A growing challenge

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A growing challenge
A growing challenge
It's a snowballing health crisis: Just as the number of obese Americans continues to swell, so do the ranks of those considered severely, or morbidly, obese. And the latter pose new challenges to long-term care operators interested in serving them — challenges ranging from orienting staff to this special needs population, to acquiring specialized equipment and devising appropriate physical therapy and occupational therapy goals.

Helping staff become sensitive to the challenges severely overweight residents face is a priority for facilities considering treating these people, says Mary Pidich, director of compliance and education for Select Rehabilitation in Chicago.

“Many people might have psychosocial issues with weight discrimination,” she explains. “Staff could have a built-in bias that these people have just eaten themselves to their current condition. First and foremost, staff has to be sensitive to the fact that if given the choice, these people would not be obese. They're as equally concerned about their condition as someone who might have had an amputation or suffered a stroke.”

According to the Centers for Disease Control and Prevention, one-third (35.7%) of Americans are obese, which is defined as having a body mass index of at least 30.

Moreover, using 2004 as a baseline, the National Bureau of Economic Research forecasts that by 2020, Class 3 obesity will climb 80% for both men (from 3.3% to 6.3%) and women (from 6.9% to 12.8%). Class 3, or morbid obesity, is defined as having a BMI at 40 or above. People in this category are 50% to 100% — or 100 pounds — above their ideal weight.

As if to underscore a societal bias against the obese and severely obese individuals, Pidich adds that the condition historically had been regarded as a personal problem, not an illness.

“Even Medicare considered obesity not to be an illness, but that language changed in 2003,” she notes.

Bariatric equipment
Specialized equipment is important not only for effective and safe rehab of bariatric residents, but also for their therapists and nurses.

“Proper equipment is a big factor to help prevent injuries among staff,” says Shelly Mesure, MS, OTR/L, McKnight's “Rehab Realities” blogger and general manager at Orchestrall Rehabilitation Solutions.

Beds, commodes, wheelchairs, lifts, scales and walkers — along with larger rooms and wider doorways — to accommodate people who are 300 pounds or heavier are essential.

Ceiling lift systems in patients' rooms can raise residents' limbs while staff help them perform personal hygiene. Floor lifts outside of patient rooms are needed to help residents who might have fallen or otherwise need transferring.

Equipment advances for bariatric residents during the past few years include new walkers and wheelchairs, Mesure explains.

The bariatric walkers feature handles farther out from the user's body, which accommodate bariatric patients' wider stance and helps improve their balance.

“There are also wheelchairs with wider seats [in increments of 26, 30 and 32 inches] and solid seat inserts to replace the previous canvas seats, which would often look like slings when people sat in them,” Mesure says.
Suppliers are increasingly expected to offer not only bariatric-based support surfaces, but standard beds and mattresses in larger sizes, such as 39” and 42”, says Moxi Enterprises' Scott Fiss.

Bariatric patients are at a particular risk for pressure ulcers, especially since it can be difficult for clinicians to rotate them as needed, Fiss notes.

Additional issues include poor circulation and sweating.

Physical therapy priorities
At Kindred Healthcare, the primary physical therapy priority for bariatric patients “is to get them moving immediately,” says Vienna Lafrenz, OTR/L, CLT, rehabilitation education and compliance coordinator, West Region, for Kindred's Rehabcare rehab division.

As such, physical therapy can begin even before a person is capable of getting out of bed.

“When you have a person of size and you're having them exercise in bed, just the weight of an extremity [an arm or leg] is like having a weight put on their body,” Lafrenz says. “So often we just use the weight of the extremity to get them exercising and increase their strength to a point where they can actually push themselves out of bed and get up.”

While the ultimate goal is to help the person return home and live as independently as possible, Kindred physical therapists establish realistic, incremental rehab goals by learning the resident's recent history, such as how long it has been since they could bear their own weight or walk.

Keeping them moving
Once residents  are ambulatory, the priority is to gradually increase the exercise level, says Pidich.

“You select an enjoyable aerobic exercise, such as walking, to be done in conjunction with strength training, and you start very slowly, about 15 minutes a day,” she says. “They learn to pace themselves and not to conserve their energy so they don't become too fatigued.”

She adds that aquatic therapy is among the most effective physical therapies for bariatric patients. Compared to exercising on land, aquatic exercise can feel almost effortless because of the body's natural buoyancy in water.
“The reason overweight people often quit exercising is because of pain,” says Michele Reber, public relations director for HydroWorx, a maker of therapeutic pools and other aquatic therapy equipment.

“They have that extra weight that's hard on their knees and other joints. But when they get in water, it's as though they've taken off 75 percent to 90 percent of their weight and the pain is gone,” she says.

The company's therapeutic pools can be equipped with treadmills, which can more comfortably provide the same calorie burn in water as on land.

Occupational strategy
Establishing healthy hygiene habits, under the guidance of occupational therapists, also is a priority for bariatric patients in rehab. A major concern for the morbidly obese is their multiple skin folds, which can harbor bacteria and fungus growth, Pidich explains.

“We teach them to find all the areas within their body that have to be considered for hygiene care, and they learn to use adaptive equipment such as long-handled sponges for places they can't reach,” she notes.

Whether it's reaching physical therapy or occupational therapy goals, the prerequisite for attaining them is keeping the patients motivated.

Lafrenz subscribes to the strategy of breaking down tasks into simple components.

“So instead of having them sit at the edge of a bed to do their grooming, we may have them do it lying down at first,” Lafrenz explains.

“Then, as they get strong, they do it sitting on their bed, with the ultimate goal being to groom themselves while standing at the sink. Accomplishment gives them motivation.”

Identifying the resident's passions can be pivotal to success. Lafrenz points out that residents could have multiple reasons to make an effort at rehab. 

“For some it's their kids, a class reunion, something they want to do in their lives,” Lafrenz says.

“We need to go deeper back to find what they're passionate about. In many cases, that is our starting point. And we tell them, ‘I'm here to help you get there. Let's break down every barrier in the way. I'm here to help you.'”

Bariatric surgery patients
Patients admitted to long-term care facilities immediately after bariatric surgery face modified physical therapy and occupational therapy goals. For instance, they typically will have lifting restrictions for six to eight weeks or until their physicians clear them, says Mary Pidich, director of compliance and education for Select Rehabilitation.

“Therapy can start small and slow,” she says.  “Walking at a slow pace and for short periods is a good starting point. Doing two or three short walks at a slow pace for the first week may be all the person can tolerate initially, and then building up to 30 to 40 minutes daily.”

On the other hand, post-surgery bariatric patients should be doing stretching and strengthening exercises as soon as possible to ensure their muscles don't atrophy and they remain limber.

McKnight's “Rehab Realities” blogger Shelly Mesure, MS, OTR/L, also the general manager at Orchestrall Rehabilitation Solutions, points out that fall prevention assumes added importance for post-surgery bariatric patients. She explains that the relatively quick loss of weight after the surgical procedure provides patients with a modified center of gravity, which can upset their sense of balance. Consequently, the patients need added help at facilities and when they return home, to adjust to their new sense of balance.

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