Meeting the Prosthetic Needs of Patients With Greater Body Mass

As O&P practitioners encounter more patients who are overweight, they need to be creative in finding solutions and may have to look beyond their preconceived notions about the patients' abilities. While treating patients who are larger can pose unique challenges, experts say it remains the practitioner's job to meet the challenges to help their patients become as mobile and active as possible. "Sometimes people have certain stereotypes in their minds about these patients and may not provide them the treatment that they would to anyone else," says Michelle Hall, MS, CPO, FAAOP(D) , prosthetist residency director, Gillette Lifetime Specialty Healthcare, St. Paul, Minnesota. "We can't lose sight of our jobs." This is a patient population that prosthetists can expect to encounter in their careers, the experts say. As rates of obesity have risen in the United States, so too has the chance that clinicians will have patients who are larger in size. According to the Centers for Disease Control and Prevention (CDC), 37.9 percent of adult Americans age 20 and over are considered obese.a rate that is double than that 35 years ago. The average American is more than 24 pounds heavier now than in 1960, according to the CDC. "In general, the population trends are that people are increasing in size and weight and that translates into a greater percentage of people that have amputations [and also] have an increased size and weight," says Mark Edwards, MHPE, CP , director of professional and clinical services, Ottobock North America, Austin, Texas. Additionally, patients with obesity are more likely to have health conditions that can lead to amputations. "The statistics say the leading causes for amputations are diabetes and vascular disease," Hall says. "Often those go hand in hand with obesity." Prosthetists who work with this population will often be required to be resourceful to find the best solutions to help their patients. Some of the challenges outlined by the experts include: A limited number of component options due to weight limits Designing a socket that can fit the larger residual limb without being so heavy as to render it unusable An increased chance of other health conditions that make mobility more difficult Hall says that practitioners should not be deterred, but instead should see their larger patients as having unique complications, just like everyone else they treat. "We tend to think of them as being different from the rest of our patient population, but they are not," Hall says. "Their needs are similar to those needs of other patients and we can't lose sight of that because of any preconceived notions about their weight." Limited Number of Options One of the obstacles when treating patients with obesity is limited componentry due to their weight, experts say. "Most components are weighted up to 275 pounds and some up to 350," Edwards says. "Beyond that, there's really a drop in availability." The situation has gotten better in recent years, says Justin Pratt, CP , director of Össur Academy, prosthetics, Foothill Ranch, California. As more manufacturers see the demand for these components, more are being built. "If you go back 15 to 20 years, components were maxed out at 220 to 250 pounds," he says. "As manufacturers see the need, they've been adding more components, with some components [rated] up to 500 pounds. Not every manufacturer, but most can now accommodate people over 350 pounds." However, even with improvements in the past few years, prosthetists are limited in their choice of components, Hall says. "I still don't think there are enough options out there," Hall says. "We can't choose certain manufacturers whose products we like because they are not rated high enough for that particular patient.... I don't want to say that they are limited because of their weight, but rather they are limited by the components they use because of their weight." For instance, Hall says, she once had a patient who wanted to lift weights, but because of his body weight, combined with the weight he would be lifting, she was initially concerned it would have been too much for his components. She had him work with a physical trainer so he could lift some weight or incorporate weight training machines in his workouts, like a leg press, so he would only be lifting that weight and not that weight plus his body weight. Also, Edwards points out, some patients who are overweight are too heavy for components that would allow them to run. "You have to temper expectations and say, 'That's a great idea, but the current choices we have are limited and will not allow you to run at this time. Certainly we can look at this in the future.'" Fewer available components mean that prosthetists often resort to custom designs and solutions. Pratt says he's never found a great manufactured product that helps patients who are larger to don and doff their prostheses, and he's seen a number of inventions created by prosthetists as he has toured the country. "Necessity is the mother of invention, and that comes to light really quick when you are dealing with this patient population," Pratt says. But custom designs can pose their own difficulties. Edwards says it can be tough to make prostheses that are as lightweight and durable as they need to be. "We are continually trying to develop these components, but it takes time because you are limited in the materials that can take the weight and still be lightweight and functional," he says. "We can create a prosthetic that is strong, but may be too heavy for an individual to use." If it's too heavy, then it really doesn't matter how good the components are, he says. "If it's too heavy to use, [the patients] can't become mobile and they get worse in their ability to function." Getting the Right Fit Even if clinicians have all the components they need, fitting a patient for the socket still poses its own challenges. One issue, Hall says, is simply having the right equipment or personnel in the office to help these patients. In an Academy TODAY article (" Prosthetic Treatment of an Obese Patient ," January 2013, Vol. 9 No. 1) Hall outlines her challenges working with a patient who weighed 446 pounds. When she was fitting him, she did not have the proper bariatric equipment in her office and needed two male colleagues to help the patient with sit-to-stand activities. "There are so many things you might not even think of," Hall says. "For instance, are the bars in the bathroom strong enough to hold the patient, is the stand to balance the patient for the check socket strong enough, or will the walker being used by the patient be strong enough." In her article, Hall outlines multiple complications she encountered fitting the patient. For example, during the fabrication process, the length and weight capacity of the vertical jig were maxed out