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Toni Talks about PT Today

Physical Therapy and Obesity

Published August 5, 2009 9:45 AM by Toni Patt
This month I was actually able to stay current when I read my PT Journal.  I found an interesting article.  The researchers looked at the approaches and attitudes of PTs toward the obese.  They questioned a random sample of currently practicing therapists using mailer surveys. The results suggested that PTs have neutral attitudes toward people who are obese. (Sack, Radler, Mairella, Touger-Decker, Khan, 2009)  In addition, many of the PTs (20.4 percent) who responded identified the need to lose weight, but did not feel qualified to provide that intervention.  (Sack, Radler, Mairella, Touger-Decker, Khan, 2009)  Those results didn't surprise me.

Obesity is defined as an increase in body weight beyond the limitations of skeletal and physical reinforcement. Morbid obesity is defined as excess body fat that has an adverse effect on health.  (The Free Dictionary, 2009)  There is a general consensus that the rate of obesity is continuing to climb in America.  Obese patients are a common part of practice today.  Research concerning PT and obesity is necessary to determine evidence for the best practices.  In this case, though, I think the researchers asked the wrong question.

PTs are trained health care providers.  They view obesity as just one of a multitude of possible co-morbidities.  It would be expected that their opinion as a whole would be neutral.  I think a more telling question would have been to ask how those PTs felt about treating obese and morbidly obese patients.  I think the answers would have been somewhat different.   It's already been established that obesity is associated with poorer outcomes and longer length of hospital stays.  The same relationship is probably true between obesity and PT. 

For example, an obese person s/p a total joint replacement is going to be at a disadvantage. The increased weight on the joint will increase pain.  More muscle strength will be needed for the limb to move so the limb will require additional strengthening.  The extra weight will cause fatigue more quickly.  The overall therapy will take longer to get the same results.  The added days will cause the insurance company to pay more.  Progress in therapy will be slower.

The problem is more acute in an inpatient setting.  Whenever I have an overweight or obese patient I know I'm going to have to work harder to mobilize that patient.  I usually don't have help so I'm going to have to do it myself and my fatigue level will decrease.  Two weeks ago I worked with a CVA patient who tipped the scales at 534 pounds.  I had orders to mobilize her.  With the assist of the CAN, I got her to the EOB.  She had right-sided weakness and fell to the left.  Even with my whole body weight sitting on the bed I couldn't keep her from falling over.  I had to elevate the HOB as high as possible and have her lean on a bed rail.   We never got beyond sitting EOB. 

Let me be clear.  I'm not complaining about that patient.  Working with patients like that is part of the territory.  What I am doing is using her as an example of the difference in treatment the extra weight made.  I would be very interested in the opinions of PTs concerning the actual provision of care to an obese person.  I would also be interested in knowing how many facilities have purchased bariatric equipment in adequate numbers.  In my experience as soon as someone goes into the bariatric w/c you will need another one.  The rest of the time the chair will sit and gather dust.  I would also like to know if facilities have changed staffing patterns to accommodate the obese.  Finally I would like to know how many therapists who work with obese patients are concerned about potentially injuring themselves while providing therapy.   I worry about that all the time because I am a single income person.  If I don't work, I'm out of luck so to speak.

The research in this article is a good start.  It answers one question but asks dozens more.   Clearly more research is needed on the topic.  Maybe someone could survey obese patients about how they perceived therapy in addition to surveying therapists.  I'm sure that would have interesting results.  From the answers to these questions will come changes in practice patterns and educational offerings. 

References
The Free Dictionary. (2009) Retrieved from http://medicaldictionary.thefreedictionary.com/morbid+obesity

Sack, S., Radler, D., Mairella, K., Touger-Decker, R,. Khan, H.  (2009)  Physical therapists' attitudes, knowledge and practice approaches regarding people who are obese. Physical Therapy, 89, 804-815.

