Obesity in Rehab a Weighty Topic

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1 Obesity in Rehab a Weighty Topic SelectMark 2016

2 Disclaimer Although Mr. Joshua Hogan, DPT is employed by Select Medical and NovaCare Rehabilitation, this presentation is not promoting any particular products or services with Select Medical or NovaCare Rehabilitation. 2 Obesity in Rehab a Weighty Topic

3 Obesity According to the National Institute of Health: Obesity is a complex, chronic disease that develops from multiple genetic and the environmental factors. It involves the integration of social, behavioral, cultural, physiological, metabolic and genetic factors." 3 Obesity in Rehab a Weighty Topic

4 Statistics Since the mid-seventies, the prevalence of overweight and obesity has increased sharply for both adults and children. NHANES (National Health and Nutrition Examination Survey) : Adults aged the prevalence of obesity increased from 15.0% to 32.9% Between the 1976/1980 and 2003/2004 survey.. 4 Obesity in Rehab a Weighty Topic

5 Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

6 Prevalence* of Self-Reported Obesity Among U.S. Adults BRFSS, % <20% 20% <25% 25% <30% 30% <35% 35% *Prevalence reflects BRFSS methodological changes in 2011, and these estimates should not be compared to previous years. 6 Obesity in Rehab a Weighty Topic

7 Twenty year trends In 1990, among states participating in the Behavioral Risk Factor Surveillance System, 10 states had a prevalence of obesity less than 10% and no state had prevalence equal to or greater than 15%. By 2000, no state had a prevalence of obesity less than 10%, 23 states had a prevalence between 20 24%, and no state had prevalence equal to or greater than 25%. In 2010, no state had a prevalence of obesity less than 20%. Thirty-six states had a prevalence equal to or greater than 25%; 12 of these states (Alabama, Arkansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee, Texas, and West Virginia) had a prevalence equal to or greater than 30%. 7 Obesity in Rehab a Weighty Topic

8 State Specific Statistics State has adult obesity rates of 30.2 percent, ranking it the 20th heaviest in the nation, according to a new report by Trust for America's Health (TFAH). 8 Obesity in Rehab a Weighty Topic

9 Epidemiological Reviews - May 2007, Wang & Others 58 million Americans are overweight 40 million Americans are obese 3 million Americans are morbidly obese Eight out of 10 Americans over 25 years old are overweight By 2015, 41% of Americans will be obese 9 Obesity in Rehab a Weighty Topic

10 Economic Impact of Obesity The estimated annual cost of overweight and obesity in the U.S. is $122.9 billion. Services for obesity-related diseases and conditions $64 billion: Direct health care costs related to: preventive, diagnostic, and treatment Indirect costs $58.5 billion: The value of wages lost by people unable to work and the value of future earnings lost by premature death. Obesity related conditions result in $39.3 million in lost workdays each year. 10 Obesity in Rehab a Weighty Topic

11 Economic Impact of Obesity Obesity accounts for 9 percent of national health care expenditures. The estimated cost of obesity in a hypothetical 1- million-member health plan is $29 per member per month. Over a nine-year period, overweight (body mass index (BMI) between 25 and 29.9) spend 37 percent more on prescription drugs; obese (BMI >30) spend twice as much. Employees with a BMI > 40 had twice as many workers compensation claims as employees at their recommended weight. 11 Obesity in Rehab a Weighty Topic

12 Life Expectancy The risk of death for people with a BMI >= 25 at age 50 is 20 percent to 40 percent higher than those with a BMI of less than 25. Obesity was associated with double the mortality risk in men and a 60 percent increase in women compared with those of normal weight. 12 Obesity in Rehab a Weighty Topic

13 What is Obesity Obesity is the over accumulation of fat that exceeds the body s skeletal and physical standards. According to the National Health (NIH), an increase in BMI of more than 30 is the point at which excess weight becomes a health risk 13 Obesity in Rehab a Weighty Topic

