2/25/13. Obesity: having a very high amount of body fat in relation to lean body mass, or Body Mass Index (BMI) of 30 or higher.

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1 International Seating Symposium 2013 Ginger Walls, PT, NCS, ATP/SMS Medstar National Rehabilitation Network Washington, D.C. Jeff Cupps, ATP ATG Rehab, Baltimore, Maryland Participants will be able to identify 5 clinical impairment and functional mobility limitations specific to the bariatric population Participants will be able to identify 5 wheelchair and seating product features that are designed to meet the needs of bariatric clients Participants will be able to discuss clinical rationale for selection of various custom seating and mobility interventions for 5 bariatric case scenerios. USA: 30% of the US population is obese = 93,069,859 people Source: rankorder/2119rank.html CDC 2009 Weight Statistics in America: Over 12 million persons are obese in the stroke belt. Canada: 4-fold increase in morbid obesity in 20 years (Katzmarzyk et al. CMAJ 2006) 1

2 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) Understanding_Needs_Bariactric_Population.pdf 25% of people with disabilities were obese as compared to 15% of people without disabilities (2002 Weil, et al) Bariatric manual and power w/cs are the types of w/cs trending the most rapid growth At a certain weight, even individuals with normal strength are no longer able to functionally propel a w/c. Because rolling resistance is related to weight, a person with a disability who weighs more will require greater effort to propel a manual w/c Despite this known relationship, obesity alone is currently not considered an acceptable reason for a power w/c. Cooper, Rory and Cooper, Rosemarie: Trends and issues in Wheeled Mobility Technologies; %20-%20Trends_iss_WC%20(Cooper).htm Obesity: having a very high amount of body fat in relation to lean body mass, or Body Mass Index (BMI) of 30 or higher. Overweight Class I Obesity (Moderate) Class II Obesity (Severe) Class III Obesity (Very Severe) > 40 or Morbidly Obese 2

3 Weight (kg) divided by (height (m)) 2 Overweight BMI 25 kg/m 2 Obesity BMI 30 kg/m 2 Morbid obesity BMI 40 kg/m 2 From Taking Stock of the Obesity Epidemic; Scott Lear, PhD; Canadian Obesity Network Pounds to kg: #lbs/2.2 = kg Example: 150lbs/2.2 =68.18kg Inches to cm: 1 = 2.54 cm Example: 66 * 2.54 = cm 167/100 = m 2.81 m 2 Body Mass Index = Weight(kg) / Height(m) 2 Example: 68.18kg/2.81m 2 =

4 Widely used in clinical setting Most common measure in population surveys Good predictive value for future health risk in populations but questionable in individuals Perceived ease of measure Highly correlated with body fat No information of fat distribution or body composition Misclassification (lean muscle mass in athletes) Circumference at iliac crest height at end of normal expiration; tape parallel to floor and not compressing skin Preferred to waist/hip ratio Only need measuring tape Crucial to standardize measurement WC is highly correlated to total adiposity and to BMI 5 2, 190 pounds and 6 2, 450 pounds could both be considered bariatric patients Both will have impairments and functional limitations directly related to obesity Both will need w/c seating systems that are bigger, stronger, and have features that address obesity related clinical needs. 4

5 Normal Risk High Risk of Comorbidity Waist > 102cm Male BMI Waist >88cm Female Waist <102 Male; <88 Female BMI >30-40 Coronary heart disease (CHD) 70% of diagnosed cases are related to obesity Direct relationship between increased BMI and mortality due to CHD Direct relationship with CHD and increasing abdominal circumference High blood pressure Obesity more than doubles one s chance of developing high blood pressure Associated Impairments and Functional Limitations Pump size versus amount of resistance Mobility issues affecting exercise and metabolism Risk factors for further complications (CVA, OA) Direct relationship between increased BMI and increased risk of Type II Diabetes 80-90% people with Type II DM are overweight Being overweight places extra stress on your body in a variety of ways, including your body s ability to maintain proper blood glucose levels. 5

6 The more insulin you use to maintain your blood glucose level, the more glucose is absorbed into your cells, rather than eliminated by your body. The absorbed glucose is stored as fat, which makes you gain weight. diabetes-and-obesity Peripheral Neuropathy loss of sensory motor function distally Peripheral Vascular Disease PVD and PN can lead to wound healing and skin problems (sepsis, edema, amputation) Renal disease ESRD dialysis Vision loss Loss of mobility Pulmonary Disease abnormal function, obstructive sleep apnea, hypoventilation syndrome Stroke Osteoarthritis and Gout Skin changes Chronic non-healing wounds due to pressure, stasis, and/or intertrigo PVD - Phlebitis and lymphedema from venous hypertension 6

