**2. Addressing bariatric functional limitations**

Obesity affects physical, biopsychosocial aspects of an individual's health and function. The complex nature may require rehabilitation interventions to be carried out in various settings to accommodate for different functional goals and engaging a multidisciplinary rehabilitation team to tap into different expertise to achieve the desired functional milestones. The bariatric individual presents with unique challenges to the treating team in both functional limitations and the approaches that can be employed to address these impairments and prevent further functional deterioration. The ICF highlights the domains that are affected by excessive weight: pain, cutaneous sensation, neuromusculoskeletal issues and movement difficulties as well skin issues due to difficulty in reaching during cleaning and toileting are the most commonly impaired function and complications leading to limitation in general tasks, mobility and poorer quality of life [1]. Concurrent presence of medical comorbidities can add up to tip the individual into compromised functional independence [1]. Common comorbidities related to obesity such as osteoarthritis of the weight bearing joints and cardiopulmonary conditions impacts severely on an individual's functional reserves. Thus, the goal for bariatric rehabilitation program should include assisting the attainment of optimal weight reduction; to address current and potential medical complications especially metabolic syndrome, CVD and MSK conditions; to address functional limitations resulting from physical disabilities and improve quality of life through improving functional independence, self-confidence and empowering self-management.

Severe obesity with multiple comorbidities requires admission to medical facilities structurally adequate to assist in supporting and assisting individuals with excess body mass to transfer and mobilise with the use of bariatric- safe lifting devices, mobility equipment and transfer aids. Ideally these rehabilitation facilities are linked to a bariatric- dedicated medical and surgical specialities [4].

The bariatric patients frequently develop medical complications that may run a protracted course [5]. Common medical complications readily noted at admission include:

*From Prehab to Rehab: The Functional Restoration of a Bariatric Individual DOI: http://dx.doi.org/10.5772/intechopen.94418*


These complications may indicate specialised nursing care or aids to protect during mobilisation. It may also preclude the use of some rehabilitation modalities i.e. hydrotherapy and priorities needs to be given to address medical conditions that delays resumption of weight bearing or therapeutic standing.

Hospitalisation-related complications that tend to occur are mainly as a result of prolonged recumbency, also known as deconditioning. While deconditioning is not exclusive to bariatric population, its effects are more pronounced as bariatric individuals face challenges for immediate resumption of upright posture especially those who were admitted acutely for medical complications such as cardiopulmonary emergencies, following falls or exacerbation of musculoskeletal conditions leading to pain on weight bearing. Deconditioning can affect both physical and psychological domains as prolonged bed rest affects nearly all body systems. Specific to bariatric population these complications may entail a prolonged stay and protracted course of recovery:


The result impacts on a bariatric individual's functional reserves in terms of muscle power, balance, and coordination, jeopardising functional performance and results in the development of psychological sequelae as a direct result of deconditioning or from the loss of function it entails. Confusion and disorientation are part of the deconditioning constellation seen earlier on the bedrest period which can culminate in clinically significant anxiety and depression once the impact of functional loss sets in as self-care, leisure activities and gainful employment becomes challenging. Reconditioning as a rehabilitation goal will be discussed further in the prehabilitation section. Given the prospect of functional deterioration that can occur at an accelerated rate in the bariatric population due to inherent difficulties in mobilisation, special attention should be given to addressing factors that negate upright sitting and to promote lower limb weight bearing in cases that permit them as soon as possible. These include identifying at risk bariatric individuals with hip and knee replacements, paralysis, amputations, contractures, osteoporosis, respiratory and cardiac conditions, and skin conditions such as pressure ulcers. Availability of bariatric mobility aids such as hoists, tilt tables, chairs or wheelchairs and walking aids greatly assist in preventing the ill effects on deconditioning and translates to better cost-efficiency to prevent such deleterious complications rather than treatment of the aforementioned complications.

Various models of bariatric rehabilitation exists to generally addresses 5 key factors: knowledge to empower action, goal-setting and self-care; beliefs surrounding causes and solutions to obesity; behavioural adaptation focusing on diet and physical activity, psychological coping strategies and adjustments of physical activity to include exercise, current functional capacity and that expected after bariatric surgery. A holistic model such as bio-psycho-social model explained via ICF helps to provide a multi-dimensional framework to evaluate the needs, identify the barriers and provide intervention or solutions to improve independence. Selection of the model to address such an individualistic experience such as function is paramount as the different considerations of the desired rehabilitation goals and outcomes of interest are given priority by different models [6]. The lack of obesity-specific outcome measures to quantify physical impairments and ADL limitations prevents stratification of bariatric individuals based on the magnitude of disability [7]. This is useful to establish as a threshold value for inpatient rehabilitation admission, and serves as an objective severity identification tool that impacts on the decision of appropriate rehabilitation setting and chart progress during rehabilitation. An example of such tool is the Obesity-related Disability Test (TSD.OC) developed by Donini et al. that aims to evaluate pertinent obesity- specific functional dimensions [8]. The main targets for bariatric rehabilitation are the cardiorespiratory, musculoskeletal and multi-systemic effects of deconditioning as described above. Strategies that reduce pain, increases strength and mobility as well as optimise functions can be delivered in various settings depending on the severity of obesity-induced disability. Inpatient rehabilitation facility offers an opportunity for more intensive rehabilitation input and caters well to bariatric clients admitted acutely for MSK or CVD that often runs a prolonged hospital stay and poorer functional recovery if left without rehabilitation input. The goals of inpatient rehabilitation are focused on attaining maximal functional independence for safe home discharge through improvements in strength, balance, and endurance coupled with initiation of CVD risk factor control and body weight reduction through dietary and physical activity prescription. An outpatient program may provide significant functional improvements in clients who can access both the centres and their lodging with appropriate means of transportation between them. This is attained by promoting increased pain-free joint range of motion, increasing muscle strength and cardiopulmonary endurance during functional activities. Concurrent efforts to optimise CVD risk factor and improve lean-to-fat mass ratio are also continued in the outpatient setting through education and individualised counselling on dietary and physical activity

