MOst of us have become familiar with the term bariatric during the last decade. The epidemic of obesity is globally reported, occurring especially in developed countries and bariatric surgery has dramatically increased. Surgical weight reduction procedures with morbidly obese and extreme morbidly obese patients place demands on hospitals for surgical intervention and treatment. There are also many mild and moderately obese patients who are hospitalized for primary diagnosis unrelated to their weight. Where to start Rehabilitation professionals are challenged to maximize function with basic daily activity and seating and mobility needs for many consumers who have obesity as a secondary diagnosis. Finding appropriate equipment to meet the requirements of bariatric clients is often difficult. While more commercially manufactured cushions, back supports, manual and powered mobility devices are available than ever before, properly measuring the client and configuration of the equipment is necessary to achieve success. The first step to providing appropriate equipment is to complete a thorough evaluation. Start with an accurate history, including a weight history to determine recent weight loss or gain and if it can be attributed to illness, medications or surgical intervention. Also, an accurate current weight is critical. This can be difficult for some morbidly obese consumers who may not have access to a scale. Some clinicians have used two scales, one under each foot and combined the total weights. For patients who are unable to stand unsupported, there are scales designed with platforms for wheelchairs to be rolled up onto, allowing the weight to be measured. The same chair is then weighed without the client and the chair weight can be deducted from the combined total. Unfortunately, many of the platform scales are only large enough to hold an 18 or 20 inches-wide manual wheelchair. Some patient transfer/lift systems have scale options—a smart option for facilities to consider. Measurement of the patient is the next vital component to the prescription process. Depending on the consumers’ diagnosis and endurance, this may require two to three people for safety and accuracy. Measure the client in a sitting position on a firm planar surface. Avoid measuring anyone in bed, sofa or “easy chair” as the soft surfaces accommodate tissue. Ideal for this activity is a height adjustable therapy mat; the height adjustment allows femur support on the table surface while the feet can be in contact with the floor. An adjustable height table also makes sit-to-stand transfer assessment safer. Gluteal depth and height Excessive adipose tissue in the gluteal region can prevent obese consumers from sitting with adequate spinal support, which can contribute to incidence of back pain for this population. Measurement from the evaluation support surface to the top of the gluteal tissue can help determine the height at which a back support surface is mounted, perhaps allowing some of the redundant tissue to stay below the back support and posterior of the back canes. Obviously, seat cushion thickness must also be taken into account with this approach. The depth of excessive gluteal tissue, measured in the lateral view as the difference from the popliteal to the posterior aspect of the gluteal tissue and from the popliteal to the posterior aspect of the trunk above the gluteal shelf, should be considered in the specification of the seat pan/cushion depth. The orientation of the back support may require adjustable depth of the back canes or adjustable depth of the back support mounting hardware, so measuring popliteal to posterior trunk can determine those needs. Several different bariatric body types are described by Michael Dionne in his book Among Giants; Courageous Stories of Those Who Are Obese and Those Who Serve Them. Each of these body shapes distributes weight differently—so much so that, if not considered, the equipment selection could be completely non-functional for the consumer. Abdominal obesity (described commonly As the apple shape) has the primary excessive weight distribution in the belly area, which can lead to more anterior instability of the wheelchair. This forward instability can be problematic for many manual wheelchair bases as well as some mid-wheel and front-wheel drive power bases. Weight distribution The other complication for patients with abdominal obesity is the effect this type of weight distribution has on their seated posture. The mass of adipose tissue can prevent the consumer from sitting upright. Evaluation of the clients’ tolerance for seat to back angle is very important for the “apple type” weight distribution, both for comfort, respiration and function. A chair and/or back support which allows adjustment to open (recline) the back angle may be the answer. Some consumers’ hip flexion may be limited and/or their abdominal tissue may exert pressure on their femurs forcing their upper legs into a more abducted posture. This in turn can make the use of footrests on a wheelchair very difficult; the lateral aspect of the knees or lower legs may be in constant pressure against the footrest hangers. Gluteal/femoral obesity is described as the pear shape. These patients carry most of their adipose tissue below their waist and above their knees. Dionne further differentiates these patients into “Pear Adduction” and “Pear Abduction” types. It is important to note if the distribution of adipose tissue is more medially or laterally distributed. Excessive medial femoral tissue will prevent the femurs from achieving a neutral alignment in sitting. Excessive lateral femoral tissue can require larger seat widths for accommodation, a necessity which can have a negative consequence for footrest and armrest position as well as trunk/back support. Lower extremity supports are usually attached at the front of the side frames of a wheelchair which means the foot plates are spaced out to the width of the chair. It is important to note orientation of the feet when any patient is evaluated. Some options or modifications can bring the foot supports closer to the midline or bridge the span between the plates. This can accommodate feet, which may come to the center, a common issue for clients with adipose femoral tissue. While excessive gluteal tissue can prevent the consumer from sitting in contact with the back support surface (as described above), it can also keep the patients’ center of gravity more forward in relation to the mobility base promoting anterior instability and limiting effective manual chair propulsion. Bariatric clients with a forward center of gravity can place too much weight on the front casters of the wheelchair, which limits the forward movement and turning of the chair. Optimizing performance Bariatric consumers who require/utilize wheeled mobility devices would benefit from optimal performance from their equipment, just like any other person who utilizes a wheelchair. The key to maximizing the function and performance of any manual or power wheelchair is the distribution of weight in relation to the chair’s drive (propulsion) wheels. The consumer’s weight distribution will effect the center of gravity and ultimately the wheelchairs overall performance. Many manual chairs have a non-adjustable rear axle integrated with the rear frame & back post component of the chair. Obese consumers whose excessive adipose tissue in the posterior gluteal area and/or the posterior trunk can struggle with propulsion of a manual wheelchair due to their anterior position away from the rear wheels. This rear wheel position also lends to less weight being placed over the rear wheel and too much on the front castors, which leads to poor mobility of the chair. There are some manual wheelchairs designed with the needs of bariatric consumers in mind. More adjustable rear wheel placement can help, as well having the castors further forward, in other words a forward wheelbase to accommodate for the forward center of gravity of the bariatric client, thus providing better mobility of the wheelchair. This same weight distribution issue is a factor with power wheelchairs. It is important to consider the clients weight distribution in relation to the drive wheels (especially with so many power bases having mid-wheel or center-wheel drive) as well as the length of the wheelbase for anterior stability. Short wheelbases with suspension stabilizers in the front can compress with excessive anterior weight loads, pitching the system forward—especially with navigation down inclines. A power-sliding seat that can move the seat system posterior in order to distribute weight over the drive wheels can enhance the chairs performance. In the forward position, it can make transfers safer by allowing the feet to reach the floor in front of the casters or anti-tip wheels. Prescribing appropriate mobility bases for bariatric consumers is not simply a matter of getting the width right. Taking the time to carefully evaluate and measure the client and problem solve some of the challenging aspects can assure more successful outcomes and greater consumer satisfaction.