric patients. Clementson admits that there have been several cases in which patients were transferred to other institutions but needed to be discharged since they did not have beds, walkers, and wheelchairs that would ensure the patients' safety.

"It's also amazing when you learn that there are physicians' offices in town that don't even have doors wide enough to accommodate an obese person's wheelchair," says Clementson. Other patients have commented that their physicians' offices did not have scales that were capable of weighing them so they either were left unweighed or in extreme cases were weighed on a loading dock behind the hospital, which is extremely humiliating. Since it is difficult for many obese patients to visit their doctor, what typically happens is that they avoid making appointments and end up with comorbidities.

Although there are still some facilities that do not adequately treat obese patients, institutions like Madonna Rehabilitation Hospital have proven that with the right equipment and trained staff, bariatric patients are able to successfully achieve rehabilitation goals while learning the right information to help them start losing weight, if even a small amount. Clementson stresses that even a 5% to 10% decrease in weight will increase their muscle mass and improve overall fitness. "For those obese patients who are really motivated, they will leave Madonna with increased function and the ability to live a higher quality of life," she says.

Carol Daus is a contributing writer for Rehab Management.

LOOKING FOR EXPERT ADVICE? Experts here are available to answer all your questions! Please contact us for more information about this feature, or to become an expert.

MEDIA CENTER Interactive Media  Archives  · December 2008  · November 2008  · October 2008  · August/September 2008  · Fall 2008 Product Directory  · July 2008  · June 2008  · May 2008  · April 2008  · March 2008  · All Archives  Newsletter  · Rehab Today Resources Classifieds Calendar Consumer Resources Media Kit Advertiser Index EAB Reprints Submit an Article