#### *From Prehab to Rehab: The Functional Restoration of a Bariatric Individual DOI: http://dx.doi.org/10.5772/intechopen.94418*

plan to maximise functional capacity despite excessive weight. Capodaglio et al. conducted a prospective 4-week inpatient bariatric rehabilitation with orthopaedic conditions consisting of strengthening and aerobic exercises adapted to the patient's mobility; caloric restriction and nutritional education with psychological counselling [7]. The results exemplified that mild and severely disabled bariatric individuals with orthopaedic comorbidities can significantly experience functional improvements independent of the weight loss sustained; with the higher BMI and younger individuals showing the most functional gains. Similarly, Hanapi et al. employed an approach based on the cardiac rehabilitation model and resources for inpatient bariatric clients with CVD risk factors and orthopaedic comorbidities [9]. Employing adapted physical activity and exercise prescription, dietary modification, provision of psychological and social support, their approach successfully addressed weight, cardiometabolic profile optimisation prior to bariatric surgical intervention and conferring postoperative improvement in mood, dependency level, perceived physical and mental health during the postoperative phase with sustained functional capacity, endurance and quality of life up to 3 months post operatively.

Admission planning for an inpatient rehabilitation stay is crucial to ensure logistic requirements, staffing ratio, bariatric-compliant equipment, administrative support and a mobilisation plan is developed as part of a function-centric rehabilitation plan. By definition, bariatric individuals include individuals whose weight exceeds or appears to exceed the identified safe working loads for equipment, lacks mobility or presents with challenges in manual handling [10, 11]. Moving and handling of bariatric clients can accentuate the risks of musculoskeletal injuries and excessive spinal loading in health care workers. Planning of staff and equipment reduces the risks associated with the care of bariatric patients. Safety of patients and health care workers can be enhanced by developing a movement and handling plan as each bariatric admission often presents with unique issues that require problem solving and an understanding of equipment or patient transfer procedures. Involvement of occupational health and safety representatives as well as risk reduction efforts can minimise unplanned situations that may differ between patients due to individuals' risks, goals and resources available. Every aspect of patient- HCW interaction should be therapeutic from rehabilitation perspective including communication. Open discussion on equipment use and transfer techniques can lead the way to more serious discussions on dietary habits, adapting lifestyles and long-term functional goals. Education on the importance of physical activity and dietary management to aid weight loss and maintain functional independence helps boost motivation and compliance [9]. Discharge planning should include not just physical preparation of the destination. Consideration should be given to post-rehabilitation functional limitations that may require physical help or adaptive equipment as functional goals attainment may require repeated cycles of rehabilitation. Potential home modifications and long-term plans for adapted physical activity, dietary maintenance, psychological support, surveillance for relapses and complications as well as plans for higher functions such as return to work and driving should be discussed with the patients and their social support.

Outpatient bariatric rehabilitation continues the inpatient gains made with focus on long-term prevention of function and weight- gain relapse. The common impairments addressed are osteoarticular pain especially of the lower back and knees as well as joint malalignment. The effects of excessive weight on systemic inflammation, joint compression and premature degenerative disease of the joint can be offset by the role of adapted physical activity which is more pronounced in this setting to maintain compliance to caloric expenditure, CVD prevention and positive psychosocial reinforcement. A combination of both aerobic, resistance and flexibility exercises adapted to individual MSK conditions working on large muscle

groups alongside dietary modification has led to improvement in CV biomarkers, fat loss and skeletal muscle gains conferring enhanced functional improvements in programs that include resistance exercises [12, 13]. In comparison to diet modification intervention alone, multimodal exercises program combined with diet interventions conferred lean mass sparing effect [14]. This is also evident in a systematic review of sarcopenic obesity treatment whereby excess fat mass and reduced lean mass impairs physical performance in which weight loss attained through exercise in combination with dietary intervention is the best treatment strategy that improves metabolic consequences of excess fat mass while preserving lean muscle mass and promotes functional recovery [15]. Aerobic exercises for caloric expenditure, reducing joint pain and controlling weight which is a risk factor of osteoarthritis as well as resistance exercise for strengthening of the joint supporting musculature and cartilage health reduces obesity-related joint conditions [16, 17]. As the client returns to the community, psychological support to sustain weight loss motivation and purpose as well as addressing stigma associated with excessive weight is equally important to ensure sustained functional and weight loss gains are maintained. Chronic pain and its effect on gait, psychical activity, participation and quality of life also needs to be addressed.

In conclusion, bariatric rehabilitation addresses common medical comorbidities and obesity related MSK complications through multimodal rehabilitative and allied health interventions, including prescription exercises and diet modification to increase cardiopulmonary endurance and caloric expenditure while minimising fear of movement and joint pain. This in turn leads to progressive body weight reduction and improved comorbidities profile leading to better body composition and physical function capacity.
