Perhaps the most significant misconception that bariatric mobility clients — and their seating teams — must face is the misconception that higher body weights simply require wheelchairs with higher weight capacities and wider seats.
A second misconception: Seating clients with body weights in the bariatric range are all similar to each other, and their weight is uniformly distributed throughout their bodies.
In reality, clients using bariatric seating and mobility present uniquely. They carry their weight differently, with greatly varying centers of gravity. They have a wide range of diagnoses, including ones that aren’t neuromuscular in nature.
Yet while bariatric clients can have vastly different presentations, mobility funding policies don’t always reflect those complexities.
Brad Peterson, Amylior’s vice president of global clinical sales and education, is a seating veteran with a long history of positioning bariatric clients with complex presentations. In this Mobility Management interview, Peterson discussed challenges in working with these clients, and best practices that can make the difference.
Q: Many manual wheelchairs for sale online have bariatric weight capacities, but aside from being wider, the wheelchairs look very much like standard wheelchairs for lower weight capacities. But we’ve also seen bariatric clients who sit in those seats, and because of redundant tissue, their backs aren’t making contact with the wheelchair backrest. What’s happening there?
Brad Peterson: I think a lot of times that’s because our larger clients are evaluated while on the edge of a bed or sitting in a bed. You don’t see them in a seated position because a lot of times, they’re not able to get into a seated position safely. Or they don’t have access to a clinic, or they don’t have the ability to come to someplace where a team can get them an appropriate evaluation.
I don’t know how often they’re looked at in a true seated position, where they have a solid surface underneath them, and where they’re not sitting posteriorly rotated or semi-reclined in a bed. You really [want to] get them to sit up and see where their shape is and where their curves are.
Q: Let’s move to power mobility and talk about center of gravity. I assume one of the complications is that bariatric patients can carry their weight differently; their weight can be distributed, for example, in their lower extremities if they have lymphedema.
Brad Peterson: Center of gravity is a huge thing, and not just for stability of the chair.
In my previous lives with different companies, we’d ask for pictures [of the client], or we’d ask for more information on how someone may look in a chair. [Seating teams] would say, “Can’t you just tell by the width, depth and weight where their center of gravity should be set?” But without really seeing someone in that seated position, we have no way of knowing where their center of gravity is going to lie.
And the center of gravity can make or break many things in power mobility. First and foremost, it can make or break what happens with the overall stability of the chair, especially when you’re dealing with mid-wheel-drive chairs. Center of gravity will make or break how stable that chair is.
From a stability standpoint, [we need] both forward stability and rearward stability. And then beyond the stability of a system is the performance of the system. Someone who is sitting way too far back is going to be loading the casters or the drive wheels or other parts of the chair differently. So it may not turn at a low speed as easily as it should because the casters are too [heavily] loaded. Or it may be unstable rearward in a full tilt/recline. So there’s stability, there’s performance, and there’s maneuverability.
Of course, we also want to get people into power chairs that are as maneuverable and as small as possible.
Q: Bariatric power chairs need to be able to maneuver well inside homes. Is that sometimes a challenge?
Brad Peterson: Sometimes they have to be smaller than they should be because of their environment, to get them through doorways. To get them to be maneuverable in the home, the chair might not be what you would ideally put someone in based upon their shape or size.
The impact of weight on the seating system
Q: In addition to creating stability and the performance ability of the power base, you also need to consider the ability of the power seating to operate while carrying higher weight capacities, correct? So as a power seating manufacturer, you also need to be sure power tilt will work properly.
Brad Peterson: When you put someone in a chair and they have tilt, for example, the tilt is a horizontal tilt; they’re not vertical. And when you’re pushing and pulling in a horizontal plane or motion, it’s not as efficient as if you’re just lifting someone up and down.
We see a lot of times where the chair is so front loaded that you can hear it in the actuator. The system will not tilt that person, or it will tilt, but it won’t be doing it for long. You can just tell by how the actuator strains.
Q: And that’s an example of how changing the center of gravity could help?
Brad Peterson: If you’re able to get someone back a little bit more, that takes a lot of strain off of that actuator from lifting that much weight. When more weight is forward, a lot of times there’s an exponential increase in the true weight of the system that actuator is trying to lift. So, we do modifications like vertical actuators.
Q: So even if a client’s weight is less than the weight capacity of the chair, we need to consider other factors, such as how the center of gravity is impacting the power seating?
Brad Peterson: I think too often people look at the weight capacity of a power chair and they say, “Its [weight capacity is] 550 lbs., so it’s going to work.” But you have to look at where you’re positioning someone in that chair. You have to look at where they’re sitting in the system and where it is in relation to the lifting and the stability of the system.
A system that supports transfers
Q: What do we need to keep in mind regarding transfers in and out of the power chair?
