The state of bariatric seating & mobility seems full of contradictions:

• Clients weighing more than 350 lbs. are typically grouped together in a generic “bariatric category” — but in fact have unique clinical presentations, and their everyday mobility concerns can vary widely.
• These disparate needs require equally diverse seating, mobility and accessibility solutions — but product choices for bariatric clients are limited compared to options available for “average-sized” patients.
• And — while demographics and anecdotal evidence suggest a great need for bariatric seating & mobility specialists, they remain relatively few compared to, for instance, the number of complex rehab technology providers specializing in pediatrics.

Becoming a true bariatric seating & mobility specialist requires more than just keeping an inventory of DME with higher patient weight capacities… and here’s why.

1. Bariatric Clients Have Unique Presentations

Mainstream self-help books, reality television programs and news stories tend to suggest that obesity is a prevalent, but easily defined and understood healthcare issue, with common causes and common solutions.

But that’s not always the case — and especially not for clients who seek the help of seating & mobility clinicians and providers.

A subset of patients in the bariatric weight category may be well served by “off -the-shelf” DME, such as walkers or rollators, lift chairs and bath safety products with higher weight capacities.

For many other bariatric patients, however, the challenges are far greater — and they’re unique.

That’s because, first of all, just knowing a patient’s body weight may not tell an ATP much at all about that person’s clinical or environmental needs.

Jerry Traylor, engineering manager at PaceSaver, says, “Where the redundant tissue is positioned on people varies. Are they apple shaped? Pear shaped? Th at’s the wild card.”

Two clients with the same body weight can carry the excess weight in different places, and therefore will present very differently.

“It’s much easier to fit someone who’s 6’6” and weighs 400 lbs.,” Traylor notes, “than somebody who’s 4’8” and weighs 400 lbs.”

Because clients’ measurements and clinical needs differ, their seating & mobility solutions will diff er as well from patient to patient.

As PaceSaver Product Manager Jim Ernst says, “One size does not fit all.”

2. Other Diagnoses Are Exacerbated

Obesity may be the main mobility-related diagnosis for some clients, but many other clients are living with obesity in addition to other medical conditions.

Jay Brislin, MSPT, VP of Quantum Rehab, says, “If somebody is diagnosed with MS, spinal cord injury or some form of disease, and they’re also a bariatric client, your issues automatically increase tenfold. You’re not only managing the disease at this point, but you’re also managing what their capabilities are based on how much additional weight they are carrying.

“So for instance, one of the things that happens pretty much with any diagnosis is fatigue and decreased strength. When you have fatigue and decreased strength, and you’re carrying a lot more weight, you can imagine how much more difficult that can be. So somebody’s mobility or function can decrease pretty rapidly. If you have a bariatric client with MS, their function is going to decrease much quicker versus a very thin client with MS.”

3. The Environment Will Impact Product Choices

Evaluating the environment should be part of the assessment process for any seating or mobility product. But knowing the environment in which the product will be used is even more critical when working with bariatric clients, because bariatric products tend to be larger and heavier than the equipment used by average-sized clients.

“Something that we hear about again and again is doorways,” Traylor says. “People have to get through the doorways with the equipment. Th ose are daily challenges.”

DuWayne Kramer, president of PaceSaver, says another tricky product choice is beds.

“One of the key things is having a bed that is wide enough,” he explains, “because if you have a bed, but you can’t roll them over for cleaning and hygiene and putting the lift sling under them, that’s a real problem.”

To try to preserve space in a bedroom or living room, consumers sometimes choose beds “that are just barely wide enough for them,” Kramer says. “But you need a wider bed to actually have good nursing care. You have to be able to roll the person over safely so the bed doesn’t tip over.”

Patient lifts are popular products to facilitate safe transfers for bariatric clients and caregivers, but Kramer says the lift s can cause additional complications.

