All Bariatric Patients Were not created Equal

It Takes More than a One-Size-Fits-All Approach to Match Clients to the Right Wheelchair Option

For one day, a person who otherwise feels self-conscious and secluded takes a break from his normal routine and decides to leave his home. It may be to venture out to the mall or to dine in a restaurant. Then out of nowhere, something catastrophic happens to his wheelchair. In a flash, he’s incapacitated, lying on the ground or stuck in his chair and waiting for police or paramedics to come in with a patient lift to move him. Why? Because he’s too large for anyone else in the room to manually lift.

This is what can happen when the mobility needs of a bariatric individual are not adequately met. Bariatrics, the branch of medicine that deals with the control and treatment of obesity, is a rapidly growing market. The epidemic of obesity in the past decade has doubled among adults and quadrupled among morbidly obese patients, says Dr. Kevin Huffman, bariatric advisor for Gendron, Inc., and a board-certified bariatric physician with 20 years of clinical experience in obesity management.

Obesity is recognized as a disease by the U.S. government. It stems from a combination of factors, such as food consumption, basal metabolic rate and genetic propensities. A person is considered morbidly obese when he or she is 100 pounds overweight. There are even some rare conditions of genetic diseases and medications that can cause a person to be unusually large. So it’s not always about overeating.

“In the past, we just pointed at patients that were obese and said, ‘Well, they’re just lazy and they overeat,’” Huffman says. “We weren’t doing them any good, and we weren’t doing our society any good by ignoring them.”

Huffman says a person’s mobility significantly diminishes when he gets into the bariatric criteria of 350 pounds plus. A concern that must be addressed when dealing with bariatric patients is that their weight is not always evenly distributed, and different patients carry weight differently. Generally, women carry weight below the waist, and men above. When fitting a patient into the right bariatric equipment, the physical structure of the person must be considered, Huffman says.

All Bariatric Clients Aren’t Built the Same

Building bigger seating systems isn’t the solution. The equipment has to be designed to actually fit the patient. It isn’t just a matter of constructing the chairs to be able to hold more weight.

Steve Cotter, president of Gendron, says he’s seen this situation many times with “bariatric” chairs that are simply “stretched” editions of adult wheelchairs. Some of the features of the bariatric wheelchair that must be considered are seat width, seat depth, seat back height, seat back angle, seat plane angle and adjustment for seat floor height. A good bariatric chair must have the ability to accommodate different seating adaptations, and there are certainly structural integrity concerns, he added.

Cotter, referring to the hypothetical situation mentioned earlier, asked who would physically be able to get a person out of a chair that malfunctioned because it didn’t accommodate his size and unique needs. How do you get the person from point A to point B?

“The patient is self-conscious as it is, so let’s call the local EMS crew with this mammoth patient lift and roll it into the shopping center for everybody to see so I can pick you up off the floor,” Cotter says sarcastically. “So there’s more to it than ‘I’ll just stretch this, and now I’ve got (a bariatric chair) too.”

When dealing with different body structures, it’s imperative for mobility dealers to consider depth, width, angle and plane of the chair. Cotter says the seat plane is not always going to be parallel to the floor. It could be tilted backward or forward. It all depends on how the person carries his weight and how he’s positioned in the chair.

Brad Peterson, VP of sales and education at Motion Concepts, agrees. Every bariatric client is shaped differently, he says. It is important to be accommodating since you’re dealing with different issues. Someone may have larger legs (which can greatly affect the balance of the system), some will have different types of transfer status, and some are much wider through the hips than they are through the trunk, so those things have to be kept in mind.

“We try to accommodate their shape to increase their function and give them more of a support surface,” he says. We also try to look at where their weight is distributed and manufacture a system that will ensure that their base or chair maneuvers well and performs well.”
Jane Fontein, OT and clinical educator at PDG Mobility Technologies, agrees that chairs shouldn’t be made just wider and stronger, but instead should be fit to meet the client’s needs. Bariatric wheelchairs should include a forward wheelbase for easy mobility and adjustability for weight gain or loss, and for posture.

Fontein says a lot of people say that it’s difficult to push a bariatric client in a wheelchair because of his weight. But it’s more about where the weight is located in the chair that makes it difficult to push them, she says. For example, too much weight on the front casters makes it difficult to push the chair. This is true for all wheelchairs. With bariatric clients and their forward center of gravity, they tend to put more weight on the front casters unless the chair is set up correctly.

Putting too much weight on the front casters can be attributed to a client’s large legs or because of where their mass is sitting — usually in the stomach area, which puts more weight on the front of the system.

