Clinical Decision Making and Physical Therapy Intervention for a Morbidly Obese Adults Patient Following Severe Deconditioning

Introduction

The purpose of this project is to provide a case report for an obese individual with severe deconditioning. This project first provides a detailed review of the case, including a thorough patient history and chronology of the condition. A review of literature is then provided, focusing on background information, pathophysiology, major theories surrounding this condition and existing intervention strategies. A description of the examination is then presented, detailing the intended evaluation and diagnostic methods. A more detailed explanation of the proposed intervention is then included, followed by outcome measures and results. Discussion focuses on possible interpretations for the results, drawing on research presented in the literature review. This case report concludes with a brief summary, implications for future practice and recommendations for future research. 

Case History

The current case relates to a 61-year-old right-handed Caucasian female who is morbidly obese. This patient was recently hospitalized due to several complex medical conditions, most notably related to chest pain and severe migraines. This pain was described as being located in the sternal area of the left side, characterized by an intermittent stabbing-like pressure. This pain was mild at rest and worsened during deep breaths or movement. This pain radiated to her jaw and left arm, which she rated as a seven out of ten in terms of severity. This patent denied having any nausea or vomiting, and there were no signs of coughing or fever. This patient underwent evaluation and was found to have mildly elevated ST segments, as well as troponin levels of less than 0.01 x3.

A chest x-ray demonstrated that this patient experienced mild cardiomegaly, although there were no acute findings. A CAT scan of the chest showed cardiomegaly and multiple pulmonary emboli in the right lung. This patient was initially administered a heparin drip, and then was converted to a 1mg/kg dosage of heparin drip twice per day. Unfortunately, this patient subsequently developed a retroperitoneal hemorrhage and was transferred to the intensive care unit. Upon arriving at this unit, this patient underwent an exploratory laparotomy, evacuation of hematoma, and also had a drain placed. However, this patient then developed methicillin-resistant staphylococcus aureus (MRSA) infection and was placed on intravenous antibiotics. This patient also showed signs of pneumonia and atrial fibrillation and was unable to continue on anticoagulation therapy as a result of her retroperitoneal hematoma. She was, therefore, given an inferior vena cava (IVC) to prevent further pulmonary emboli. 

 As a result of this patient’s prolonged hospitalization period, this patient developed a critical care myopathy. This subsequently induced a significant feeling of weakness on all of her extremities. This weakness caused her to experience a loss of mobility. This patient was transferred to the acute inpatient rehabilitation unit with an accompanying referral for physical therapy to promote continued recovery. The rate taken from her atrial fibrillation has been fairly well controlled, and she has been continued on bi-level positive airway pressure (BIPAP) for her obstructive sleep apnea. 

Additional Demographic Information

This patient is currently employed as a fulltime registered nurse in an acute hospital. This patient is responsible for the night shift within this unit. The patient reports that her elderly mother also lives with her and has been diagnosed with Alzheimer’s disease. These two reside together in a one-story house that does not contain any steps. The patient drives regularly, and her brother also lives nearby and helps look after the patient’s mother. This patient has a very supportive daughter who lives locally. The patient is a community ambulatory and does not currently use any assistive devices.

Health Status

This patient reports a positive perception of her own health. Additionally, this patient reports that, prior to this episode of ill health, she was living relatively independently and was able to perform all her daily living activities fairly autonomously. Additionally, the patient was able to perform all instrumental activities of daily living in complete independence and was even able to take care of minor household chores.

Social and Health Status

This patient currently reports being a non-smoker, having quit since a family diagnosis of lung cancer. Additionally, she is free of any alcohol or drug use.

Family History

This patient’s family history is believed to be noncontributory to her current health conditions and treatment.

Past Medical History

A patient should be aware of and taught about their medical history. This patient has tested positive for hypertension, hyperlipidemia, osteoarthritis, diabetes mellitus, depression, asthma and morbid obesity. No previous surgeries have been documented or reported. 

Allergies

The patient has no known allergies or intolerances to relevant medications.

Medications

The following is a list of medications the patient is currently taking:

• Amiodarone HCl 200 mg tablet: one tablet by mouth daily

• Aspirin 325 mg tablet: one tablet by mouth daily

• Cefdinir 300 mg capsule: one capsule by mouth daily every 12 hours

• Ferrous sulfate 325 mg capsule: one capsule y mouth daily

• Magnesium oxide 400 mg tablet: one tablet by mouth twice daily

• Metformin HCl 500mg/bottle: 500 mg by mouth twice daily

• Nebivolol 10 mg tablet: five mg by mouth daily

• Oxycodone/acetaminophen 10/325 mg tablet: one tablet by mouth daily every six hours as needed

• Pantoprazole sodium 40 mg tablet: one tablet by mouth daily

• Prednisone 20 mg tablet: one tablet by mouth twice daily

Rationale for Case Selection

This case study was selected due to the rising obesity epidemic in the United States (Rochester, 2009). According to Rochester (2009), obesity in the United States has steadily increased over the past five decades and appears likely to continue increasing in the near future. The purpose of this case study is to delineate the changes affecting morbidly obese individuals, as well as to evaluate the effectiveness of various physical therapy treatments. The information gathered from this intervention may have implications for more evidence-based practice pertaining to obesity and physical therapy.