14 BMI and Disease Risk Body mass index (BMI) using the following equation: BMI = Weight (lbs.) x 703 Height 2 (in.) An adult who has a BMI between 25 and 29.9 is considered overweight. An adult who has a BMI of 30 or higher is considered obese and > 40 is considered morbidly obese. Waist Circumference is also an important measure in determination of disease risk 14 Obesity in Rehab a Weighty Topic

15 BMI and Disease Risk BMI is only one factor related to risk for disease. Two other predictors: The individual s waist circumference (because abdominal fat is a predictor of risk for obesity-related diseases). Other risk factors the individual has for diseases and conditions associated with obesity (for example, high blood pressure or physical inactivity). Fat stored around the abdomen and waist (also called, central adiposity, intra-abdominal fat, or central obesity) is a predictor of weight-related diseases. 15 Obesity in Rehab a Weighty Topic

16 Waist Circumference Predictor Body Types include: Apple-shaped" tend to store excess body fat around their stomach and abdomen Pear shape" tend to gain weight on their buttocks and thighs. Apple-shaped individuals have a greater risk of weight-related disorders and need to pay more attention to normalizing their weight. Where we store fat is largely the result of gender (men tend to be appleshaped, women pear-shaped), or age (after menopause women become more apple-shaped). Waist circumference is a rough guide to determining whether you are a higher-risk apple-shape, or a lower-risk pear-shape. Measure your waist just above your belly button. If you are male, a healthy waist measurement is less than 40 inches provided your body mass index is less than 25. If you are female, a healthy waist measurement is less than 35 inches provided your body mass index is less than Obesity in Rehab a Weighty Topic

17 BMI 17 Obesity in Rehab a Weighty Topic

18 Percentage of Adults Inactive vs. Percentage of Adults who are Obese 20% 24% 25% 29% 30% 18 Obesity in Rehab a Weighty Topic

19 Archives of Internal Medicine April 2007 Ostbye & Others Obesity and Workers Compensation Results from the Duke Health and Safety Surveillance System Study of relationship between body mass index (BMI) and number and types of workers' compensation claims, associated costs, and lost workdays. 11,728 health care and university employees Ostbye, T MD, PhD; Dement, JM, PhD; Krause, KM, MA Archives of Internal Medicine; Arch Intern Med. 2007;167(8): Obesity in Rehab a Weighty Topic

20 Results 20 Obesity in Rehab a Weighty Topic

21 Conclusion The researchers found that workers with a BMI greater than 40 had: claims per 100 workers, compared with 5.8 claims per 100 in workers within the recommended range. In terms of average lost days of work, the obese averaged per 100 employees, compared with per 100 for those in the recommended range. The average medical claims costs per 100 employees were $51,019 for the obese and $7,503 for the non-obese. The body parts most prone to injury among obese workers were the lower extremity, wrist or hand, and back. The most common causes of these injuries were falls or slips, and lifting. 21 Obesity in Rehab a Weighty Topic

22 Implications As obese workers continue to gain weight and their BMI approaches 40, their strength does not keep up with their weight gain. Making them more susceptible to injury What impact does this have on the morbidly obese worker s ability to safely perform the essential functions of the job? 22 Obesity in Rehab a Weighty Topic

23 Specific Cost Added healthcare cost in 2007 of obese worker compared to normal weight ~$2,000 Morbidly obese worker higher Added absenteeism/presenteeism cost in 2007 of obese worker compared to normal and overweight ~$600 Sources: J. Cawley, et. al., J. Occup Environ Med. 2007; 49: ; D. Gates, et. al., J. Occup Environ Med. 2008; 50:39-45; E. Finkelstein, et. al. Health Affairs Web Exclusive. 2003; J. Ricci, et. al. J. Occup Environ Med. 2005; 47: Obesity in Rehab a Weighty Topic

24 Comparing Obesity Related Cost In Industrial Workforce: Employees, Indirect Cost x (Projected) Obesity Cost $104,575 $135,355 $276,617 Lost Productivity Cost $31,620 $42,526 $81,568 Total Direct Costs $136,195 $177,881 $358,185 Indirect Costs $272,390 $355,762 $716,369 Total Costs $408,584 $533,643 $1,074,554 Sources: J. Cawley, et. al., J. Occup Environ Med. 2007; 49: , D. Gates, et. al., J. Occup Environ Med. 2008; 50:39-45 E. Finkelstein, et. al. Health Affairs Web Exclusive. 2003, J. Ricci, et. al. J. Occup Environ Med. 2005; 47: Obesity in Rehab a Weighty Topic