The shape of a bariatric patient’s body is a critical issue, Peterson says. Some bariatric clients’ legs alone make up two-thirds of their body weight. This is why it’s important to ensure that the balance of the system is not too front-loaded, which would make it unstable and perform poorly.

To ensure that balance is kept in check, Peterson says, at Motion Concepts they ask for precise measurements and in larger clients look at whether or not their weight is centered. Motion Concepts has a system that is adjustable on the power base so it can be moved forward and backward on top of the power chair for ideal balancing. In addition, seating systems are also made to slide back and forth with the touch of a button. This enables better transport and ensures that the system is balanced when the client is driving.
Motion Concepts also has a sliding seat that accommodates a lot of different needs for larger clients. The sliding seat gives a lower seat to floor height and better balance.

In addition to width, depth, height and adjustability, bariatric chairs should come equipped with the ability to have a forward center of gravity. The weights of many bariatric clients often change, so it is important for those clients to have chairs that will change with them, Fontein adds.

PDG offers a variety of manual chairs that are designed specifically for the bariatric client. A moveable axle enables a person’s center of gravity to be positioned over the rear axle. An important factor to remember when setting up a wheelchair is that you want to get the person’s center of gravity over the rear wheels as much as you possibly can. This proper positioning is critical for bariatric clients and can be achieved by having a forward wheelbase with casters further forward and a moveable axle that can also be brought forward. The majority of the client’s weight should be located over the rear wheels. When the center of gravity pushes forward, a client’s weight shifts over the front casters, decreasing the ease of mobility and increasing the chance of forward tipping and jeopardizing the person’s well-being.

The center of gravity for a bariatric client tends to be further forward than that of a non-bariatric client — making it important to be able to have a forward-positioned front caster and the ability to move the rear axle back and forward. The axle is the center of the rear wheel and in a lot of inexpensive wheelchairs, the axle is part of the back post, Fontein says.
“If your weight is already further forward than the rear wheel is to the back, then you’re already starting with a bad situation,” she says. Designing a chair with an axle that moves allows the center of gravity to be moved forward to accommodate that particular person’s forward center of gravity.

Going a Step Further

Although a bariatric and a non-bariatric client may share some of the same clinical issues, there are some differences. One way that the bariatric client differs from the non-bariatric client is sometimes additional measurements are needed when assessing for a wheelchair. When bariatric clients appear to be sitting in a reclined position, it is usually because the client’s buttocks hit the wheelchair seat back before their actual back does. This position may cause the client to lean back to fill up the space. When reassessing the seat depth, this position can be corrected. Seat depth is typically measured from the back of the buttocks to the back of the knee. However, when the buttocks protrude beyond the back, measurements must be taken from the back to the seat surface to the back of the knee — using these measurements will determine true seat depth for the bariatric client. Also, the back support should accommodate the shape and space of the buttocks to achieve an upright position for the client, Fontein says.

But you can’t just stop at measurements. A patient must be asked how and where the equipment will be used, Cotter says. One major issue he notices as it relates to bariatrics is environmental access.

“It’s all well and good for a therapist to prescribe a wheelchair with a 30-inch wide seat because that is what’s going to best fit the patient,” he says. “But by the time you get that 30-inch wide wheelchair, it’s going to be so wide overall that the patient is really restricted. They can’t get it through a bathroom or a bedroom door, especially if these patients are at home. I can’t tell you how many patients we’ve had in our wheelchairs that are confined to one room because they can’t get though a door way.”

So the supplier needs to take into account access issues: Where is the equipment going to be used? Where does the patient live?
Some clients still use public transportation and van lifts, Peterson added. So you’ll want to look at the size and weight of the system to make sure that they are still able to fit in ramp-equipped vans and public transportation or onto wheelchair lifts. The seat-to-floor height on the system is also crucial. Peterson says sometimes bariatric systems are so tall that they greatly impact the client’s ability to transfer.
For 99 percent of the wheelchair-user population, the standard traditional adult wheelchair fits, experts say, but at least some bariatric clients will have access problems.

“For the bariatric patient, not assessing that patient and prescribing the right chair would be like not assessing a wheelchair athlete and not prescribing the right chair for that individual to choose,” Cotter says. “It’s just inappropriate.”