Review of Literature

This section reviews current literature relevant to the aforementioned case study. Specifically, this review evaluates research regarding the background and pathophysiology of morbid obesity and physical therapy needs, hospital deconditioning and its effects on the body, and the development of critical care myopathy. Additionally, applicable theory related to these conditions and their subsequent physical therapy needs are analyzed. Finally, empirically tested intervention strategies for these conditions are discussed, followed by a rationale for the chosen approach for proceeding with this case. 

Background

Obesity is a term that refers to a condition characterized by an excess of body fat (Racette, Deusinger & Deusinger, 2003). This condition is unique from simply being overweight, in that the latter may be caused by factors not related to high levels of body fat (Racette, Deusinger & Deusinger, 2003) Obesity can be determined by estimating an individual’s body mass index (BMI). This measure accounts for an individual’s body weight compared to normative standards for his or her height. While this statistic is somewhat contrary to the operational definitions of obesity and overweight, research (e.g., Racette, S. B., Deusinger, S. S., & Deusinger) has demonstrated that it is reliable in assessing obesity. An alternative approach to using BMI to determine obesity is to perform an actual body fat test, which is somewhat more complicated (Rochester, 2009). Obesity is defined as having a BMI of greater than 30 (Rochester, 2009).

Morbid obesity is a condition classified as having a BMI greater than 40 (Racette, Deusinger & Deusinger, 2003). This condition is named as such due to its high correlation to cardiovascular disease, diabetes and metabolic syndrome (Racette, Deusinger & Deusinger, 2003). Each of these conditions can result in death, and morbidly obese individuals are considered to be in a state of medical emergency (Racette, Deusinger & Deusinger, 2003). 

The health and economic burden of obesity has resulted in researchers (e.g., Wang, McPherson, Marsh, Gortmaker & Brown, 2011) labeling this condition nothing short of a healthcare crisis in the United States. According to Wang and colleagues (2011), obesity has resulted in an estimated $50 million increase in healthcare spending each year over the past decade and is believed to continue to expand in the near future. Obesity is directly related to increased risk of cardiovascular disease, diabetes and certain types of cancer, making this epidemic an even larger concern (Wang et al., 2011). Unfortunately, no end is currently in sight, although a number of intervention efforts have been proposed to alleviate this concern. Among the most potentially influential strategies for reducing obesity is physical rehabilitation and exercise (Helen & Lundberg, 2005). 

One of the factors that are highly related to morbid obesity is physical deconditioning (Helen & Lundberg, 2005). Physical deconditioning refers to the deterioration and atrophy of muscle, both within the heart and throughout the skeletal system (Rochester, 2009). This condition serves as both a cause and symptom of morbid obesity, and results in a significantly debilitating physical state. Additionally, physical deconditioning can induce a reduction in lean body mass, poor oxygen uptake, reduced cardiac output, stroke volume, deep vein thrombosis, and ability to withstand exercise (Rochester, 2009). As morbidly obese patients generally are limited to periods of prolonged bed rest, physical deconditioning produces an impaired ability to function (Helen & Lundberg, 2005). Hospital deconditioning is a specific type of physical deconditioning in which patients with alternative ailment experience muscular atrophy as a result of an extended in-patient stay (Helen & Lundberg, 2005). Physically recovering from this condition presents a tremendous challenge to both patients and physical therapists (Racette, Deusinger & Deusinger, 2003). 

In some situations, patients who are admitted for extended in-patient stays also experience critical care myopathy, or a syndrome in which these patients experience a general feeling of weakness or immobility throughout the body (Rochester, 2009). This condition is separate from hospital deconditioning, as its symptoms seem to be related to alternative causes (Burnham, Moss & Ziegler, 2005). Critical care myopathies remain somewhat of a mystery to researchers, as the underlying contributing factors to this condition are not currently understood (Burnham, Moss & Ziegler, 2005). 

Morbid obesity, physical deconditioning and critical care myopathy are related in many ways and require several of the same physical therapy intervention techniques (Rochester, 2009). As these conditions are commonly experienced in conjunction with each other, identifying evidence-based strategies for addressing their related symptoms may improve physical therapy practice within the critical care unit (Helen & Lundberg, 2005). Physical therapists face several challenges in performing rehabilitation programs within such units, and promoting long-term recovery necessitates identifying these challenges and adopting efficacious strategies for overcoming them (Helen & Lundberg, 2005). 

Each of these conditions may be associated with psychological and cognitive symptoms as well (Rochester, 2009). Early rehabilitation strategies are critical in preventing and treating critical care-induced deconditioning or myopathy (Rochester, 2009). Furthermore, as patients may need to acquire sufficient mobility to perform bed to chair transfers, in-hospital transfers and transport themselves throughout the room, early rehabilitation efforts may facilitate these processes (Burnham, Moss & Ziegler, 2005). While research has emerged (e.g., Rochester, 2009) supporting the effects of early rehabilitation strategies for intensive care unit (ICU) acquired weakness, such as range of motion exercises and ambulation, research has yet to explore strategies specific to the combination of morbid obesity, hospital deconditioning and critical care myopathy. Understanding the specific pathophysiological factors related to these conditions, including their similar causes and impacts on the body, may help researchers adopt more individualized treatment programs (Helen & Lundberg, 2005). 