25 Orthopedic Issues in Obesity Being only 10 pounds overweight increases the force on the knee by pounds with each step. Therefore, a force of ~ three to six times one's body weight is exerted across the knee while walking. Increased joint loading accelerates the breakdown of cartilage. 26 Obesity in Rehab a Weighty Topic

26 Osteoarthritis Obesity is a known risk factor for the development and progression of knee osteoarthritis and other weight bearing joints Obese adults are up to 4 times more likely to develop knee osteoarthritis than normal weight adults. 35% of adults with diagnosed arthritis are obese compared to only 21% of those without arthritis. Most modifiable risk factor for development and progression of OA. 27 Obesity in Rehab a Weighty Topic

27 Knee Osteoarthritis Incidence In the Framingham study, Felson and colleagues noted: Among women with (BMI) > 25, weight loss was associated with a significantly lower risk of knee OA. For a woman of normal height, for every 11 lb weight loss (approximately 2 BMI units), the risk of knee OA dropped > 50%. Conversely, a comparable weight gain was associated with an increased risk of later developing knee OA (odds ratio 1.28 for a 2 BMI weight gain). 28 Obesity in Rehab a Weighty Topic

28 Knee Osteoarthritis In elderly persons, if obese men (i.e., BMI greater than 30) lost enough weight to fall into the overweight category (BMI ) and men in the overweight category lost enough weight to move into the normal weight category (BMI less than 26), knee OA would decrease by 21.5%. Similar changes in weight category by women would result in a 33% decrease in knee OA. Conclusion: Even small amounts of weight loss reduce the risk of developing knee OA. Felson et al 29 Obesity in Rehab a Weighty Topic

29 Total Joint Replacement Outcomes Thomas Turgeon, MD, assistant professor of orthopaedic surgery at the University of Manitoba, Canada, presented a study of 1,247 patients of varying weight who underwent primary hip replacement. He and his research team found highly obese patients: 2.3 times more likely to stay in the hospital more than five days 2.6 times more likely to be discharged to a skilled nursing facility (SNF). 30 Obesity in Rehab a Weighty Topic

30 Total Knee Replacement Outcomes The conclusion of the study: Obese patients take more time in the operating room. Obese patients are more likely to need expensive MUA with greater incidence in women Obesity limits a patient's range of motion (ROM), Prolongs recovery Extends the need for physical therapy after total knee replacement surgery Geoffrey H. Westrich, MD, The Hospital for Special Surgery in New York City 31 Obesity in Rehab a Weighty Topic

31 Joint Replacement Outcomes Using a database of nearly 1 million Americans who underwent major joint replacement surgery, a team led by researchers at Duke University Medical Center have determined: Surgical patients with diabetes, hypertension or obesity were significantly more likely to suffer post-operative complications. Of three conditions that the researchers studied, obesity conferred the highest risk of post-operative complications and the need for additional post-discharge care. Clinical Orthopaedics and Related Research 32 Obesity in Rehab a Weighty Topic

32 Duke Study Outcomes Specifically, in their analysis of patients undergoing hip, knee or shoulder replacement surgery, the researchers found: 3.7 percent of obese patients experienced in-hospital complications, compared to 2.6 percent for non-obese patients. For patients with hypertension, the rates were 2.8 percent versus 2.6 percent, For patients with diabetes, the ranges were 2.9 percent versus 2.6 percent. Journal Clinical Orthopaedics and Related Research 33 Obesity in Rehab a Weighty Topic

33 Additional Outcomes The likelihood of a "non-routine" discharge from the hospital was 30 percent higher for diabetics and 45 percent higher in obese patients For patients with diabetes who were also obese, the likelihood rose to 75 percent. Non-routine discharges are those to another facility where further care is necessary, such as short-term hospitals, intermediate care facilities or home health care. 34 Obesity in Rehab a Weighty Topic

