Bariatrics

Question 1

what is bariatrics

Answer 1

the branch of medicine relating to the study and treatment of obesity

Question 2

what are the risk factors for bariatrics?

Answer 2

Increased Risk: DM II, heart disease, HTN, Stroke, apnea, osteoporosis
BMI > 30

Question 3

what is a BMI

Answer 3

BMI is an inexpensive, quick, easy tool used to screen for a weight category
Based on height and weight
The most commonly used method today for classifying obesity is based on the BMI

The BMI Formula to calculate Body Mass Index: BMI. To calculate your BMI (Body Mass Index), take your weight (in kilograms), and divide by your height (in meters) squared.

Question 4

what are the ranges for BMI
underweight:
normal weight:
overweight:
obese:
extreme obesity:

Answer 4

Underweight: <18.5
Normal weight: 18.5 – 24.9
Overweight: 25 – 29.9
Obese: 30.0 – 39.9
Extreme Obesity: 40.0 or greater

Question 5

what are the bariatric surgeries

Answer 5

gastric bypass
larproscopic gastric banding
gastric sleeve
intrgastric balloon
duodenal switch

Question 6

what is the gastric bypass diet look like?

Answer 6

Up to 6 weeks➔ liquid or soft diet; solids added gradually

Pts work with dietician to plan healthy meals balanced in macro & miconutrients

Life-time supplement of vitamins & minerals

Immediately after surgery ➔ Pts likely feel ‘full’ with a couple sips of water

Bowel movements not regular after surgery ➔ avoid constipation & straining

Dumping Syndrome ➔ stomach empties food into SI too quickly➔ faint, lightheaded, shaky
High Sugar foods

Patients advised: no liquid during meals, before and after meal (once on solids), eat slowly, 5-6 small meals

Question 7

panniculus grading

Answer 7

Grade 1- Covers hairline of mons pubis but not the genitalia
Grade 2- Extends to cover the genitalia
Grade 3- Extends to cover the upper thighs
Grade 4- Extends to cover the mid thighs
Grade 5- Extends to cover the knees and beyond

Question 8

what are some challenges to moving a patient that is bariatric?

Answer 8

Panniculus (pannus)

Movement patterns ➔ ADLs, bed mobility, transfers, ambulation

Locations of adipose tissue➔ Adipose Folds ➔ impacts movement

Location of feet ➔ LE mechanics➔ impacts movement

Question 9

what are the co morbidities of bariatric patients

Answer 9

DM 2
HTN
liver disease
reproductive disorders
heart disease
mood disorders
cancer risk
dyslipidemia

Question 10

what are the Dionnes bariatric body types

Answer 10

Apple Ascites
Apple Pannus
Pear Abduction
Pear Adduction
Gluteal Shelf

Question 11

what is the apple ascites Dionnes body type

Answer 11

High waist to hip ratio with forward abdominal region
Cardiopulmonary intolerance to flat postures
Supine to sit ➔ roll supine to sidelying, progress to sit at edge of bed

Question 12

what is the Dionne shape of apple pannus

Answer 12

High waist to hip ratio demonstrating an inferior abdominal drift
Intolerant to supine position

Supine to sit: flat spin to
Perpendicular ➔ Then progress to
full sitting ➔ caution edge of bed

Logroll to side lying careful➔ a little
Risker due to potential to roll off edge of bed

Question 13

what is the pear abduction Dionnes body type

Answer 13

Low Waist to hip ratio
Hip abduction movement pattern
Supine to sit: Avoidance of rolling, tend to go from supine to long sitting then short sitting
Sit to stand: knee extension,
Followed by trunk extension

Question 14

what is the pear adduction shape

Answer 14

Low waist to hip ratio but able to achieve full femoral condyle contact

Hip adduction movement pattern
Supine to sit: May use log rolling
or long sitting techniques for supine to sit

W/C foot pedals challenging to fit ➔ wide WC seat and narrow foot rest needs

Question 15

what is the gluteal shelf shape?

Answer 15

Person who demonstrate excessive asymmetrical posteriorly directed tissue at the level of the gluteal region. May have either high or low waist to hip ratio

Supine may be uncomfortable

W/C seating may need to be adapted for back support

Question 16

what should a bariatric physical therapy examination include?