Pathophysiology

The pathophysiology of morbid obesity is complex because of its multiple contributing factors (Racette, Deusinger & Deusinger, 2003). As genetics, dietary, environmental and lifestyle factors can all contribute to this condition, understanding the pathophysiological maintenance of obesity is dependent on the interrelation of several underlying mechanism (Rochester, 2009). Hormonal factors play a role in regulating appetite and food intake and serve as a mechanism for perpetuating obesity from a behavioral standpoint (Racette, Deusinger & Deusinger, 2003). Additionally, the storage of triglycerides in adipose tissues is regulated through insulin, and genetic or environmental resistance to this chemical may subsequently result in obesity (Helen & Lundberg, 2005). Finally, cognitive and neurochemical factors may facilitate obesity, such as the activation of melanocortin pathways in the brain (Helen & Lundberg, 2005). A response in the hypothalamus stimulates the production of the chemical leptin, which prevents the inhibition of appetite mechanisms (Racette, Deusinger & Deusinger, 2003). 

One of the major resulting co-morbidities of morbid obesity is physical deconditioning (Friedrich, 2006). Due to its many parallels to morbid obesity, physiological responses to these conditions are commonly viewed from the same pathophysiological framework (Rochester, 2009). Chronic physical deconditioning plays a vital role in the pathophysiology of morbid obesity, and these conditions must be cared for accordingly (Friedrich, 2006). The physical deconditioning that occurs in the heart muscle, such as vasoconstriction, atrophy in the heart’s left ventricle, and fatty plaque buildup in the arteries perpetuates obesity and reduced physical mobility (Helen & Lundberg, 2005). Therefore, these conditions often induce a negative pathophysiological feedback loop (Helen & Lundberg, 2005). 

The specific pathophysiology of critical care myopathy is not fully understood (Hermans, De Jonghe, Bruyninckx, & Berghe, 2008). Perhaps the most detrimental result of this condition is its ability to induce heart and other organ failures, potentially resulting in death (Hermans et al., 2008). Additionally, reduced blood and nerve circulation is critical to the pathogenesis of this condition and may be mediated by impairments in muscle function (Burnham, Moss & Ziegler, 2005). Furthermore, patients with severe critical care myopathy experience severe deficits in energy metabolism, including reductions in oxygen uptake (Hermans et al., 2008). Furthermore, a reduced production of hormones due to this state of physical inactivity can exacerbate muscular weakness and promote increased atrophy (Hermans et al., 2008).

Recent research (e.g., Hermans et al., 2009) has discovered that critical care myopathy is associated with oxidative stress and can induce disrupted breathing patterns. This poor ventilation further compounds the poor blood and oxygen circulation already occurring (Friedrich, 2006). Critical care myopathy shares similarities with morbid obesity in its multifaceted pathophysiological pathways (Burnham, Moss & Ziegler, 2005). These multiple contributing factors and underlying mechanisms makes designing effective physical rehabilitation programs particularly difficult (Helen & Lundberg, 2005). The potential detrimental effects of some rehabilitative efforts on physical systems can counter its perceived advantages (Helen & Lundberg, 2005). Therefore, designing efficacious rehabilitative strategies requires careful monitoring of symptoms and attention to changes in patients’ ventilation, cardiovascular function, muscular weakness and physical mobility (Friedrich, 2006). The following section reviews major theory surrounding the understanding and treatment of critical care myopathy related to morbid obesity. 

Theory 

One condition that has received attention in recent research is that of the obesity hypoventilation syndrome (Olson & Zwillich, 2005). This syndrome, brought on by both morbid obesity and critical care myopathy, is commonly undiagnosed and untreated in physical rehabilitative efforts (Olson & Zwillich, 2005). According to one major theoretical framework, obesity results in a number of subsequent related conditions, including leptin insensitivity and impaired respiratory system mechanics. This impaired respiration can subsequently result in increased work of breathing and impaired ventilation. The interaction with various respiratory mechanics, ventilation, sleep-related respiration and hormonal sensitivity can influence physical manifestations, as well as treatment needs (Olson & Zwillich, 2005). Obesity hypoventilation syndrome occurs in a cyclical pattern, in which the resulting hypoxemia and hypercapnia can induce sleep deprivation, impaired respiration and chronic damage to ventilator drive that further induces hypoxemia (Friedrich, 2006). 

Theory surrounding treatment approaches and intervention methods related to obesity hypoventilation syndrome is lacking (Masa et al., 2001). This is perhaps due to the fact that the mechanism by which this syndrome induces respiratory failure is not currently understood (Masa et al., 2001). However, defects in the respiratory controller seem to play a significant role in causing this state (Masa et al., 2001). 

