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Toni Talks about PT Today

Weight-Based Therapy

Published December 28, 2010 4:26 PM by Toni Patt

Over the last 2 weeks we've had three morbidly obese patients admitted with strokes. All of the strokes are severe. It made me wonder about the relationship between stroke and obesity. There is an obvious correlation in that many stroke patients are obese but I've never seen a causal relationship documented. So I started asking stroke doctors.

The consensus was that obesity is related to strokes because of all of the comorbidities associated with being obese. I'm sure there are statistical calculations that control for various comorbidities when calculating relationships but no one knew of a simple one. I guess the causal effect is a given between stroke and obesity.

Once I started thinking about it, I noticed something else. Our stroke patients receive education on stroke, high blood pressure, smoking cessation and medical compliance. Internal medicine doctors are consulted when diabetes is out of control. I've yet to hear one medical person point out that excess weight contributes not only to stroke but also to its severity. For some reason, no one wants to talk about it.

To be fair, weight control isn't something that is normally included in the treatment of acute stroke. That doesn't mean it couldn't be addressed via a dietician or follow-up after discharge. Unless someone has a long hospitalization, weight loss usually doesn't occur. So, why aren't primary care physicians addressing this? It's not like you can't look at these people and see they're obese. The patients have to know they're obese. I think someone with a pannus that covers his genitals has to think he might have a weight problem.

A few more questions produced an answer. Doctors don't bring it up because the patients become offended. They aren't compliant with weight loss and it interferes with the doctor-patient relationship. When did that become OK? Did I miss something? What about the patient-physical therapist relationship? As a therapist, I'm also supposed to help my patients by increasing their mobility and independence. That's difficult when the patient weighs twice as much as I do.

Obese people are difficult to mobilize. It can easily take three people to get one sitting edge of bed. They require bariatric equipment to get up to a chair. Therapy is limited. Enormous abdomens pull patients forward, making it difficult for core muscles to activate for posture training. Whatever strength they have isn't enough to move the excess weight. The postural adaptations that occur to compensate for the weight make even head control a challenge.

It's not much better on the ortho unit. Total knees are painful enough without an extra 100 pounds to support. It's hard to comply with hip precautions when abdominal weight is pulling the trunk into flexion. The last time I worked on the ortho floor, it took two people to mobilize everyone on my list because their remaining limbs weren't strong enough to move their torsos.

I wish doctors would start telling these people about some of the consequences of obesity. There are days when I sit at the nurses' station and watch as people walk by. Sometimes I find myself hoping they have their stroke somewhere else because I'll never be able to mobilize them.



Interesting topic.  It's a catch 22 - 2 ways.  If the physician broaches the topic of weight loss and offends the patient, then the patient may not seek out help for other medical conditions - some of which may be other stroke/heart attack risk factors.  On the other hand, if the physician does not broach the topic, a patient who wants help may not get it because he/she is too embarrassed to ask for help.  

There are + and - either way.  Individually, the doctor has to decide which consequences he can live with.  Unfortunately, the demand on doctors to produce $$$ limits their opportunity to develop a relationship with their patients.  They herd clients through in an effort to reach productivity goals instead of taking time to develop relationships.  That relationship, if developed, could allow them the foundation needed to discuss those touchy health topics in a way that patients would be receptive.

Realistically, do any of these patients NOT realize they are morbidly obese?  Maybe.  After all, they haven't taken Medical Terminology 101.  But, not one of them is unaware that he/she is fat.  Sorry, that is politically incorrect, but it is the truth.  And it is in language noone can misinterpret.  

So, the real questions is, if the doctors do talk with patients, how much good is it going to do?  The solution to obesity requires real investment on the part of the patient.  He/she can't just pop a pill.  Effort and self-control are prerequisites.  Those aren't exactly characteristics our society promotes.  

I don't think obesity revolution is as simple as doctors need to man up and address the issue.  Honestly, I don't think that would make much of an impact.

Jane Goude December 30, 2010 8:45 PM

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