Morbid Obesity Implications

for Physiotherapists

Dawn Kennedy
CSP Congress C.V. IG
October 2010
Half an hour !

 No chance
 Alarming Statistics
 WHO (2010) estimates that over 300
million people are obese.
 In the UK, the figure for obesity has
doubled in the last twenty-five years
and overweight is now the norm
(Foresight Report, 2007)
 Alarming facts
 Childhood obesity has had a 250%
increase over the last three decades
(Wittmeier et al, 2008).
 The Department of Health (2008)
estimates that 56% of the U.K.
population is obese.
Hypertension, Coronary Heart
Disease (Owens, 2003)
Gallbladder disease (Stampfer et
al,1992), Osteoarthritis (Bray, 2004),
Breast cancer, uterine cancer and
colon cancer (Bessesen and Kushner,
2002 Manson et al, 1995).
Type 2 Diabetes, (Hart et al, 2006)
Diabetes has been identified “as the
greatest risk for overweight and
obese patients” (Foresight, 2007).
Predictions of a diabetic epidemic in
10-20 years as a consequence of
obesity,
 There is also the risk of pressure
sore development due to skin being
stretched beyond its point of
elasticity (Dionne, 2002). Chronic Kidney
disease as also been linked with
obesity (Stengel et al 2003),
Cardiovascular (Mctingue et al, 2006, Somers
et al, 2008,) neurological (Polkey et al, 2008,
Vogalzangs et al, 2010), musculoskeletal,
(McInnis, 2000) cellulitis, venous stasis
of legs and diminished hygiene,
 respiratory problems, pickwickian
syndrome, obstructive sleep apnoea
(Somers et al, 2008), endocrine (Vogalzangs et al,
2010), gastrointestinal and GU (Van Itallie,
1979).
 Studies into genes have identified
hormonal and neural feedbacks
loops that affect hormone levels (Bray,
2004 and Vogelzangs et al, 2008).
 Adipose tissue releases lipids
out into the body, causing a cascade
of enzymatic reactions, which in turn
influence hormonal behavior,
affecting appetite regulation and in
turn behaviour (Foresight report, 2007).
 Obesity is linked with psychological
factors, (Lavie and Milani, 2006),
depression, (Luppino et al 2010) and
low self esteem (Owens, 2003).
Case study
 Second admission of a patient who was
admitted because she could not get out of
bed.
 Being treated for cellulitis
 Septic
 Chest infection
 Increased HR and increased BP.
 Weighed 42 stone.
 Height 5’6”
 Early 40’s
Second admission front of house removed to
get access
“Trapped 40st mum saved by firefighters
smashing down her home”
The Sun
“Firefighters had to demolish the walls of a
bungalow to save a 40st woman who nearly
killed herself by eating too much”.
Metro
PMH/ previous 3 month admission
with same conditions.
Personality disorder
SH/ Had family but not in touch,
mum and daughters
Did not leave the house
Not worked for many years.
 Goals
 To be able to walk to the shops.
 To get back to work
 Goals
 To be able to wash own face.
 To turn in bed with the gantry hoist and 2
people.
 To compliantly follow own exercise
programme and to progress exercises.
 To comply with rehabilitation sessions 2-3
x a week
 To sign contract for above.
Previous admission patient lost 5 stone.
Went home independently mobile but
refused all services. Referred to
community physio to engage in outdoor
walking and progress.
Refused dietary and psychological
support.
 Risk and assessment
What is the risk to the patient?
What is the risk to the
physiotherapist?
What is the cost to the organisation?
TASK:
 
Factors to consider re PATIENT: (circle & comment): e.g. medical condition, medication, drips/drains/catheter
etc, respiratory support, state of bladder/bowel control, skin condition, pain, tremor, contracture, tone, posture,
balance, arousal, relationship between height & weight, distribution of body mass/skeleton, cognition, perception,
predictability, time of day, tiredness, emotional vulnerability, motivation to move, fear, tolerance to physio
intervention, other,
Comment:
 Factors to consider re THERAPIST(s): (circle & comment): e.g. skill, experience, height, pregnant, MSK
constraints, other constraints, current workload and priorities, physiological cost, fatigue, repetitive manual
handling procedures
Comment:
 Factors to consider re the ENVIRONMENT: (circle & comment):
Bed, bed height, bed width, bed weight limits (patient PLUS therapist(s)), mattress stability, cot sides, height of
chair, ‘fit’ of chair (Too wide to push up from? Too low? Too high?), space etc
Comment:
 
If the patient falls how will you get them off the floor?
Comment:
 
Taking into account skill mix / equipment / environment and handling methods, how will you achieve this task?

 
 
 
 
 
 
 
 
 
 Factors to consider re PATIENT:
(circle & comment): e.g. medical
condition, medication,
drips/drains/catheter etc, respiratory
support, state of bladder/bowel
control, skin condition, pain, tremor,
contracture, tone, posture, balance,
 arousal, relationship between height
& weight, distribution of body
mass/skeleton, cognition,
perception, predictability, time of
day, tiredness, emotional
vulnerability, motivation to move,
fear, tolerance to physio intervention,
other
 Factors to consider re
THERAPIST(s) e.g. skill, experience,
height, pregnant, MSK constraints,
other constraints, current workload
and priorities, physiological cost,
fatigue, repetitive manual handling
procedures
 ENVIRONMENT:Bed, bed height,
bed width, bed weight limits (patient
PLUS therapist(s)), mattress
stability, cot sides, height of chair,
‘fit’ of chair (Too wide to push up
from? Too low? Too high?), space
etc
Comment:
 Morphology
 Distribution of fat/ excess weight
 IS it all fat or fluid? Type of fluid?
 Quality of skin
 What movements are limited by body shape
 Which body landmarks can you identify.
 Use a body chart to identify depth of skin
fold.
Body Mass Index BMI=kg/m2
Waist circumference (Janssen et
al, 2004)
88cm women 102 cm men non-
Hispanic blacks, Mexican
Americans, non-Hispanic
whites, and people of Asian
descent.
 Factors
 Cardio-respiratory
 Physiological response coupling
 Physical  Length of time on bed
 Function rest
 General health/
previous level of
fitness
 Septic cause
 Heart rate and BP
work of breathing and RR
saturations
perceived work of breathing
Borg
Perspiration
 Ability to exercise
Application of cardiac rehab
principles and the American College
of sports medicine Leg lifts.
Arm lifts or curls. Lifting wrists up.
Chin lifts. Upper thoracic rotations.
Shoulders off the bed.
 Equipment
 Gantry hoist
 Repo sheets
 Bed with extra width and supports weight
 Slings
 Walking pants
 When to get a chair and which – (altered
biomechanics of movement)
Get the patient working.
Think movement.
Think activity.
Avoid static positions
Avoid restrictions
Education and motivation
Give them the reality facts
but it has to come from themselves
for successful intervention
No one size fits all solution.
Any questions
Enjoy your Lunch