Treating obesity-related critical care myopathy and its resulting symptoms and co-morbidities require a multidimensional approach, similar to that of Racette, Deusinger and Duesinger (2003). According to these researchers, these conditions are brought on by a complex web of interacting mechanisms, and long-term treatment requires a combination of evidence-based strategies for alleviating symptoms and promoting recovery (Rochester, 2009). For example, Racette and colleagues’ (2003) model for treating obesity incorporates a three-pronged approach of dietary intervention, behavior modification and physical rehabilitation. These researchers acknowledge that physical rehabilitation is generally not effective in isolation and works best in conjunction with dietary and psychological strategies to weight loss (Racette et al., 2003). This idea can be transferred to the treatment of critical care myopathy as well, in which regaining mobility and recovering physical strength should not be limited to just physical therapy (Friedrich, 2006). An effective physical therapy intervention is one that is holistic in nature and caters to the patient’s specific clinical needs (Friedrich, 2006).

The theory of bioenergetics failure causes additional consideration of treatment strategies for critical care myopathy and obesity in the hospital environment (Latronico et al., 2007). Considered to be a relevant explanatory model for morbid-obesity-related critical care myopathy, this theory suggests that the sudden decrease in compound muscle action potential (CMAP) is related to bioenergetic factors (Latronico et al., 2007). This action potential is what regulates the muscle’s ability to produce a contraction and is controlled by nervous impulses and energy chemicals within the body. The relationship between bioenergetic failures and reduced muscular functioning highlights the need to incorporate a multidimensional treatment approach to critical care myopathy interventions (Latronico et al., 2007). The following section discusses intervention strategies for critical care myopathy, specifically emphasizing those related to morbid obesity. 

Intervention Strategies

Friedrich (2006) conducted a seminal review of intervention strategies for critical care myopathy. While the research in this area is scarce, this author also drew on literature from adjacent fields to examine the efficacy of various treatment approaches to this condition. One of the strategies reviewed was the use of electrophysiology to diagnose causes of myopathy and design more effective treatments. As recent research (e.g., Rochester, 2009) had posited the potential efficacy of this intervention strategy, the current author explored the existing evidence to support its use. Friedrich (2006) discovered that the use of pathophysiology and the search for pathomechanisms is pivotal in identifying specific intervention targets for clinical care myopathy. Specifically, these targets may include an increased inflammatory response throughout the body, higher levels of proteolysis and the decreased capacity for antioxidation (Friedrich, 2006).  Muscle weakness is a result of impairments in the excitation-contraction-coupling at the cellular level, and this condition is mediated by critical illness (Friedrich, 2006). According to Friedrich (2006), intervention strategies should be targeted at alleviating specific symptoms related to these signs.

Interestingly, Morris and Trinder (2002) found that the use of electrophysiology provides little added benefit to the diagnosis and treatment of crucial care myopathy. According to these authors, the various electrophysiological alterations that occur as a result of clinical illness are too varied to be indicative of specific myopathic symptoms (Morris & Trinder, 2002). Similarly, Burnham, Moss and Ziegler (2005) assert that these signs can be highly varied and related to multiple factors. However, these authors suggest that the prevalence of myopathies in critically ill patients is higher than previously thought. According to Burnham, Moss and Ziegler (2005), the influx of glutamine serves as, perhaps, the most indicative sign of myopathy and demonstrates that intervention is needed. Intervention strategies should be holistic and target both primary and secondary strategies (Burnham, Moss & Ziegler, 2005). Primary prevention strategies include drugs, such as glutamine and glutathione, while secondary strategies physical therapy rehabilitation and nutritional efforts to improve chemical imbalances (Burnham, Moss & Ziegler, 2005). 

Hermans, De Jonghe and Bruyninckx (2009) reviewed intervention strategies for alleviating symptoms of critical care myopathy. These authors specifically sought to identify strategies that were effective for reducing neuromuscular complications that were acquired during prolonged hospital stays. After clinical trials with more than 800 patients, these authors examined the effects of intensive versus conventional therapies and corticosteroids. Results demonstrated that intensive insulin therapy was substantially more effective in improving ventilation and conditions related to respiratory distress syndrome (Hermans, De Jonghe & Bruyninckx, 2009). These authors concluded that this review serves as support for intensive insulin therapy for improving ventilator mechanics in patients with critical care myopathy (Hermans, De Jonghe & Bruyninckx, 2009). 

While the above review provides insight into the therapeutic effects of insulin in treating respiratory impairments, a significant gap in the literature exists regarding the alleviation of hypoglycemia risk (Hermans, De Jonghe & Bruynincks, 2009). Additionally, there is limited research investigating physical therapy interventions for muscular impairments in cases of critical care myopathy (Hermans, De Jonghe & Bruynincks, 2009). For example, little is known regarding the efficacy of range of motion and flexibility exercises, as well as functional mobility training for individuals who have acquired myopathy due to prolonged deconditioning (Hermans, De Jonghe & Bruynincks, 200). Additionally, strategies such as pressure relief positions and the use of bariatric walkers need to be explored as potential secondary approaches for improving symptoms of critical care myopathy (Cup et al., 2007). The evidence supporting these rehabilitative strategies has been widely documented in similar fields (Cup et al., 2007). Therefore, it is somewhat surprising that this topic has been yet to be explored in great detail in the case of clinical care myopathies. The information gained from exploring these strategies further has the potential to improve and individualize current myopathy therapies (Hermans, De Jonghe & Bruynincks, 200). 

