Bariatric seating & mobility, as a specialty, may be this industry’s perfect storm.

While some patients in the bariatric category — defined as weighing more than 300 lbs. for the purposes of this article — do well with consumer mobility products, many more are truly complex rehab clients who need personalized assessments and customized assistive technology. Add in the difficulty of fitting the equipment into the user’s environment, funding sources’ incomplete understanding of this niche, and society’s lack of empathy, and the result can be a threat to access for patients and a never-ending struggle for the providers who work with them.

Who Is the Typical Bariatric Client?

For this story, we focused on bariatric clients with more complex needs, and tapped several specialists in the field.

• From ATG Rehab: Cody Verrett, VP of sales & marketing; and Jacquie Ohanesian, ATP, CRTS, from the Cerritos, Calif., office.
• From Falcon Rehabilitation Products: Christie Martinez, GM.
• From Leisure-Lift/PaceSaver: DuWayne Kramer, president; Jerry Trayl or, engineering manager; and Jim Ernst, VP of product development.
• From Motion Concepts: Stephanie Tanguay, OTR, ATP, clinical education specialist.
• From PDG Mobility Technologies: Jane Fontein, OT.

But when we asked these experts to describe the “typical” bariatric client, they quickly pointed out that there is no such person.

The first challenge in working with this patient group, therefore, is that providers can expect to encounter many different diagnoses and prognoses.

“The reality is that any and every diagnosis that providers work with can include a bariatric consumer with those diagnoses,” says Motion Concepts’ Stephanie Tanguay. “I have worked with consumers over 300 lbs. in weight with spinal cord injuries, head injuries, amputations, strokes. Kathy Fisher (OT, ATP) from Shoppers (Home Health Care) in Toronto has presented on the bariatric pediatric client, so this really can be any patient.”

In addition, Tanguay points out, providers might also work with clients who have higher body weights to begin with, who then sustain “the type of things which can happen to anyone: a fall, a fracture, a tumor, an epidural abscess — some rather sudden change in health and/or physical ability, which is made even more challenging because of the consumer’s weight.” For that reason, she tends to think of bariatric clients in one of two general groups: “the consumer with a diagnosis of a specifically bariatric nature including morbidly obese, lymphedema, elephantiasis — and the consumer who happens to be bariatric and sustains an injury or an event which alters their health.”

ATG Rehab’s Jacquie Ohanesian says that as an ATP, she has worked with clients diagnosed with “edema, diabetes, cellulitis, heart problems and respiratory deficiencies that may result in COPD (chronic obstructive pulmonary disease). With diabetes complications, you could have amputations and possibly renal failure.”

Christie Martinez of Falcon Rehabilitation reports that as a seating manufacturer, she hears providers are working with patients with “a lot of edema, mainly in the legs.” For these clients, articulating legrests, Martinez says, can help to reduce the pressure on the lower legs.

PaceSaver’s DuWayne Kramer, as a power mobility manufacturer, adds osteoarthritis — “especially knee bone-on-bone and severe joint pain” — to the diagnoses list and says many clients he hears about have significant balance issues. “They can’t feel their legs, they don’t have muscle control, they have a history of falling,” he explains.

And he sums up the challenge of working with a patient population that can have so many different diagnoses. “We’ve come to understand that seating bariatric people can be just as difficult as seating people with severe MS or scoliosis,” he says. “We see people who may have one leg that’s three times the diameter of the other leg. There’s all sorts of unique things that you deal with.”

How Weight Impacts Mobility Function

When clients weigh 400, 500 or more lbs., it’s easy to focus on that number. But when it comes to the physics of mobility systems, PDG’s Jane Fontein says there’s more to it than just body weight.

“One of the things that I always say is that manual chairs should not just be made wider and stronger,” Fontein notes. “Then you’re just addressing the weight issue and not the issues related to the person.”

Specifically, Fontein says the location of the weight has a critical impact on how manual chairs perform.

“Generally speaking, the center of gravity for a bariatric person is more forward than the average-sized person,” she explains. “You have to design the chair to accommodate that.”

When a bariatric client sits in a manual chair, “There is more weight put on the front casters, which then makes the chair hard to push. The assumption is that because of the extra weight, the chair is hard to push. But it’s not the extra weight. It’s where the weight is located.”

Tanguay concurs: “Anterior weight distribution poses many concerns for manual and power mobility bases. Perhaps we think of this more clearly in relation to a manual wheelchair, where the caster assembly bolts onto the frame. The casters can be mounted anterior of the frame (leading) to extend the wheelbase and gain anterior stability. This might be done if a manual chair is set up ‘front loaded’ (with too much weight on the casters), an obvious condition when we attempt to propel or push a wheelchair when the weight distribution is over the casters.

“Power wheelchairs can experience the same issues, although the prevalence of ‘mid-wheel-drive’ power bases creates an issue with anterior instability.”

