Size matters

Caring for people who are grossly overweight presents a real challenge to physios, as sally priestley finds out

When Lou Bradley went into hospital for her first bariatric procedure she was faced with having to haul herself onto a standard hospital bed.

It was too high for her to mount and unsafe for her weight.

There were no staff trained to help bariatric patients and, to make matters worse, an audience formed, watching the embarrassing scene unfold.

At that stage she weighed 48 stone and had a body mass index (BMI) of 93; a BMI of 25 is considered overweight and 30 is obese.

‘They hadn’t ordered a bariatric bed, there was no hoist available and I did not have the strength in my knees to get me onto the bed,’ Ms Bradley says.

Even getting to this undignified stage had taken a battle of wills. When Ms Bradley decided it was time to do something about her weight, she went to her GP and was prescribed the obesity drug Xenical.

The medication was not successful. When she asked for a gastric bypass operation, she was told at first that it would not be done on the NHS as it as it was a cosmetic procedure.

Her husband went to see local MP Theresa May, who was ‘fantastic’, and Ms Bradley had the operation, at an NHS hospital in Chichester, in January 2007.

The procedure was a success, but, she says, the after-care was clearly lacking.

She was offered a limited course of physiotherapy, every couple of weeks, with exercises mainly to strengthen her legs, and also attended the optional weight-loss surgery follow-up meetings.

But that was it.

Lost 18 stone in a year

Even so, Ms Bradley lost a massive 18 stone in the first year after the operation.

‘It felt amazing, but of course I was then left with lots of excess skin, and was then referred for plastic surgery.’

The excess tissue was removed in March 2009 at St Thomas’ Hospital in London. Again she had limited post-op treatment and was not offered any kind of long-term support.

‘It’s been very hit and miss,’ she says, about what she feels to have been standard treatment for bariatric patients in the UK. ‘At both hospitals and clinics there is a total lack of equipment, facilities and care for bariatric patients. They aren’t geared up at all.’

Yet bariatric care is becoming a major issue in the UK. Larger bodies with bigger BMIs are now commonplace in healthcare settings, putting a further strain on the NHS system.

The cost to the UK economy, including absence from work, is estimated at £49.9 billion a year.

The National Audit Office says treating obesity costs the NHS at least £500 million a year, and it is expected to reach £10 billion a year by 2050.

A government-commissioned report in 2007 predicted that by 2050, if no action is taken, 60 per cent of men and 50 per cent of women in the UK would be obese.

Opportunities for physios to specialise in this area are still rare. But physios play a key role in a few stand-out services.

The Tone Up Feel Good programme set up at Aintree University Hospitals NHS Trust over 10 years ago is a great example.

Physiotherapy assessments are generally offered from the outset to patients with a BMI above 40 who are referred by their GP or hospital doctor.

They are then offered a tailored multidisciplinary care pathway that may include a 12-week programme of exercise, diet advice and group sessions aimed at supporting them on the road to better health.

Weight management

The service was conceived by Professor John Wilding, an international expert in the causes and treatment of obesity, who had the foresight to get physios involved from the off.

One of them was clinical lead Elaine Conlin, originally recruited to work one day a week on the project. She and her colleagues used their core physiotherapy skills to help patients complete their goals, and quickly saw an expanded role.

‘There are many different weight management systems out there, but there isn’t always that level of skill that is required to deal with bariatric patients and give them the care and service they need.

As physios we can fill this need,’ says Ms Conlin, who spent nine years developing the service.

‘It’s a holistic way of working, so it’s great for physiotherapists because we get to use all our skills. I believe bariatric care should now be integral to training for physios on all degree courses, and in rotations and in static posts. It’s that important.’

Newly qualified physio Claire Rigby joined the Aintree weight management service in 2010 and has helped oversee its expansion into community services.

She is now operational manager on the new ‘Lose weight feel great’ service in Ashton, Leigh and Wigan PCT.

The service is for patients with a BMI over 35 plus co-morbidities, or BMI over 40 with no co-morbidities. Patients are referred by a healthcare professional or GP, or can refer themselves.

‘This programme is a unique pathway,’ Miss Rigby says. ‘It’s picking up on what was offered by Aintree and developing it for use in the community.’

It offers general health and wellbeing services as well as specialist weight management: one-to-one care, followed by a 24-month tailored programme.

The initial assessment is by consultant and the patient is then referred to a dietician or physiotherapist for their one-to-one care programme.

‘It’s not just about weight loss, it’s about improving quality of life,’ she says.

‘A key element is making exercise more accessible and offering options people will enjoy and stick with.’

The local Walk for Health group is an example: patients attend with their physios who offer advice on health and wellbeing while they are walking.

Swimming has also been a focus. In addition to hydrotherapy, body-conscious patients can attend private swimming sessions.

‘As physios we’ve always had to fight for our position on weight management teams,’ says Miss Rigby.