Rationale for Intervention 

Based on the lack of research described above, the current intervention intends to draw on multiple physical rehabilitation strategies to alleviate symptoms related to critical care myopathy. As existing strategies for improving symptoms related to critical care cardiomyopathy and deconditioning have largely emphasized medication and drug therapies, the aim of the current case is to supplement this regiment with bedside physical therapy. Cup and colleagues (2007) suggested that muscle strengthening exercises, aerobic exercises, lifestyle modifications and combinations of these approaches were effective in preventing and treating other forms of neuromuscular diseases in a hospital setting. Therefore, this intervention aims to utilize similar approaches in the treatment of an elderly Caucasian woman with severe deconditioning and myopathy.

Based on the suggestions of Cup and colleagues (2007), as well as the personal discretion of the current author, this intervention will explore a range of physical rehabilitative strategies. These strategies will include activities to improve range of motions (ROM), flexibility, functional mobility training in activities of daily living and self (ADSL) care. Additionally, this intervention will include the use of necessary equipment, such as a bariatric bed, wheelchair and walker. Pressure relief devices will also be used for pressure relief position. The patient will be educated regarding home practice strategies and will be taught how to perform self-detection tests as well. Finally, this intervention program will include social and lifestyle support, such as family involvement, education, fall support and secondary prevention methods. The specific content of this intervention is discussed in more detail below.  

Explanation of Proposed Examination

According to the American Physical Therapist Association’s (APTA) Guide to Physical Therapist Practice (2003), this patient falls under cardiovascular/pulmonary pattern A. Additionally, according to APTA criteria, this patient fits under primary prevention/risk reduction for cardiovascular/pulmonary disorders and integumentary pattern A. This pattern reflects primary prevention/risk reduction for integumentary disorders. This section outlines the evaluative and diagnostic methods, drawing on APTA (2003) guidelines. Appropriate references and tests are cited where necessary.

Evaluation

Evaluation measures are all to be made during the initial and discharge evaluations, and are included as follows: 

• Aerobic capacity and endurance

• Anthropometric characteristics

• Circulation and ventilation

• Muscular performance

• Range of motion performance

• Integumentary integrity

Initial evaluation will include history taking, systems review and the aforementioned tests and measures. Full history taking will include general demographics, social history, employment status, growth and developmental issues, environmental issues, general health, social habits, familial background and history, medical and surgical history, current concerns, functional status, medications and any other relevant clinical tests (APTA, 2003). Systems review will include documentation of data related to cardiovascular and pulmonary system functioning, integumentary issues, musculoskeletal system and neuromuscular functioning (APTA, 2003). 

Aerobic capacity and endurance will be assessed to determine capacity during functional activities, as well as during exercise testing. Furthermore, these tests will be employed to assess oxygen demand and pulmonary functioning during rest and exercise. Similarly, circulation assessments of the arterial, venous and lymphatic systems will be implemented to determine cardiovascular signs and symptoms. Additionally, these tests may provide an indication of physiological responses to positions changes (APTA, 2003).

Body composition tests will be assessed to determine changes on body fat, weight, and body dimensions as a result of the intervention. Furthermore, these tests may provide an indication of edema (APTA, 2003). Integumentary integrity will be assessed through examining activities, positioning and scarring of the skin. Additionally, devises that may be influencing trauma to the skin will be evaluated (APTA, 2003).

A multitude of ROM and muscular performance tests will be implemented to assess functionality in these areas throughout the course of the intervention. Muscle performance tests will include electrophysiological integrity, strength, power, endurance and muscular tension (APTA, 2003). These outcomes will be evaluated during both functional activities and at rest. ROM performance will be assessed by determining functional ROM, active and passive movement of the joints, length of the muscles, extensibility of the soft tissues and overall flexibility of the joints (APTA, 2003).

This evaluation process will follow the recommendations implemented by the APTA (2003) regarding perspectives on documentation and data collection. According to the APTA (2003), evaluation is considered a thought process that is not necessarily limited to formal documentation of assessment data. This process may, however, include recording of any existing impairments related to these tests, as well as participation limitations or inability to perform an activity (APTA, 2003). A problem list will be created in such cases, as well as a statement of the evaluation of critical factors related to the client’s status (APTA, 2003).

Diagnosis

In accordance with the APTA (2003), diagnoses will be documented, and relevant data will be gathered to form a specific prognosis and plan of care. The documentation of the diagnosis will be decided by the lead physical therapist. This documentation may consist of any limitations, prohibitions or restrictions related to joint function and mobility, muscular performance, neuromuscular functioning or ROM (APTA, 2003). Additionally, this documentation may be related to impairments in motor and sensory function or other related disorders of the nervous system (APTA, 2003). Cardiovascular and aerobic impairments may play a role in the diagnosis, such as the dysfunctions in the cardiovascular pump (APTA, 2003). Finally, issues related to skin involvement and scar formation will be assessed to determine integumentary integrity damage (APTA, 2003). 