Brad Peterson: There are some larger clients who still maintain the ability to transfer, whether it be a stand-pivot or an assisted transfer. I just saw someone in the last couple of weeks who transfers by basically getting on the front of the chair, and then they use tilt and gravity to get them back in the chair. And they leverage off of their footrests. That all needs to be taken into account when you’re looking at how they transfer and how they position themselves back in the chair. So there are many different factors to look at.
I think one of the big things with bariatric systems is the seat-to-floor heights are pretty high, especially for power chairs. If the seat-to-floor height’s too high, and they do have the ability to transfer, whether it be with a little guidance or a little assist, they’re not going to be able to get in that chair and all the way back a lot of times because of seat-to-floor height. So they’re going to leverage themselves off of whatever they can, whether it be armrests or footrests or tilting themselves back with gravity.
That puts a lot of strain on the system as well, and that has to be considered when you’re choosing your power mobility or any mobility at all.
Q: Have you ever taken a call about a seating system that has “failed,” but when you’ve gotten a better look at the situation ….?
Brad Peterson: … and the person’s basically sitting on the front third of their chair. We hear “The actuator, is it working? It should be lifting them. It’s a 450-lb. weight capacity, and they only weigh 375.” But all that weight is on the front part of their seat; it’s not going to lift.
Q: Is that one of the most common problems you hear about?
Brad Peterson: I don’t want to say “problem.” Because it’s not a problem if it’s identified so we can work with it.
A lot of times people say front-wheel drive works for someone who’s doing a transfer because that whole front end is clear. There’s nothing in the way of getting as close to the chair as possible. But the issue sometimes is those front-wheel drives can be tall. And then you’re sacrificing maneuverability in other ways. A lot of different factors play into choosing the ideal power chair.
You also need to consider the long-term reliability of the components, the armrests, the footrests, all those mechanical components that someone’s putting all of their weight on to use whatever function and strength they have to get themselves back in that system.
Every bariatric client is unique
Q: It sounds as if a best practice could be for the seating team to work closely with the power seating and power base manufacturer to say, “Here’s our client, here’s our situation. Do you have any input for us?”
Brad Peterson: I always tell our reps: If you’ve got someone who really is 325 or 350 lbs. plus, you should be looking at them differently than you look at someone else, just because there’s a lot of ways that weight can go. They may not be necessarily [needing a] very heavy-duty or extra heavy-duty system, but at 350 pounds, you’ve probably got some extra weight somewhere. So that could affect the maneuverability. There might be soft tissue. There are just a lot of things that we have to look at when we’re accommodating that shape and trying to make them as independent as possible.
Q: But funding wise, even if actuators are working harder due to a higher weight capacity — the policy doesn’t really take into account that repairs or replacements might be needed earlier, right?
Brad Peterson: A tilt is a tilt. A recline is a recline. [Medicare] has a [wheelchair] code group for people who weight 750 lbs., but we don’t have a separate code for that tilt or that recline.
I think if you look at the number of people who fall into these groups of weights compared to how many are actually in mobility, it’s very small. Because [the benefit is] underutilized. There are people who just sit in bed because they can’t get anything or because there’s nothing out there that will accommodate them. It’s not that they wouldn’t be more independent with it. But there’s just nothing out there for them, whether it’s because they don’t have a correct diagnosis — needing to have a neurological diagnosis to get into a good Group 3 power chair — or the fact that there isn’t a tilt or recline that will accommodate their shape or size.
Q: So we need to keep in mind that every bariatric client presents differently. And that just knowing someone’s weight without knowing other details isn’t enough for a thorough seating assessment.
Brad Peterson: We were working with a veteran, and he got one of our narrower chairs. [The seating team] was concerned with his stability: They were concerned with his rearward stability, if he tilted or reclined back and then leaned over to grab something — they were concerned about that type of rear-corner stability.
I said, “Let’s have some pictures. Tell me about this guy.” And I hear, “He’s only 275 lbs.” But I was thinking something wasn’t right.
Well, he was a 273-lb. man with bilateral total hip disarticulation [with lower-extremity limb loss]. And he was 20 inches wide. So when he tilted back, all of his weight was on the back of that chair; there was nothing anywhere else. So 275 lbs. is not always 275.
If I have a chance to talk to ATPs or clinicians, I’m going to say look at your folks in a seated position. And ask, “OK, what’s going to be difficult to accommodate or what do we need to think about when we’re looking at this shape and size and environment?”
Q: And maybe so that you get the whole picture — such as that veteran with the bilateral total hip disarticulation — it’s helpful to have photos of the client?
Brad Peterson: I think we’re going to strongly suggest that anyone over 350 lbs., we just want some photos. We don’t need to see their face. We just need to see where they’re at.
Q: Because if you don’t get that information up front, the entire system can take a lot longer to get right?
Brad Peterson: Ultimately, as a manufacturer we always take care of people. Ultimately, it’ll always get to be right. But yes, there’s a cost. It’s time for the ATP and the provider, but for the consumer it’s probably a lot of frustration as well. So if we can take it all in at once, if we can look at it up front and take care of them the first time around — I think everybody benefits.