While making wheelchairs wider and stronger might sound like a reasonable move, Kramer says the high body weight of bariatric clients “accentuates the limitations” of chairs built for average-sized people. He points out the long turning radius of rear-wheel-drive chairs, which can make them difficult to maneuver indoors. And he agrees that mid-wheeldrive chairs also have designs that may not work for these clients.

“With mid-wheel-drive, you’ve got a spring section on the front, and (a provider) commented he never uses mid-wheel drive because if you happen to hit a door sill, it catches and dumps the person out,” Kramer says. “There’s a spring section on that front anti-tip, and if you’ve got a spring set for 350 lbs., that’s fine. But if you have to go up to a 450-lb. person, those springs don’t work. So you’re either going to high-center that person, or they’re going to be really tippy. When the (user) leans forward, the chair tips way forward.”

PaceSaver’s Jerry Traylor has used a so-called “3/4 drive” — described by Kramer as “not quite a full front-wheel drive” for bariatric clients’ chairs. On the positioning front, providers and manufacturers have had to get equally creative.

“People call up and say, ‘This guy is so big and so wide that we need to put the anti-tips in the center of the chair because he couldn’t get his legs together,’” Kramer recalls. “He wanted his footrests a minimum of 18” apart. There’s all these special things that you need to do.”

Ohanesian says finding positioning accessories can be a major challenge. “I have found that footplates are not made wider or stronger,” she says. “Calf pads for ELRs are not made larger. Some bariatric clients cannot keep their legs together enough to even get them on the footplates. (Or footplates) are not strong enough if the client needs to push themselves back to reposition or do some type of pressure relief. Same for the armrests: If full length is required, then they need to be longer and of course stronger.”

At some point, however, mathematics do start taking over. Fontein points out the special challenge with lymphedema patients whose lower extremities are affected; she’ll often refer such people to power mobility specialists, she says, “because there’s no way you can get the person back over the rear wheels because of the nature of their dimensions. Their seat depth might only end up being 8″ because their legs hit the seat before they can get back in.”

Says Tanguay, “The more anterior the weight, the more crucial it is to have adjustments for the mounting position of the seating system in relation to the base. The consumers with severe lymphedema present with the most anterior-distal weight scenario. Forward instability is a serious issue during transfers, mobilization — especially on declines — and stopping. I think some people are surprised when the power base performance is altered. At a certain point, it is simply physics.”

Skin-Integrity Concerns

Although many bariatric clients do maintain some or full sensation, their immobility as well as their weight puts them at risk for skin breakdown. “They’re sitting in one spot most of the day,” says Ohanesian. “It’s just too much of an effort to move around.”

“People of size,” Fontein notes, “are at risk because their blood circulation isn’t as effective. So then their skin is at risk, or underneath the folds (of skin), tissue can be at risk.”

“They have huge maceration problems and skin breakdown because of moisture,” Kramer adds. “They’re constantly sweating, and profusely. There’s so much tissue, they have lots of shearing and friction issues.” Risk of skin breakdown can also increase because clients have poor contact with the wheelchair seat back, and therefore suffer compromised weight distribution. That can happen when posterior redundant tissue prevents clients from sitting all the way back in their seats.

“If you don’t have some sort of accommodation in the back, the redundant tissue is going to hit the backrest and push their hips forward,” Traylor says. “They can no longer reach the backrest with their back. Some people may have back-angle adjustment, where they’ll tilt the backrest forward. Then they get a narrow band of (contact) across their shoulders. It’s not a good seating position, but that’s what’s done sometimes.” Other solutions include mounting the arms on the back canes to enable redundant tissue flow-through on the sides, or providing a gap between the wheelchair back and seat to promote similar posterior flow-through.

While tilt is often effective at relieving pressure and redistributing weight for wheelchair users, current Medicare funding policies can make tilt systems very difficult to acquire, ATG Rehab’s Cody Verrett says.

“Until Medicare broke out the power chair codes specifically into the 60-plus different subsets, there really was no reimbursement allocated specifically for bariatrics,” he points out. “Now that they have the heavyduty, very heavy-duty and extra heavy-duty (codes), they provide reasonable allowables for those that meet Group 3 power chair requirements. But remember, the folks in Group 3 have to have a chronic, progressive diagnosis to qualify. Often times, if they’re just extremely heavy, they may not have a diagnosis that will get them into Group 3. The allowables that have been placed into Group 2 for bariatrics are pretty abysmal in my opinion. There is no reimbursement for anyone over 300 lbs. who needs power positioning.”

Verrett adds that a bariatric tilt system is coded K0108, the miscellaneous code. “There is no specific code for power positioning over 300 lbs.,” Verrett points out. “There are no reimbursement codes with a set allowable for power positioning that accommodates people over 250 lbs., which is a definite oversight.”

The Challenges with Funding

The lack of a HCPCS code for bariatric tilt hints at a bigger problem: that payors often don’t understand the serious and individualized needs of this patient population.