Diagnostic information will be gathered to form a prognosis to be included in the plan of care (APTA, 2003). This plan of care includes the primary goals of the intervention, as well as the statement of purpose regarding the specific interventions. A proposed timeframe and implementation of therapy is presented as well, followed by the excepted date of discharge (APTA, 2003). In the current case, the primary outcome goals are to achievement significant improvements in the physical assessments described above (i.e., aerobic capacity and endurance; anthropometric characteristics; circulation and ventilation; muscle performance; ROM in the trunk; and integumentary integrity). The specific diagnostic instruments include: ADLS scales, Borg ratings, BMI and waist circumference, muscle performance testing, goniometry, flexibility tests and Braden scale assessments. The current intervention aims to achieve these goals through a range of physical rehabilitative strategies and lifestyle modifications, which are discussed in greater detail below. The duration of the current intervention is six weeks, at which point the patient is expected to be discharged into a home care setting. 

Intervention

The current intervention will utilize a holistic approach to relieving the physical symptoms of the current patient’s deconditioning and myopathy. Physical rehabilitative strategies will include activities to improve ROM, flexibility, strength, and functional mobility. Research (e.g., Cup et al., 2007) has demonstrated that these activities are efficacious for improving both neurological and muscular symptoms related to neuromuscular disease in a clinical setting. Specifically, these activities will include muscle strengthening exercises that utilize the patient’s body weight and aim to promote basic functioning. Although the effect of these exercises was reported to be minor, patients who adhered to these exercises experienced improved quality of life (Cup et al., 2007).

Devices used will include a bariatric bed, bariatric wheelchair and bariatric walker. Additionally, pressure relief devises and pressure positioning will be used to relieve pain. A bariatric bed is a device designed for patients recovering from bariatric surgery and can help patients experience improved functioning and mobility during the recovery process (Cup et al., 2007). Additionally, the, bariatric wheelchair and walker will promote improved ADSL during the early treatment phase as the patient regains neuromuscular and respiratory functioning (Di Lima, Hildenbrandt & Schust, 1996). Pressure relief strategies will be employed to prevent sores and ulcers. These strategies will be conducted in accordance with Di Lima, Hildenbrandt and Schust (1996).

Lifestyle modification factors will include educational strategies for both the patient and her family regarding fall prevention and general safety. Research (e.g., Rosenblatt & Grabiner, 2010) has demonstrated that obese individuals, particularly elderly women, experience an increased risk of serious falls. These falls can be dangerous, and preventative strategies can include increased awareness of risk factors and exercises for improving strength and balance (Rosenblatt & Grabiner, 2010). Cup and colleagues (2007) also demonstrated that including family and friends in intervention efforts significantly improved their efficacy in improving treatment outcomes for patients with neuromuscular diseases.

Secondary prevention efforts will include educational strategies regarding complications such as deep venous thrombosis, pneumonia and debility. Additionally, the patient and her family will be educated regarding signs and symptoms of infections. Finally, a home exercise program will be prescribed, and the patient will be required to monitor her adherence to this program. The total

The intention of this intervention is to explore a holistic and multifaceted approach to treating an elderly Caucasian patient with severe deconditioning and myopathy. Due to the lack of research regarding this topic, this intervention serves as a preliminary assessment of physical therapy for a patient with these respective symptoms. The total expected intervention duration is six weeks, and this program will be consistently monitored and evaluated throughout.

Outcome Measures

The assessment of aerobic capacity and endurance was selected, as previous research (e.g., Helen & Lundberg, 2005) has demonstrated that ventilation suffers as a result of deconditioning and crucial care myopathy. Therefore, improving respiratory mechanics and physiology is a primary intervention aim. This intervention will specifically utilize activities of daily living (ADL) scales, general daily observations, and Borg ratings of perceived exertion to assess exercise intensity. The ADL scale is a 20-item assessment of independent functioning that evaluates individuals’ ability to perform activities such as shopping, bathing and transportation (Bucks, Ashworth, Wilcock & Siegfried, 1996). This instrument has been used to assess functioning in individuals with a variety of conditions and achieved sufficient reliability and validity scores (Buckst et al., 1996). Results from an extensive evaluation of the ADL instrument, this assessment received a test-retest reliability rating of r = 0.95, p <0.001 (Bucks et al., 1996). Additionally, Bucks and colleagues (1996) report that the instrument displayed sufficient face validity and concurrent validity among its multiple subscales, although the date for these findings was not revealed. 

The Borg scale is an instrument designed to assess perceived exertion in response to physical activity (Pfeiffer, Pivarnik, Womack, Reeves & Malina, 2002). This instrument provides an indication as to an individual’s psychological and physical adaptation to increased physical activity and may indicate the efficacy of a particular physical rehabilitative intervention. According to Pfeiffer and colleagues (2002), the Borg scale has demonstrated reliability estimates as high as r = 0.95, p < 0.001, as well as validity coefficients of 0.86 and 0.89 for evaluating maximum heart rate and volume of oxygen consumption, respectively. Therefore, this instrument appears to be efficacious in predicting physiological response to exercise (Pfeiffer et al., 2002). 

