During employment at a long-term acute care hospital, Eagler worked with a 5-foot, 5-inch woman in her early 60s. The woman was close to 400 pounds, needed a ventilator to help with breathing, and had extremely limited mobility. Numerous comorbidities made therapy a dicey prospect, but the healthcare team focused relentlessly on improving the practical elements of her daily living.
"She had broken her ankle and had surgery on it," explained Eagler, who is now an assistant professor at Lynchburg College, Lynchburg, VA. "We worked with her on just getting to the edge of the bed. She eventually did better with a long sit, instead of rolling to the side. We had to work around her body and our equipment, and be really careful with the ventilator. We used the ceiling lift to help support her, and the bed also was able to turn, so that helped us do minimal lifting while still getting her mobile."
Excessive weight, combined with the ankle injury, necessitated a focus on small goals. Weight bearing through the legs, along with the basic transfer from sit to stand, became small victories largely thanks to the help of a lift.
"We would do some transfers until she could stand and use that as exercise until she was successful with that," said Eagler. "By the time she left our unit, she could walk with a walker, get herself out of the bed, get to a chair and walk across a room with a walker. That took us about three months to get there. She had already been in the hospital at least a month before we started."
Eagler maintains that PTs can forget how gradual the process can be, a mindset that leads to a lack of sensitivity.
"There is a misconception that bariatric patients are unmotivated," she said. "That all they want to do is lay in bed and eat, and that is not true. Most want to live their lives the way everybody else does. I got angry with a physician once because he told a patient she would never walk again. Of course I went in afterword and she was sobbing. We had been working on transfers for a couple of weeks, and she was making progress. After that comment, she just wanted to give up."
At this point, a bit of psychology inevitably enters the physical therapy picture, because patients too have misconceptions about themselves. "A lot of patients have some psychological issues as well and poor self-esteem," mused Eagler. "They are difficult [patients] to work with. You have to have extra time [and] manpower, and equipment really does help with making progress. You must have buy-in from the facility to really provide these people care. Instead, healthcare workers just write them off. But they really want to do better. It just requires a different mindset."
As a professor, Eagler attempts to work this mindset into the curriculum, but she admits that it is not part of the formal educational structure at most institutions. Instead, most of the real learning comes on the job.
In the clinic, large patients continue to pour in, and Eagler thinks the problem is only getting worse. "Our population's BMI is growing quickly, and these patients are a reality no matter what clinical setting," she said. "As PTs and educators, we really do need to catch up on how to manage these patients. There hasn't been a whole lot of education out there that I can find. That's why people who work well with bariatrics tend to have more experience under their belt."
Evolution and Definition
According to Michael Dionne, PT, owner, Choice Physical Therapy Inc, Gainesville, GA, the evolution of what constitutes "bariatric equipment" has necessarily expanded as people have grown heavier. Three hundred fifty pounds has given way to 500, 700 and even 1,000-pound capacities.
By about 1998, the accessory market caught up with beds to include such items as bariatric commodes, crutches and canes. "The problem with rolling walkers is that for years the manufacturers would say the load limit is 800 pounds," explained Dionne, who specializes in bariatric rehab. "But if you put wheels on it, the load limit drops to 500 pounds."
The realm of bariatric beds ultimately evolved to where patients could get a 90-degree knee flex, a progression that helped immensely. "And actually the foot plate comes off so the patient can stand out of it more safely," said Dionne. "Many manufacturers are making bariatric beds that go lower to the floor, which is also a huge help. There are some other unique bariatric beds. There's one that stands people up. There's a lot of stuff happening quietly in the marketplace to adapt and help clinicians transition the patient through the continuum of care."
Rehab facilities are increasingly making a large commitment to "patients of size" with bariatric suites. These rooms typically feature sturdy ceiling lifts and double doors that allow bariatric beds to be conveniently rolled in and out. Prior to these doors, bariatric beds had to be constructed inside the rooms, posing a difficult problem if patients had to be moved on relatively short notice - such as during a tornado warning.
Mobility and Safety
From a pure liability standpoint, most rehab administrators now favor a "no lift" policy when it comes to heavy patients. Back injuries that sideline PTs help no one, and patients and employers benefit when employees are on the job and not collecting workers' compensation benefits.
Still, the realities of the medical profession can often lead to costly moments of improvisation. "The problem with PTs, OTs and nurses is they have a patient every half hour," explained Dionne. "And in a 1,000-bed hospital, by the time you get to their room you're down to 25 minutes, now you have to do a chart review, and then talk to the nurse. Pretty soon you're down to 15 or 20 minutes of actual therapy, and to run down the hallway and get a lift or something-forget it. Instead, PTs say, 'I'm just going to transfer this guy to a chair.' But the risk is to your back. What I've seen is that the clinicians aren't using the equipment, or it is not accessible."
If PTs are tempted to ask patients to do the transfer on their own, Dionne cautions that a proper check should always be done first. "I used to do case reviews, and having patients step away from the bed without adequately screening them with an evidence-based screen tool specific to bariatric patients is a big mistake," he said. "With the ones that resulted in a catastrophic injury from fall, PTs basically said '1, 2, 3 stand, now pivot toward a target surface.' They never bothered to see if the guy's legs could hold his weight."
"PTs should go through the process of making sure patients have unilateral stance strength, as well as anti-gravity strength in each leg," continued Dionne, "and then build consistency such as marching three times in place. Build the evidence at the starting surface, before you leave the starting surface. Consistency gives you defensibility when or if it comes to litigation."
Dionne has been a familiar presence on the lecture circuit for many years, and PTs often call him asking for advice about marketing to weight loss surgery facilities. PTs see it as a valid expansion, but Dionne cautions that there is essentially "no reimbursement anymore" for this type of arrangement.
Why the lack of reimbursement? These days, patients who go in for gastric bypass surgery are mostly functionally independent. As such, insurance companies don't get involved. "These patients can walk into the gym so the way Medicare sees it, that patient is fine," explained Dionne. "Some facilities end up selling the patient on a wellness program as part of post-op weight loss surgery."
This is where savvy therapists can establish relationships with weight loss surgery practices, and perhaps make some money. "That's the art of the individual," said Dionne. "You can go in and negotiate with physicians to get referrals. That's where having an impressive facility helps. If you have an impressive presentation, and you provide mutual benefit without being a burden- and you provide an easy transition for the patient-it is certainly a possibility."
Greg Thompson is a freelance writer.