Says Verrett: “There’s the biggest lack of understanding for this patient population, unlike somebody with CP or spinal muscular atrophy or ALS, where there’s a clear clinical progression or diagnosis that you can tie to it. A lot of people at the funding source, in my opinion, sit at their desks and think, ‘If they would just go walk or just lose weight, they wouldn’t need this device.’”

Compounding the difficulty, Verrett says, is the relatively high cost of bariatric equipment.

“I think that sticker shock also contributes here,” he explains. “The product that’s generally provided for this population needs to be reinforced and structurally robust beyond the standard type of product. A power chair for somebody 700 lbs. is built to a whole different level of standards compared to a standard product. So it’s more expensive.

“I think a lot of funding sources see these requests and say if this person could just lose weight, they wouldn’t have to spend what they see as an exorbitant amount of money. The funding sources feel as though if somebody could just lose weight, their life would gradually improve, and they would be more productive.”

So, Verrett says, that mentality combined with the cost of a power chair — “Oh my gosh, $20,000 for a power chair for this person” — can make funding sources reluctant to give their approval.

Ohanesian recalls a case of a woman with untreated lymphedema whose bilateral knee circumferences had reached 36″ each. The woman had suffered a crushed pelvis and lymph system, but her physician offered no interventions aside from admonishments to lose weight. “Because of ATG, I was able to get that lymphedema client a totally custom chair that accommodated her average-size above-waist measurement and her belowwaist abnormality,” Ohanesian says, but only after a strong provider effort that included bringing a clinician to the woman’s home to help assess her. And Ohanesian says her claims for bariatric seating & mobility are routinely denied or at least deferred the first time, “even with the HMOs that send me out there. I will get a man who weighs 350 lbs., and they’ll tell me to do a Group 1 scooter.”

In today’s politically correct society, people of size have been called the only minority group it’s still safe to make fun of. PaceSaver’s Jim Ernst says, “I think there’s a component of that in all this.” His colleague Traylor agrees: “I also believe there’s a lot of that going on. Our society will definitely not have much empathy for a bariatric person.”

Ensuring Bariatric Accessibility

Further complicating funding issues — and further challenging providers — is making sure these wider, longer mobility systems can fit into clients’ homes.

Says Martinez, “Most doorways are about 30″. So if you’re looking at somebody who’s 450 lbs., they’re going to get a bigger chair, which is usually about 27″ wide. And then you put a seating system on top of it, and you’ve got arms that stick out. That adds another 6″. So you’ve gone past the width of the door.”

For that reason, she says, Falcon Rehabilitation does a lot of custom work on these systems, “so if (the client is) small on top, we can make the back smaller and bring the arms in to have them fit through a door.”

When Traylor is creating a custom bariatric chair to ship to a PaceSaver supplier, he asks for the maximum chair width and length that he’s allowed, with all components included. He says photos of clients also are useful: “We request them. We don’t always get them, but people are starting to use digital images to let us see the shape that we’re trying to accommodate. Front, side, basically just three or four different angles.”

After speaking to one of his providers that specializes in bariatrics, Kramer says, “One of the biggest problems he has is constantly trying to balance between the size of the person and the person’s environment. He’s constantly fighting to make sure he gets a chair that can actually get into their house. So (he must be) able to do specialty backs and really narrow arms to keep the chair width as minimal as possible, yet give maximum (redundant tissue) flow-through.”

Unique People, Unique Needs

Due to what often is a perfect storm of clinical, funding and accessibility concerns, bariatric patients can be among the most challenging clients a provider can have. Even bariatric specialists are constantly seeing new and unique cases.

Says Ernst, “I once worked with a 650-lb. young man; 125 lbs. of that was a tumor on one leg. We had to adjust the seating to make room for that tumor, which was inoperable. The other day, we saw a patient who was 4’5″, 500 lbs. plus.”

But those patients’ clinical needs, which may seem obvious, don’t guarantee smooth sailing through the funding process.

“I quite often have deferrals, and we’re constantly answering back,” Ohanesian says of her ATG Rehab team. “We’ll take it to an appeal, and if the appeal is denied, I go straight to fair hearing.”

Part of the funding challenge, Verrett believes, is that what payors really want is for beneficiaries to lose weight — which isn’t the purpose of seating & mobility systems.

“The mobility system is just a way for them to take the first step toward getting out of bed and potentially re-engaging in some activities of daily living,” he says. “I believe the funding sources don’t see it as a way to improve their health.

“What they’re missing is that if you don’t get them up, get them comfortable, start to manage their pressure, they’re going to end up with hospitalization, which is going to cost far more than a mobility system ever would. Can you imagine the special care that somebody who’s 750 lbs. requires? In a hospital?”

Even given their medical needs — not to mention society’s often judgmental viewpoint — Ohanesian says providers can still play a crucial role in helping this vulnerable patient population.

“Are you your client’s advocate?” she asks. “You have to be, for everything, whether they need a doctor, whether they need access, whether they need a fair hearing. They look to you for a lot of their answers.”