“When you get to bigger-sized people — 500 lbs. or more — they’re very concerned about falling,” Kramer says, in part because it is typically very difficult for such patients to get back up.

While portable (e.g., Hoyer) patient lifts that are easily transported and stored are oft en preferred by consumers for use in their homes, Kramer says healthcare facilities and assisted living centers are moving toward ceiling lift s. But either way, he notes, “when you put a lift under (the patients), you’ve got to put the sling under them. If they’ve got really tender skin from maceration or other things, you’re creating a barrier that can cause skin problems. It’s a big, heavy sling, thick and strong to lift them, yet on the other hand, it creates pressure points and doesn’t allow for the tissue to breathe.”

Skin integrity, in fact, is just one of many additional clinical concerns to consider for this patient population.

Skin Breakdown Is a Common Problem

One of the reasons that seating & mobility providers and clinicians may be best positioned to work with bariatric clients is that even those patients without additional medical conditions can be at high risk for other very familiar problems.

For instance: skin breakdown.

“When you talk about somebody that’s rail thin and has a decrease in sensation, obviously they’re more susceptible to skin ulcers, wounds, etc.,” Brislin says. “You would think someone in a bariatric situation wouldn’t be as susceptible because of all that extra tissue; they have a lot further to go before they get to the bony prominences. But what happens is that extra tissue is just sitting on itself, which creates moisture and heat.”

Adding to pressure sore risk, Brislin says, is the fact that many bariatric clients aren’t able to perform frequent, effective weight shifts.

“They’re going to have a lot of difficulty weight shift ing,” he explains, “because again, fatigue and decrease in strength may hinder that person even more.”

The extra weight, perhaps coupled with other medical conditions that can limit range of motion, can also make it difficult for clients to practice good hygiene, which can also raise the risk of skin breakdown.

“The skin-integrity issues are still there if they have decreased mobility,” Brislin says.

Unique Presentations Need Customized Solutions

Another reason ATPs are well positioned to serve the bariatric patient population: They are accustomed to creating customized seating& mobility solutions.

And make no mistake: Whether or not they have additional medical conditions or diagnoses, bariatric clients frequently have unique symptoms or needs that are best addressed by customized seating & mobility interventions.

For instance — people carry extra weight or redundant tissue in different places.

“It can depend on the person’s overall body makeup, in differences in men and women because of body type,” Brislin says.

In addition, certain conditions such as lymphedema may cause redundant tissue and large amounts of weight to be concentrated in one part of the body…which can make seating the client very difficult, and can impact the driveability of the manual chair, power chair or scooter.

First, the seating concerns. As Traylor says, “You have to have flexibility in the seating system to take care of somebody who’s got a gluteal shelf” — i.e., protruding redundant tissue at the buttocks.

Ernst says about such clients, “If they were in a chair with a solid back, (the redundant tissue in back) would push them too far forward. Th ey wouldn’t be comfortable, they wouldn’t be sitting right, and it would aff ect the balance (of the vehicle).”

“Now you’re looking at things like biangular backs,” Brislin says, “and the depth of the seating system becomes very tricky. It can be for manual mobility as well. Many times you have to decrease somebody’s seat depth in order to take in the redundant tissue, but ultimately, their weight is so shift ed forward because the seat depth isn’t necessarily where it should be.”

Shift ing all that weight forward, Brislin adds, can cause mobility problems.

“When somebody’s weight is shift ed forward, if it’s a manual chair, their weight isn’t distributed throughout the whole chair,” he says. And when those clients try to self propel, “Th ere’s a lot more energy they’re expending.”

For power chairs and scooters, having too much weight toward the front of the vehicle can cause stability problems while driving.

Says Kramer: “You may see, in center-wheel-drive chairs, these people just lunge forward all the time when they try to stop even on flat surfaces, because the chair cannot accommodate the weight shifts that happen simply during driving.”