‘But as a physiotherapist I’m a rehab specialist, so my skills lend perfectly to this area of practice.’

A chance to make a difference

Healthcare professionals who get involved with bariatric care often find they have the chance to make a real impact and never look back.

One of these, now a leading expert on bariatric care, is Anita Rush, clinical nurse specialist with Berkshire Community Equipment Services.

‘I first got involved in the 1990s after having a patient in my care whom I was asked to help bring back into the community,’ she says.

She became so involved, she went on to study bariatric care for her degree dissertation. But when she graduated in 2002, there was very little bariatric expertise in practice.

‘People thought I was mad!  But it’s been the most rewarding experience working with these patients – and it’s opened up my world.’

She says bariatric management is complex and needs a ‘whole systems approach’.

Key considerations for patients are environmental constraints and equipment provision. Beds, mattresses and chairs all have to be taken into account, and there are many aspects to consider for even these basic forms of equipment.

Bariatric patients are at high risk of musculoskeletal injuries and tissue damage, says Ms Rush. And physiotherapists’ skills are essential in ensuring safe practice and appropriate care.

‘Physiotherapists have to be able to recognise a patient’s particular body shape and dynamic and how this impacts on how they move, for example, and how their weight is positioned in different stances and where their centre of gravity is according to where their weight is held,’ she says.

‘The right assessment will facilitate patient function, increase independence for patients and eliminate some of the high-risk care tasks for healthcare staff.’

This is where physios can play a key role, she says.

‘Rehabilitation is actually the hardest bit,’ says Ms Rush. ‘Practitioners can often be fazed when faced with patients with such high BMIs, and have no idea how to handle it. We need specially trained staff who can do that.’ fl

Rubber band gang...

Computer artwork of a gastric band.

The ring (white) is placed around the top portion of the stomach to create a small pouch (upper left) that holds approximately 50 millilitres.

When the patient eats, the pouch fills up quickly and a full message is sent to the brain, therefore helping the patient to eat smaller portions.

 The band can be adjusted by injecting saline into the balloons around the ring via the access port (at bottom right) to allow for optimal weight loss.

Ground-breaking territory

One physiotherapist who has both specialised in bariatric care and pushed the boundaries of what physiotherapists can offer is Sara Hawkins.

With a background in women’s health in a hospital setting, she saw several patients coming onto the ward following bariatric procedures.

And she realised that many of their problems were the same as she saw in general women’s health. Ms Hawkins saw an opportunity for physios to help.

‘I now work with bariatric patients, using my skills as a women’s health specialist, as there is so much crossover,’ says Ms Hawkins.

The specialist role she has developed, at the BMI Alexandra hospital in Cheshire, has taken her into ground-breaking territory.

Sitting within a multidisciplinary team (MDT) on a weight management programme, Ms Hawkins deals with patients who have had clinical help, or have been on conventional weight loss programmes that have not worked, and have led to surgery and /or referral onto the service.

Patients are assessed by a consultant and referred onwards as appropriate within the MDT, often for surgery: gastric band and gastric bypass being the most common.

Having time to talk through the needs of patients is key to what makes physios so well suited to bariatric care, says Ms Hawkins.‘I see patients all the way through the process and can offer support throughout,’ she says.  

This led to a bid to move into a whole new clinical practice – gastric band filling

‘It’s common for gastric bands to be fitted either too tightly or too loose,’ Ms Hawkins says. ‘Either way, the patient becomes aware of the problem soon after their procedure.’

A relatively straightforward procedure, band filling can be carried out during a follow-up consultation by a specialist nurse or a consultant. But these staff are often not available, Ms Hawkins says.

‘I went along to a band filling training course just to observe the process,’ she explains, ‘and I knew it was something I could be trained to carry out independently, if it were allowed.’

The process involves adding or removing fluid through a port just under the skin near the armpit and attached to a tube carrying it down to the band around the stomach.

‘I thought, there is no reason for physiotherapists not to do this, and we can offer it to patients there and then.’
She came to the CSP for help making her idea a reality, and CSP professional advisers Leonie Dawson and Pip White worked alongside her to do just that.

Throughout the four-month project, there were two main hurdles, Ms White says.

‘Firstly, what was the status of the band and the saline – was it medicine or equipment?

And secondly, if she was trained to do it, would it be within scope of practice?’.

Scope of practice

The first hurdle was most simple to overcome, Ms White says, ‘through a bit of research with the medicines regulator and patient group direction’.

The second hurdle was how the practice linked to the overall philosophy of physiotherapy.

‘The argument was made that the gastric band was adjunct to Sara’s other interventions and used to help patients manage their weight, help them move, and prevent associated health problems.

‘Ongoing maintenance of the gastric bands requires knowledge of total human performance and functioning, and that’s what physios can offer these patients ,’ adds Ms White.

Sally Priestley

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