7 2/25/13 PATIENT CONCERNS: Wheelchairs too small and/or lack necessary features Doorways too small Difficulty getting accurate weight because of access to scales Embarrassing when requires additional staff to maneuver a patient Constant lecturing re: losing weight Perception that clinicians dislike them PATIENT GOALS: To get in/out of a chair independently To get on/off the commode independently To get washed/dressed To be independent with mobility To be able to access public places To be able to continue to live as independently as possible The Facility Guidelines Institute (2010). Guidelines for Design and Construction of Health Care Facilities. Chicago, IL: ASHE (American Society for Healthcare Engineering). ISBN:

8 Specialty Evaluation required by Medicare for an Ultra-lightweight wheelchair, Group 2 SP/MP PWC, any Group 3 PWC ; but a best practice at any time to ensure optimal clinical assessment and w/c meets client needs and supplier has optimal documentation Specialty eval documentation links patient needs to w/ c-seating product and then to coverage The patient's diagnosis; abilities and limitations as they relate to the equipment level of independence, frequency, and nature of the activities the pt performs, the duration/changes of pt s condition, the expected prognosis, and past experience using similar equipment. A description of the patient's routine activities. Document how pt s diagnosis, impairments or functional limitations result in a mobility limitation that reduces their ability to participate in MRADLs in the customary place in the home (toileting, feeding, dressing, grooming, and bathing) or causes a safety problem; or prevents the patient from completing an MRADL within a reasonable time frame. Obtain accurate patient weight to qualify for optimal w/c for long term use The pt s weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC i.e., a Heavy Duty PWC is covered for a patient weighing pounds; a Very Heavy Duty PWC is covered for a patient weighing pounds; an Extra Heavy Duty PWC is covered for a patient weighing 570 pounds or more. Same for POV Diagnosis, history, co-morbidities surgeries Height and Weight (include changes) Strength, sensation, skin, edema Cognition, vision, ability to use w/c Postural and Mat Eval and Measurements Functional status falls, O2 Saturation, SOB, DOE, pain limitations, TUG Test, pressure relief transfer, and ambulation ability; MRADLs Home Eval and accessibility Community mobility and transportation; lift weight capacity and size 8

9 Pt in sitting position is asked to stand and walk 10 (3 M), turn and return to sitting. May use assistive device if needed. Normal healthy elderly usually complete the task in ten seconds or less. Very frail or weak elderly with poor mobility may take 2 minutes or more. Cut-off Values Predictive of Falls Community Dwelling Frail Older Adults:> 14 seconds associated with high fall risk Post-op hip fracture patients at time of discharge:> 24 seconds predictive of falls within 6 months after hip fracture Frail older adults:> 30 seconds predictive of requiring assistive device for ambulation and being dependent in ADLs Pulse Oximetry: Provides quick, objective measure to show blood oxygen saturation levels Obtain resting pulse oximetry value Repeat with w/c propulsion or attempts to ambulate % is considered normal Below 90% is considered low; may also see SOB 9

10 Seat width What is widest point? Soft tissue containment vs. forgiveness via armrests Seat depth Chest width apple or pear? Chest thickness/depth for LTS Back post position if posterior gluteal shelf present Foot width or feet width and placement Armrest width Overall width accessibility considerations Body Shapes Pear hips larger than waist Apple waist larger than hips Understanding_Needs_Bariactric_Population.pdf Manual: Folding double X-Brace vs Rigid Power: FWD, RWD, MWD LE and foot placement needs Leg rests S/A leg rests vs center mount; E/ALRs vs platforms Power Seating Options Tilt, Recline Power transfer foot platform 10

11 Armrest types Full vs Desk Length Pads Cantilever vs. Dual/Single Post Armrest position Back Posts Endomorph Mesomorph Ability to accommodate for gluteal shelf Postural Support Issues Bariatric custom seating Cushion Specs sizes and weight capacity Cushion goals and strategies special concerns: moisture, temperature, comfort, durability, skin protection Back Specs endo/meso and positioning options; consider armrest interface and mounting HDW Pressure mapping may assist with evaluation Bariatric case studies to be presented at ISS: Paraplegia, lymphedema and obesity 2 Cerebral Palsy & obesity case studies Tetraplegia and obesity Muscular Dystrophy and obesity 2 Multiple medical problems and obesity case studies 11