He says solutions to the driveability and stability problems can include attaching weights on the back part of the chair to make weight distribution more equal, or providing seats with an opening in the back, and armrest systems that allow tissue to flow through the back and sides.

“We try to eliminate barriers to flow,” Kramer says.

Positioning Needs Are Unique, Too

Positioning challenges don’t end with the wheelchair or scooter seat.

Kramer points out, “It’s not uncommon for people with lymphedema to have their legs be way apart. A traditional chair may not fit them because they can’t get their ankles narrow together enough to get into the chair, so you may have to come up with another system that allows their ankles to be out as wide as possible.”

Brislin agrees that foot and leg positioning for patients with lymphedema can be very challenging.

“Let’s take a scooter, for instance,” he says. “You’re trying to keep that person’s legs within the area of the deck on the scooter. With lymphedema, the person’s feet splay out, so the contact area for the feet certainly changes.

“When you look at a manual wheelchair, you can use swingaway legrests, but do they interfere with the front casters? How are you able to get that person’s legs up far enough to actually be able to swing those legrests away?”

Foot positioning can also be a challenge on power chairs, Brislin says. “If you’re looking at a mid-wheel-drive or a rear-wheel-drive power chair, your front riggings become a large issue because you’re dealing with front casters that you need to try to overcome.”

“There are times when positioning the feet and legs is the biggest challenge,” Traylor agrees. “We have people who have a lot of tissue in that area, and their legs are far apart. Th at oft en puts them in the situation where they don’t reach the footplate anymore. People start talking about elevating legrests, but those tend to make the products wider, and some people can’t lift their legs on and off of them if they’re trying to do a self transfer. Center-mounts create an issue with somebody trying to transfer in and out of the chair; they can be an obstacle out in front.”

Steps to Success with Bariatric Clients

Fortunately, ATPs are well accustomed to taking an individualized approach to assessing their clients with neuromuscular or musculoskeletal conditions. Th at approach should absolutely apply to the bariatric patient as well, Brislin notes.

Due to the complexity of the assessment and the individualized nature of the solution the patient needs, “I would consider him a rehab client,” Brislin says, “even if he’s going into a scooter — a bariatric person in a bariatric scooter.”

Providers who want to become bariatric specialists therefore need to know, Brislin says, how to seat and position complex rehab clients, including those with additional diagnoses.

Brislin also says ATPs could do well to adjust their mindset when working with bariatric patients.

“I think one of the biggest things you need to do to really be a true specialist is change the initial approach you would have with a client 300 lbs. and under,” he explains. “As you move beyond that category, it’s not just that the client becomes bigger, but that the equipment has to become bigger in order to help. When you start making equipment bigger, you have to think about moving through doorways and moving through diff erent places in the home. We always talk about doing home evals for our clients, but for bariatric clients, it’s probably one of the first things that needs to be happening. You have to start assessing how they would get through the spaces in their home, and then start picking products that are available based on some of these measurements.”

Product choices for bariatric patients aren’t as numerous as for average-sized patients, which causes additional challenges, Brislin says: “Currently, there certainly is not much choice when you’re looking at all the bariatric devices that are out there versus your 300-lb.-and-under devices.”

Kramer says providers can give themselves and their clients more options by choosing product lines that offer plenty of adjustability regarding, for instance, fore and aft seat positioning so weight distribution can be changed.

“Knowledgeable bariatric dealers, I think, really want to have a lot of adjustment so they can make the (system) work for that particular customer,” he says.

Traylor says providers also need to make sure that bariatric patients feel comfortable with the evaluation and consultation process.

“Make sure you have furnishings to keep the clients safe and comfortable while they are visiting your facility,” he suggests. That starts with seating in the waiting area and extends to tables and mats used for evaluations.

Bariatric clients indeed have a range of clinical and environmental needs, but Ernst notes of working with them successfully: “It’s very rewarding, because for most of these people, these are their legs. It may be the first time they’ve been out of the house in forever.”