Answer 16

Social History: Home set up & Family Support
PMH
Strength
ROM, Flexibility
Sensation
Skin integrity, folds, infection
Balance
Pain
Mobility ➔ bed mobility, transfers, gait
Movement Patterns
Mental Health

Question 17

what are some exam considerations around the topic of home set up, family support and medical history

Answer 17

Where do they live?

Do they have help at home?

Stairs

Prior level of function/techniques of mobility

Assistive devices➔ walkers, wheelchair, cane

Activity habits➔ do they exercise/leave home?

Co-morbidities

Question 18

what are some exam considerations for rom and flexibility

Answer 18

Are there acute or chronic impairments?

ROM may be limited by excess tissue

Is ROM functional for ADL’s?

Can they reach areas necessary for ADL’s or skin inspection?

Are there restrictions from surgeries?

Question 19

what are the exam considerations for a bariatric patient when it comes to strength?

Answer 19

Are they strong enough to move their body?

Are they strong enough to move their limbs?

Are their strength issues acute or chronic?

May need to adjust hand placement for any MMTs

Patient may not be able to lie flat

Patient may try to use muscle substitution due to difficulty achieving test positions

Question 20

what are the exam considerations for sensation

Answer 20

Do they have dermatomal deficits?

Do they have neuropathy due to co-morbid conditions of diabetes or peripheral vascular disease?

May have poor blood supply or peripheral nerve injury as a result of impingement by fatty tissues

Question 21

what are the considerations for bariatric patients when it comes to skin integrity and integumentary systems?

Answer 21

Skin integrity & integumentary system

Do they have DM?

Do they have ulcers?

Can they examine their own skin?

Can they reach all areas necessary for hygiene?

Skin fold inspection

Edema

Attention to reducing shear and friction with bed mobility

Is their skin being pinched by lifts, bedrails, or wheelchairs?

Question 22

what are examination considerations for bariatric patients when it comes to balance?

Answer 22

Test in sitting and standing
Posture may be affected by excess tissues, affecting center of mass

Pear abducted body types may have abducted femurs
Pear adducted body type may have adducted femurs
Apple pannus body types may have increased lumbar lordosis
Apple ascites body types may have a flexed trunk

Question 23

what are examination considerations for bariatric patients when it comes to pain?

Answer 23

Will this affect treatment or examination?
How does the excess weight affect long-term stress on weight-bearing joints?
Pain score & location

Question 24

what are examination considerations for bariatric patients when it comes to behavior?

Answer 24

What are their personal goals?
Consider psych history
Be aware of your biases

Question 25

what are examination considerations for bariatric patients when it comes to mental health?

Answer 25

Are they motivated to participate?

Question 26

what are examination considerations for bariatric patients when it comes to mobility?

Answer 26

When was the last time they mobilized?

How did this mobility occur?

Do they use physical assist, or assistive device at baseline?

Independent or level of assist

Egress Test by Michael Dionne, PT
(1) Patient clears hip 1-2 inches from bed and returns to seated position. If successful then,
(2) Two reps of sit to stand are then performed. If successful then,
(3) Patient stand and marches in place 3 reps, if successful then,
(4) Patient steps forward and back with one leg then the other

Hospital No Lift Policy: use mechanical lift

Question 27

Hannah Williams is a 28 y.o. female with PMH significant for extreme morbid obesity with BMI 54 (5’4”, 314 lb), grade II panniculus, HTN, HLD, and obesity hypoventilation syndrome who was initially admitted for cellulitis, now transferred to the MICU for Bipap therapy and sleep study d/t obesity hypoventilation syndrome and chronic hypoxic respiratory failure. what might you use to mobilize this patient?

Answer 27

Ezlift
ARJO (near weight limit)
Hoyer lift
Sarah lifter
ultralift

Question 28

what equipment options do you have for bariatric patients

Answer 28

EZlift -1,000lb limit
ARJO- 350lb limit. Sling-420lbs
Hoyer -600lbs
Trans Aid-600lbs
Sarah lifter-350lbs
Ultralift-600lbs

lifts and slings might be different