1. Total Joint Replacement in the Obese Patient
April 13, 2018
Presented by: Jaclyn Martz, DPT & Jessica Rubino, OTR/L

2. Learning Objectives
To review the role of OT/PT in the acute care setting
To discuss barriers to functional activities in bariatric patients
To explore appropriate DME for bariatric patients post orthopaedic surgery

3. Understanding Obesity
Defined as a condition characterized by the excessive accumulation and storage of fat in the body
BMI=weight (in pounds) / height (in inches) ^2 * 703
Overweight: BMI
Obese: BMI 30 or more
Centers for Disease Control and Prevention

4. Obesity Statistics
More than 1/3 of adults in the U.S. are obese (36.5%)
17% of the U.S. youth population is obese
Obesity prevalence is higher in women than in men
An estimated $147 billion annually spent in medical costs in the U.S.
Within the last 3 months at Forbes Hospital, 1/3 of our total joint replacement patients were obese

5. Obesity Prevalence in the U.S.
Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2016

6. Barriers in Acute Care Co-morbidities Decreased activity tolerance
Lack of appropriately sized equipment
Fear of falling
Potential of injury
Lack of staff support/education
Psychosocial status
Weight bias

7. Body Functions and Structures
Postural Control
Decreased ability to adapt to changes in terrain or grades during transfers and mobility
Compensate with fewer steps per minutes and decreased step length
Can threaten the ability to recover from a loss of balance and cause tripping or a fall
Impact on Joints
High BMI is associated with increased risk for knee OA

8. Body Functions and Structures
Neurocognitive Function
Obese adults (BMI >35) perform poorly on executive functioning tasks compared to normal weight adults
Obese adult males present with deficits in the areas of learning and visual memory
Possible causes can include impaired metabolic processing and decreased O2 flow to the brain

9. Obesity Body Types Apple Shape Pear Shape More weight above the waist
Difficulty tolerating lying flat
Log roll
Can be difficult with THP
Pear Shape
Low waist-to-hip ratio or weight is distributed over the lower trunk
Supine to long sitting
Sit to Stand: Knee extension, followed by trunk extension
Difficulty wearing knee immobilizers

10. Obesity Body Types Gluteal Shelf
Higher risk of developing skin break down
Decreased tolerance of supine position
May need support under low back

11. American Occupational Therapy Association (AOTA)
AOTA’s statement on obesity
“Functional ability is not defined by the diagnosis of obesity; disability is determine by the client’s ability or inability to successfully participate in daily life (World Health Organization, 2001). Identifying the client’s positive attributes and functional limitations is a precursor to developing any intervention for obesity (Lollar & Simmeonsson, 2005).

12. Role of OT in Acute Care Initial evaluation Begins POD #0
ROM, MMT, sensation
ADL assessment
Functional transfers (bed, toilet, tub/shower)
Functional mobility
Home set up and previous level of function
AE/DME use prior to surgery
Support at home

13. Role of OT in Acute Care Treatment Discharge planning
BID starting POD #1
Instruction of AE use for ADL’s
Transfer training with DME
Activity tolerance
Patient/family education
Discharge planning
Home with home care vs. additional therapy
Equipment needs
Home care referrals

14. Role of PT in Acute Care Initial Evaluation Social history QD POD #0
Assessing ROM/strength BLE
Transfers (bed mobility, sit<->stand)
Gait assessment
Therapeutic exercise (isometrics, ROM)
Egress Test

15. Egress Test Egress: the act or instance of going
Developed by Michael Dionne, PT
Screening tool used to help determine the ability to transfer/ambulate safely
Three test series
Patient begins three repetitions of sit-to- stand (at bedside), marching in place, and advance step forward and backward with each foot.
If a patient can perform the progression of the test, ambulation is indicated.

16. Role of PT in acute care Treatment Discharge Planning
BID begins POD #2
Progressing gait (reciprocal pattern, LRD)
Increased therex
Stair negotiation
Discharge Planning
Determining appropriate DME
Home PT vs additional therapy at a facility

17. Bariatric Equipment Tub Transfer Bench Bedside Commode
Weight capacity of1000 lbs
With or without drop arm
Maintains THP
Tub Transfer Bench
Weight capacity of 500 lbs
With or without back
Maintains THP
Eliminates need to step over the tub

18. Bariatric Equipment Sock aid Non-slip socks Wider than standard
Hard and soft versions
Non-slip socks
Fall prevention

19. Bariatric Equipment Wheeled Walker Rollator Weight capacity of 500 lbs
Width inside hand grips: 20 1/2"
Width inside base legs: 28"
Rollator
Weight capacity of 400 lbs
Seat Dimensions 19" (W) x 13" (D)
Unit Dimensions 28" (W) x 27.5" (L)

20. Bariatric Equipment Crutches Straight Cane Weight capacity 500 lbs
Standard and tall height
Crutches
Weight capacity 500 lbs
Standard and tall height

21. Bariatric Equipment Hospital bed
Head and Trendelenburg angle indicators
Air mattress redistribution
Adjusts automatically based on patient’s body type, weight, movement, bed position
Can prevent pressure ulcers
Turn assist function
Helpful with rolling, transfers, skin checks, linen and brief changes, donning braces

22. Bariatric Equipment Mat Table Stair training
Weight capacity 450 lbs
Anti-slip material on surface
Mat Table
Electric and non- electric
Weight capacity 900 lbs

23. Bariatric Equipment Wheelchair High and low back option
Weight capacity of 700 lbs
Adjustable and removable leg rests
Reclining option
Anti-Tippers

24. Bariatric Equipment Cushions
Constructed with foam, gel, air, memory foam, or a combination
Designed to enhance comfort, trunk stability, and positioning
Weight capacity of lbs
Assist with prevention of pressure ulcers

25. When all else fails… Hoyer Lift Hoverjack Weight capacity: 300-700 lb
Portable and ceiling mounted
Nursing staff trained to use
Hoverjack
Hoverjack demonstration

26. Clinical Pathway for Safe Patient Handling
Agency for Healthcare Research and Quality

27. Questions?

28. References
American Occupational Therapy Association. (2007). Obesity and occupational therapy position paper. American Journal of Occupational Therapy, 61, 701–703.
Centers for Disease Control and Prevention. (2014). Adult obesity facts. Retrieved from
Forhan, M., & Gill, S. V. (2013). Obesity, functional mobility and quality of life. Best practice & research Clinical endocrinology & metabolism, 27(2),
Jean L Minkel, PT, Susan Johnson Taylor, OTR/L, and Brenda Canning, OTR/L. Seating and Mobility Considerations for the Bariatric Client, Presented at the 23rd ISS (
Ogden, C. L., Carroll, M. D., Fryar, C. D., & Flegal, K. M. (2015). Prevalence of obesity among adults and youth: United States,  (pp. 1-8). US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.
Tool 3E: Clinical Pathway for Safe Patient Handling. Content last reviewed January Agency for Healthcare Research and Quality, Rockville, MD.