7 comments

Obese children need a thorough medical evaluation by a pediatrician or family physician  to consider the possibility of a physical cause.  In the absence of a physical disorder, the only way to lose weight is to reduce the number of calories being eaten and to increase the child's or adolescent's level of physical activity.  Lasting weight loss can only occur when there is self-motivation.  Since obesity often affects more than one family member, making healthy eating and regular exercise a family activity can improve the chances of successful weight control for the child or adolescent. 

http://www.fightobesity.net/treatments-for-obesity.html

syra sunita.rikhav@yahoo.com, seo - seo executive January 7, 2011 1:59 AM
lake city FL

I wonder how many therapists, either in private practice or other clinical setting, are working directly on obesity and helping with weight loss/fitness as a goal. I would love to do this kind of work and wonder if insurance would reimburse. I'm guessing probably not.

Susan, RPT November 1, 2010 6:12 PM
Oakland CA

Policies & procedures need to be in place and followed regarding lifting limits/staffing requirements. I would not personally feel comfortable lifting/transferring a person by myself over 180 lbs, and less than that if they were a total assist.  I definitely would not try to sit someone up EOB if I knew I could not complete it safely for myself or the patient.  Remember, what would you do if that patient fell or passed out and you had no help - is it worth the risk?  We need not feel guilty about refusing to do a treatment that is potentially dangerous for the patient or ourselves.  Facilities need to stop admitting patients that they are unprepared to care for and refer them on to those that are. And those that are prepared need to be compensated appropriately for the additional staff and equipment required.

Connie Sutherland, P.T. August 28, 2009 4:42 PM
Midland TX

Check out Lisa's blog from August 27, "A Big Problem".

For two PTs to be writing such a similar blog post in the same month speaks volumes about the prevalence of this issue.

janey goude August 28, 2009 1:58 AM

Sorry for the typos just saw them

Judy Thomas, RN August 22, 2009 1:13 PM

Granted, personal responsibility should come into play with ALL illness, including COPD'ers who smoke, heart pts who smoke, or eat fatty foods. Should a heart patient who smoked for 20 yrs be provided less care because they "knew" better. Should the parent who smokes with an asthmatic child be held financially responsible for the child's care. Many of the new inhalers are very expensive and Medicaid bears the cost. Should the renal patient who drinks more than 500cc of fluid in a 24 hr period be provided less care. Should my facility spend the money on extra oxygen equipment so the patients will have adequate portable. My facility purchased 10 beds at $35,000/bed so we can adequately percuss respiratory patients (99% of smoked).  

In general, all illness and diseases have a level of personal responsiblity. It seems in my 25 years the overweight patient had more  negative comments made and less proactive treatment.  In my area of the country I have never heard of an obese pt being referred to PT for fitness or weight loss, maybe they should. It is a long term treatment program. PT sees hip patients for 6-8 weeks, sometimes more. What kind of impact could be made if they saw all patients with BMI>35 for 3 months?  But alias who would pay?

Judu, RN August 22, 2009 1:04 PM
Amarillo TX

Toni, you pose an interesting dilemma. When I was younger I foolishly went ahead and did all the transferring of the larger patients in the acute care hospital where I was working. This was requested by the nurses and female therapists who wanted "the guy" to do it. I've paid the price with some back issues throughout the last decade. I know better now but had to learn the hard way.

But what do you do when confronted with a dangerously large person on an understaffed unit that may or may not have the mechanical lifts, etc to accomodate them? The person you described would be too heavy for a standard hoyer lift which tops out at 300 #. It is an interesting ethical question.

This brings to the surface another aspect of our current health care debate. Where is the personal responsibility of someone morbidly obese? Yes, the rehab will take longer and the risk of complications is higher. Should we all bear the cost of that? Should health care organizations and institutions be required to pay out more or incur greater losses for something that could be controllable? What about the cost of injured health care workers who try to step up to the plate and treat them?

The cost of obesity goes far beyond the extended stays required and in so doing taxes all of our resources; physical, financial, and societal.

Great questions, if only we had some answers.

Dean

Dean Metz August 12, 2009 9:09 AM
New York - Newcastle Upon Tyne NY

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