34 Additional Orthopedic Outcomes: Research shows that Obesity: Is associated with a substantially higher risk for infection in women, led to more dislocations (with a greater increase in women) Resulted in more revisions due to septic loosening (caused by infection). After five years, outcomes for 635 hips in non-obese patients and 183 hips in obese patients were evaluated. Obese women, but not obese men, reported moderately lower functional outcomes and slightly less satisfaction, mostly due to a higher incidence of complications. 35 Obesity in Rehab a Weighty Topic

35 Rehabilitation in Obesity Understanding the role of rehabilitation in the treatment of joint replacement patients has been studied and found to improve outcomes. Exercise participation prior to total joint arthroplasty dramatically reduces the odds of inpatient rehabilitation Among THR patients, exercise intervention was associated with improvements in preoperative function score. Exercise participation increased muscle strength preoperatively, whereas the control patients had essentially no change in strength. The authors concluded that a 6-week pre-surgical exercise program can safely improve preoperative functional status and muscle strength levels in patients undergoing THR. Rooks et al 36 Obesity in Rehab a Weighty Topic

36 Systems Review in Obesity Identifications key impairments and functional deficits Postural analysis: Static and Dynamic balance Strength Flexibility Range of Motion Neuromusculoskeletal System Skin assessment Functional Assessment Cardiovascular System 37 Obesity in Rehab a Weighty Topic

37 Physical Therapy Interventions ADL training Body mechanics: Safe and efficient movement Functional Training: Rising from sit to stand, Climbing stairs, lifting mobility limitations i.e bed mobility Gait Improve deficits with strength, ROM and balance that impact gait Speed Cadance Base of support Step and stride length Joint Biomechanics Improve CV endurance Aver work load for Obese women is 56%( up to 98%) VO2 Max compared to 32% in age group of yr olds. Determination of best aerobic exercise option 38 Obesity in Rehab a Weighty Topic

38 Physical Therapy Interventions Correction of impairments of: Range of motion & Flexibility Balance Strength: To facilitate improved shock absorption Endurance Treatment of musculoskeletal pain syndromes Therapeutic Exercise and Activity 39 Obesity in Rehab a Weighty Topic

39 PT Intervention Goals Goals of Rehabilitation: Remediate impairments Individualized treatment programs Weight bearing and Non-weight bearing activities Aqua therapy programs Enhance mobility and overall functional levels Appropriate activity levels for ambulatory and non-ambulatory patients to facility as much mobility as possible Weight bearing activities as soon as possible Size and weight appropriate assistive devises Gait and transfers Enhance fitness and well being Facilitate weight loss Education Patients and family 40 Obesity in Rehab a Weighty Topic

40 Obesity Related Challenges in Rehabilitation Slowed Progress which may require increased visits to achieve desired outcome Modified Positioning for Testing and Exercise Tissue Restrictions Trunk girth Extremity width Deconditioning Reduced exercise capacity Flexibility limitations due to tissue bulk Balance Abnormalities in base of support Foot placement or arm swing due to tissue bulk, flexibility etc. Postural deviations Compensations for excess body weight Reimbursement 41 Obesity in Rehab a Weighty Topic

41 Adaptive and Assistive Equipment Tub bench, may be needed to decrease effort and increase or maintain the client s level of independence. Handheld showerhead Long-handled scrub brush Raised Commode seat Transfer Bench Wheelchair Walker Quad cane Foot stool * lb capacity for Bariatric needs **Typical load capacity is lbs 42 Obesity in Rehab a Weighty Topic

42 Bariatric Patient Equipment When the resulting BMI is greater than 38, there is a possible need for special bariatric equipment. If the BMI is greater than 39.9, the patient is considered morbidly obese. For example: a 5 8 tall, 255 lb person has a BMI= 39. The process of identifying equipment needs includes the following: Create a protocol for identifying the bariatric patient at point-ofcontact areas, such as pre-admission testing, emergency, etc. Develop a method to procure or rent necessary equipment if it is not available in-house Identify and label in-house equipment with weight capacities. 43 Obesity in Rehab a Weighty Topic

43 Questions? SelectMark 2016

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