when transferring from check socket to definitive socket. Also, lamination took two people because of the size of the socket, and finding PVA bags and stockinettes to fit over the cast was difficult. During the fitting, prosthetists often encounter more soft tissue than with other patient populations, Edwards says. "When you have a larger client, usually it means there is more soft tissue and less control of the bony anatomy underneath," he says. "Being able to hold onto that via suction or a pin system is difficult because you have lots of movement between the soft tissue and the bone." He says the process requires taking an impression or using the appropriate tension values that will provide a rigid structure against the patient's soft tissue. The entire process is magnified, however, since these patients are also more likely to gain or lose mass, requiring additional fittings. "Oftentimes their weight is not stable," Hall says. "Perhaps they were sick and not active and gained weight. Now they are active and are losing weight. We have to continually monitor socket fit and have to pad and adjust. It's good that they are getting healthier and active, but it will also mean more visits and time away from their active lives." Other Health Concerns While weight is one of the biggest obstacles to overcome for practitioners treating patients with greater body mass, it isn't the only issue, experts say. These patients are more likely to have health issues that make it tougher for them to be mobile and are less likely to have the flexibility and strength they need to effectively don and doff their devices. "If they are having an amputation they might not be healthy to begin with," Hall says "You have to take into account their general health." If patients do have a preexisting health condition, such as diabetes or vascular disease, it may make them weaker than other patients, Edwards says. At the same time, their weight means being mobile takes more work for them than others. "They tend to use more energy, and if they have other medical complications, like a heart condition or so forth, they are usually taxed by their larger size," he says. "That is the most challenging factor. Do these individuals have enough physical capacity to ambulate in addition to the amputation?" Contributing to the patient's mobility issues, Pratt notes, is that a socket that fits a larger patient requires more material and thus is heavier than a traditional socket. "Honestly, I think the greatest challenge of becoming mobile falls on the patient," Pratt says. "When it comes to fabricating something, we will find ways to make it, but the greatest challenge is getting the patient to don it. That has to happen day in and day out, and if it's difficult, they aren't going to put it on and they aren't going to wear it. The prosthetist has to design something that will make them successful." Getting the patient motivated, whether they are of larger size or not, can always be tough, Hall says. "It's that way with anyone," she says. "Whether they are able-bodied or not, there really has to be a lot of self-motivation." Larger patients can face a double-edged sword, the experts say. They need to have prostheses to become active and mobile and lose weight, but their amputations and prostheses may be the very things that keep them from being as mobile as they need. "When you combine the medical complications, the more difficult it becomes for them to be able to get up and walk," Edwards says. "It's a cycle that is sort of never-ending. The goal would be to get these individuals up and walking as much as possible from a psychological and a health benefit." To get to that point, however, clinicians need to work with the patient, physician, and physical therapist to address all of the health problems, not just the weight. "Losing weight, getting stronger, and using a prosthesis would all help," Hall says. "It's not just the weight issue." A Success Story One of Pratt's most challenging patients was also one of the most rewarding. When they met, the patient weighed about 640 pounds and had recently undergone a procedure that entailed both an amputation and bariatric surgery. The patient was fitted with an Össur Modular III™ foot that was a special order due to his weight. "He was fit with all modern technology; there was no compromise," Pratt says. "He had silicone liners and a Flex Foot. We knew we could get a Mod III fit at whatever capacity we needed.... It was good to know that there were components that allowed us to care for this individual, even if we had to think outside the box." One of the biggest hurdles was the patient's rapid weight loss due to the bariatric surgery, which meant he went through several sockets, Pratt says. "One of our biggest challenges was to medically justify it," Pratt says. "He needed a replacement socket every four to six weeks as he was losing so much weight. We saw this man every week for the next 18 to 20 months and made a total of 13 sockets in roughly 16 months." Pratt says his office worked closely with the patient's physician and physical therapist and made sure to document that every new socket was essential. "We used CAD and did image overlays to prove it was medically justified so we could get paid for everything," he says. He says his office had to be diligent about documenting everything, ensuring that every procedure could be justified, and everything was signed and dated properly. "How do you provide a device that is going to be an adequate fit for the patient but also has to be reimbursed?" Pratt says. "There are challenges that don't just hinge on the success of the patient, but the billing and reimbursement as well." Although the insurance provider paid his practice for everything, Pratt says he still would have taken on the case even if there were reimbursement issues. "He was putting his life on the line, trying to be better, and trying to improve his physical and mental state," Pratt says. "We are the healthcare providers and we had an obligation to provide a solution for him.... You have to step out of your own shoes and wonder if you were in his position would you want to be denied care because you were a challenge or would you try to find a place that could meet your needs." As the patient lost more weight, he became more active, and was motivated to keep working, losing weight, gaining strength, and becoming more mobile, Pratt says. In all, the patient lost 320 pounds, became a K3 ambulator, and was able to live on his own with his diet and diabetes under control, Pratt says. "He never became an athlete, but when you go from someone who is bedridden at 38 and by 41 is fully ambulatory and is fully independent, that's a success story."

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Meeting the Prosthetic Needs of Patients With Greater Body Mass

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