Morbid Obesity - Implications for Physiotherapists

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Morbid Obesity ImplicationsMorbid Obesity Implications

for Physiotherapistsfor Physiotherapists

Dawn Kennedy

CSP Congress C.V. IG

October 2010



Half an hour !Half an hour !

No chance



Alarming Statistics Alarming Statistics

WHO (2010) estimates that over 300

million people are obese.

In the UK, the figure for obesity hasdoubled in the last twenty-five years

and overweight is now the norm

(Foresight Report, 2007)



Alarming facts

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 HeartHypertension, Coronary Heart

Disease (Owens, 2003)Disease (Owens, 2003)

Gallbladder disease (Stampfer etGallbladder disease (Stampfer etal,1992), Osteoarthritis (Bray, 2004),al,1992), Osteoarthritis (Bray, 2004),

Breast cancer, uterine cancer andBreast cancer, uterine cancer and

colon cancer (Bessesen and Kushner,colon cancer (Bessesen and Kushner,2002 Manson et al, 1995).2002 Manson et al, 1995).



Type 2 Diabetes, (Hart et al, 2006)Type 2 Diabetes, (Hart et al, 2006)

Diabetes has been identified ³Diabetes has been identified ³as theas the

greatest risk for overweight and greatest risk for overweight and obese patients´ obese patients´ (Foresight, 2007).(Foresight, 2007).

Predictions of a diabeticPredictions of a diabetic epidemic inepidemic in

1010--20 years as a consequence of 20 years as a consequence of obesity,obesity,



There is also the risk of pressureThere is also the risk of pressure

sore development due to skin beingsore development due to skin being

stretched beyond its point of stretched beyond its point of elasticityelasticity (Dionne, 2002).(Dionne, 2002). Chronic KidneyChronic Kidney

disease as also been linked withdisease as also been linked with

obesityobesity (Stengel et al 2003),(Stengel et al 2003),



Cardiovascular Cardiovascular (Mctingue et al, 2006, Somers(Mctingue et al, 2006, Somers

et al, 2008,)et al, 2008,) neurologicalneurological (Polkey et al, 2008,(Polkey et al, 2008,

Vogalzangs et al, 2010),Vogalzangs et al, 2010), musculoskeletal,musculoskeletal,(McInnis, 2000)(McInnis, 2000) cellulitis, venous stasis of cellulitis, venous stasis of

legs and diminished hygiene,legs and diminished hygiene,



respiratory problems, pickwickianrespiratory problems, pickwickian

syndrome, obstructive sleep apnoeasyndrome, obstructive sleep apnoea(Somers et al, 2008),(Somers et al, 2008), endocrineendocrine (Vogalzangs et al,(Vogalzangs et al,

2010),2010), gastrointestinal and GUgastrointestinal and GU (Van Itallie,(Van Itallie,

1979).1979).



Studies into genes have identifiedStudies into genes have identified

hormonal and neural feedbackshormonal and neural feedbacks

loops that affect hormone levelsloops that affect hormone levels (Bray,(Bray,

2004 and Vogelzangs et al, 2008).2004 and Vogelzangs et al, 2008).



Adipose tissue releases lipids Adipose tissue releases lipids

out into the body, causing a cascadeout into the body, causing a cascade

of enzymatic reactions, which in turnof enzymatic reactions, which in turn

influence hormonal behavior,influence hormonal behavior,

affecting appetite regulation and inaffecting appetite regulation and in

turn behaviour turn behaviour (Foresight report, 2007).(Foresight report, 2007).





Obesity is linked with psychological

factors, (Lavie and Milani, 2006),

depression, (Luppino et al 2010) andlow self esteem (Owens, 2003).





Case studyCase 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

³Trapped 40st mum saved by firefighters

smashing down her home´

The Sun

³Firefighters 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.



GoalsGoals To be able to walk to the shops.

To get back to work





Previous admission patient lost 5 stone.Previous admission patient lost 5 stone.

Went home independently mobile butWent home independently mobile but

refused all services. Referred torefused all services. Referred tocommunity physio to engage in outdoor community physio to engage in outdoor

walking and progress.walking and progress.

Refused dietary and psychologicalRefused dietary and psychologicalsupport.support.



Risk and assessmentRisk and assessment

What is the risk to the patient?What is the risk to the patient?

What is the risk to theWhat is the risk to thephysiotherapist?physiotherapist?

What is the cost to the organisation?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, µfit¶ 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 reTHERAPIST(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,

µfit¶ of chair (Too wide to push upfrom? Too low? Too high?), space

etc

Comment:



MorphologyMorphology 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/mBody Mass Index BMI=kg/m22

Waist circumference (Janssen et

al, 2004)

88cm women 102 cm men non-

Hispanic blacks, Mexican

Americans, non-Hispanicwhites, and people of Asian

descent.



FactorsFactors

Physiological response

Physical

Function

Cardio-respiratory

coupling

Length of time on bedrest

General health/

previous level of

fitness

Septic cause



Heart rate and BPHeart rate and BPwork of breathing and RRwork of breathing and RR

saturationssaturationsperceived work of breathingperceived work of breathing

BorgBorg

PerspirationPerspiration



Ability to exercise Ability to exercise

Application of cardiac rehab

principles and the American Collegeof sports medicine Leg lifts.

Arm lifts or curls. Lifting wrists up.

Chin lifts. Upper thoracic rotations.Shoulders off the bed.



Equipment

Equipment

Gantry hoist

Repo sheets

Bed with extra width and supports weight

Slings

W

alking pantsWhen to get a chair and which ± (altered

biomechanics of movement)



Get the patient working.Get the patient working.

Think movement.

Think activity.

Avoid static positionsAvoid restrictions



Education and motivationEducation and motivation

Give them the reality facts

but it has to come from themselves

for successful intervention





No one size fits all solution.No one size fits all solution.



Any questions

Any questions



Enjoy your LunchEnjoy your Lunch

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Morbid Obesity - Implications for Physiotherapists