Peterson believes regardless of whether or not you’re dealing with the smallest child or the largest adult, you have to think of each chair for each patient as custom. When he says custom, he isn’t referring to anything off the charts that has never been made before, but he does believe there are many ways to customize in a chair to make it more comfortable for the patient.
“When you’re dealing with larger clients, we do look at every one of them as a blank sheet of paper,” Peterson says. “With that being said, we have a standard bariatric platform that we’re able to modify. We have a lot of standard features that other people may think are custom, but they’re standard to us.”

Bariatric Clients & Skin Integrity Risk

One other problem these systems should address is that of redundant tissue or tissue that gets pinched or stuck in crevices or pinch points.
“We try to maintain their skin integrity by having a calf panel that elevates and articulates and also by having a seat that slides with the tilt,” Peterson says.
If it is indicated, Peterson says, bariatric clients should have a tilt system. But this doesn’t mean that they should overlook the legs because many times the legs are one of the biggest problems as far as positioning and edema.
“If you’re going to elevate those legs, make sure you protect them from all the sharp objects and all the sharp pieces and parts of an elevating legrest system,” Peterson warns.

Pressure sores can certainly become a problem for the bariatric patient. Peterson believes that most of the time it’s because patients are sitting incorrectly. Even with all of the excess skin that bariatric patients have, they are still subject to pressure sores. Unfortunately, the excess tissue they have leads to problems with moisture and humidity, which can lead to skin issues. Those skin issues typically manifest themselves in the form of decubitus ulcers, Peterson adds.

Many people who use wheelchairs are at high risk for pressure sores, including bariatric patients. As you would for any other client, it’s also important to promote a good sitting position in bariatric clients. PDG Mobility, too, offers bariatric tilt chairs. By tilting the client back, you can take some weight off of their bottoms and put more of it on their backs to give them a change in position.
Huffman says he tells his physicians to treat bariatric patients as if they’re quadriplegic. Some of the patients just can’t roll over, and many of them are at risk for skin breakdown, have poor circulation and become immobile.

“There’s always so much edema and so much fluid in the extremities that there’s no opportunity for the tissue to heal well, so they’re at risk,” he says. “And once they do have the wounds, they’re very difficult to treat.”

It isn’t unusual to find leg sores, edema and skin breakdown of the legs and calves behind the knees, Peterson says. Pressure and sores are an even greater issue for people that have a secondary diagnosis of diabetes or some other medical condition, he added.
Providing a standard chair without seating and positioning can cause bariatric patients to develop poor posture, which could lead to difficulty in being independent.

“So I would be concerned with the exact same things with the bariatric client that I would be with the non-bariatric client,” Fontein adds.
Not only can bariatric patients benefit from being seated correctly, but standing can introduce a world of benefits as well, says Jeff Wollmuth, sales manger at Stand Aid of Iowa.

Standing can reduce the risk of pressure sores or help existing ones to heal by getting air to the affected areas. Standing also reduces the chance of respiratory infection because lungs are able to expand better. It has also been known to decrease urinary tract infections, an issue that people in wheelchairs frequently run into.

Stand Aid of Iowa recently came up with a new frame with a 550-lb. weight rating.
“What we’ve done on that is just increased the width on it to make it more accessible to get in,” he says, “and it’s really working out well.”
While there aren’t any set guidelines on how often one should stand, Wollmuth recommends at least once a day. He says some clients tell him that they try to stand at every meal time. This does a few things for the client: It gets them up a few times a day, and it helps their food to digest better.
There’s also a positive psychological impact, he adds.
“When you’re standing, you’re up talking to people eye to eye and it could help in preventing depression,” he says. “There are a lot of benefits to standing.”

Unique Needs Won’t Fit Into the Same Box

Suppliers should keep in mind that what is right for one client isn’t always right for the next.
“So it’s really just assessing each individual and seeing where their needs are and how they sit,” Fontein says.

Bariatric clients should be treated like any other client and receive the best mobility device possible for their clinical issues. But that isn’t always the case. Sometimes bariatric patients aren’t given the opportunity to have higher-end seating systems; they’re often just given what’s available to them by seat width, she says.

Categorizing bariatric clients as a one-size-fits-all group does nothing to improve their mobility and overall independence. Because each patient has unique clinical issues, it’s important to assess each patient individually.
You can have two individuals with the exact same list of diagnoses and problems, but they can be polar opposites as far as how they deal with it, Peterson affirms.

“We learn through our experiences what works and what doesn’t work,” he says. “There’s no cookbook that says if the person has A, B and C, you must do D. Everybody’s different, and you have to be able to look at their capabilities, their diagnosis, their history and their environment to put together the best solution for them.”

This article originally appeared in the October 2008 issue of Mobility Management.

In Support of Upper-Extremity Positioning