Anthropomorphic characteristics will be assessed to document changes in body composition and fat percentage throughout the course of the intervention. Specifically, these assessments will include body mass index (BMI) and waist circumference. Although neither assessment targets body fat specifically, these two measurements provide a fairly accurate indicator of body fat and obesity when combined (Janssen, Heymsfield, Allison, Kotler & Ross, 2002). For example, Janssen and colleagues (2002) demonstrated that the combination of BMI and waist circumference explained a more substantial portion of the variance in abdominal fat percentage than either waist circumference or BMI by itself. While BMI appears to be a stronger predictor of body fat, the combination of these two variables offers a much higher validity rating (Janssen et al., 2002). Assessing body fat in this manner is more convenient and reliable than alternative measures and provides an indication of body compositional changes in response to a physical therapy rehabilitation program (Janssen et al., 2002). The patient has also been referred to more natural remedies for curative treatment. 

Similar to aerobic capacity, this intervention will assess the patient’s circulation and ventilation patterns. These measures will be included to provide a more accurate indication of the patient’s respiratory function and recovery (Janssen et al., 2002). Specifically, the patient’s blood pressure (BP), heart rate (HR) and respiratory rate (RR) will be consistently evaluated during the six-week intervention. Similar to body composition, the combination of these measurements provides an accurate estimation of a patient’s cardiorespiratory functioning, as well as adaptations to this system in response to physical rehabilitation (Parati, Saul, Di Rienzo & Mancia, 1995). As a client achieves increased fitness, his or her heart rate, blood pressure and respiratory rate should decrease due to physiological adaptations in the heart, arteries and lungs (Parati et al., 1995). These adaptations include hypertrophy in the left ventricle, dilation of the arteries and hypertrophy of the inspiratory muscles (Parati et al., 1995). 

Muscular performance measures will include manual muscle tests of the trunk as well as core control testing to assess core stability and musculature. These tests are included for their minimal invasiveness and accuracy in evaluating general muscular functioning (Helene & Lundberg, 2005). Research (e.g., Helene & Lundberg, 2005) has demonstrated that these tests are effective in muscular testing for injuries with spinal cord injuries, thus, they were considered appropriate for the current case study as well. Additionally, range of motion tests will include goniometry, relative flexibility testing and palpation. Goniometry is a measurement that assesses ROM of the extremities and provides an indication of improved muscular and joint functioning in response to physical therapy rehabilitation (Gajdosik & Bohannon, 1987). In a review of studies utilizing this method, Gajdosik and Bohannon (1987) found that this test achieved reliability scores consistently greater than r =0.9, p. < 0.05, as well as consistently high validity ratings.  Relative flexibility testing is a general strategy referring to flexibility measures of various muscle groups, while palpation is a test used to assess pain and bone abnormalities (Gajdosik & Bohannon, 1987). 

The patient will be evaluated for impaired integumentary integrity according to the physical therapist’s examination of skin involvement and scar tissue, in accordance with the recommendations of the APTA (2003). This evaluation will be conducted according to the Braden scale, a chart that predicts pressure sore risk based on a number of patient factors. When examined for predictive ability, Bergstrom, Braden, Kemp, Champagne and Ruby (1998) found that this instrument was highly predictive of pressure ulcers (p = 0.0001). Additionally, this instrument has been found to have a 100% sensitivity rating, indicating that it is highly valid for assessing pressure ulcers (Ramundo, 1995).

Results

Results from this intervention demonstrated that the patient experienced improvements in muscular performance, range of motion and integumentary integrity, which was sustained during the six weeks of the treatment. Immediate improvements were witnessed muscular performance tests and core functioning, suggesting that the physical rehabilitation strategies provided immediate neuromuscular improvements (Hermans, Jonghe & Bruyninckx, 2009). Additionally, ROM tests suggest that this patient experienced significantly enhanced flexibility and increased self-functioning as a result of this intervention. Finally, this patient reported fewer pressure ulcers or bedsores, and integumentary integrity was improved. This finding suggests that the pressure relief and positions strategies were effective in maintaining tissue health (Hermans, Jonghe & Bruyninckx, 2009).

Conversely, this patient did not achieve any significant improvements in BMI, waist circumference, ventilation, aerobic capacity, or endurance. These findings suggest that the current intervention was not effective in achieving gains in cardiorespiratory functioning within the six-week time frame allotted. Additionally, the current intervention did not contain any components that would conceivably enhance cardiorespiratory functioning, thus, obviating the need for significant evaluation of these characteristics. As impaired ventilation and respiration are well documented in patients with obesity, high cholesterol, deconditioning and myopathy, and logical advancement to the current intervention would be to employ aerobic exercises in an effort to improve these symptoms. According to Cup and colleagues (2007), aerobic exercise is a critical component of a holistic deconditioning program. Similarly, the lack of significant improvement in BMI and waist circumference is likely a result of both the short duration of the intervention and the lack of aerobic conditioning strategies. While the patient experienced improved functional status, incorporating aerobic exercises may have resulted in superior ventilation and circulation (Hermans, Jonghe & Bruyninckx, 2009).

Discussion

The primary objective of this case study was to examine the efficacy of a physical therapy rehabilitation program for a patient with morbid obesity, severe deconditioning and myopathy. Specifically, the results of this case study were intended to provide insight as to the specific needs of the bariatric population to determine best-practice guidelines and intervention strategies for this population. Ultimately, it was hoped that these results would lead to improved efficacy of treatments for these patients and to a generally higher level of care. 

After performing the current intervention for a six-week duration, the current patient experienced a significant improvement in muscular performance tests, including functioning in the trunk and core region. This finding is consistent with the study hypothesis that the utilization of functional mobility training would be efficacious in improving the independence and muscle performance of the current patient. This finding confirms that of Cup and colleagues (2007), who demonstrated that a multifaceted intervention program can lead nearly immediate improvements in these outcomes. With the first few days of the intervention, this patient reported a higher level of independent mobility, as well as gains in strength and muscular endurance. 

Additionally, the improvements demonstrated in ROM and goniometry tests were consistent with previous findings (e.g., Cup et al., 2007). According to previous research (e.g., Cup et al., 2007), ROM training is a critical component of enhancing ADL, and can relieve pain and pressure placed on joints. Dynamic stretches and progressive ROM activities can restore proprioceptive sensitivity, as well as produce hypertrophy and tensile strength of the muscles, tendons and ligaments that support problematic joints (Hermans, Jonghe & Bruyninckx, 2009). While six weeks was not sufficient to achieve marked results, the incremental gains that were associated with the current patient suggested that the effects of these exercises take place fairly rapidly.

The improvements in integumentary integrity scores were also expected and consistent with previous research (e.g., Hermans, Jonghe & Bruyninckx, 2009). Integumentary integrity is predictive of pressure ulcers, and provides an indication of mobility, independent functioning and kinesthetic awareness (Hermans, Jonghe & Bruyninckx, 2009). The improvements in these scores suggest that the physical rehabilitation intervention was effective in encouraging a greater level of activity and reduced stagnation in the current patient. The increased daily activity served to relieve high-pressure and high-pain areas, as well as improve blood and oxygen circulation to these areas, thus, preventing tissue damage (Hermans, Jonghe & Bruyninckx, 2009). 

Although the current intervention was found to be effective for improve muscle performance and functioning, general independence and mobility and reduced pressure ulcers and pain, a number of limitations were also evident. First, the current patient did not achieve any improves in measures of cardiovascular or respiratory functioning. Although the lack of improvement in these areas was not expected, this finding can be explained by the fact that the current intervention did not include any activities that would logically target these physiological systems. Research (e.g., Cup et al., 2007) has demonstrated that cardiorespiratory gains are most effectively improved through aerobic exercise. Placing the cardiorespiratory system under a greater demand challenges the heart and lungs to make physiological and cellular adaptations that result in increased cardiac output and improved oxygen transport (Hermans, Jonghe & Bruyninckx, 2009). As the current intervention did not include any form of this exercise modality, the failure to achieve any noticeable gains in these areas supports this research. Future studies can advance on the current intervention by incorporating aerobic exercise into its methodology.

Furthermore, the lack of significant improvements in BMI and waist circumference was not expected, but can be explained by previous research (e.g., Rochester, 2009). According to Rochester (2009), reducing body fat is best achieved through aerobic exercise. While functional mobility training, ROM, and flexibility may result in some small improvements in percentage of lean body mass, these exercises should be combined with activities that target the cardiorespiratory system to maximize the oxidation of fat (Hermans, Jonghe & Bruyninckx, 2009). Similarly, the lack of noticeable reductions in BP, HR and RR suggest that the current intervention was not effective in targeting the cardiorespiratory system. While this finding was not desired, the lack of gains in this physiological system provides a possible direction for future research. 

An additional issue that is worth discussion pertains to the logistics of conducting a physical therapy intervention within an intensive care unity. Regardless of the cause of the admission to this unit, performing interventions in this setting is associated with an array of complexities that limit therapists’ ability to achieve all the gains they seek. According to Hodgin, Nordon-Craft, McFann, Mealer and Moss (2009), physical therapists can play a valuable role in reducing fatigue and weakness, as well as improving functional status of patients within such units. However, bureaucratic issues related to gaining access to the patient and transferring him or her into a supportive physical rehabilitation environment can hinder efforts to improve a number of physiological indicators of exercise (Hodgin et al., 2009). The current study found similar feasibility concerns when attempting to employ the desired intervention with this patient. This lack of access and mobility may have explained some of the limited findings related to BMI, waist circumference and cardiorespiratory gains (Hodgin et al., 2009). 

Overall, the current study achieved a number of positive effects and served to improve a variety of symptoms of deconditioning and myopathy. While this study also included a number of limitations, the contributions this intervention makes to the understanding of bedside physical therapy for obese individuals with severe deconditioning and myopathy. Due to feasibility concerns, achieving sufficient aerobic exercise proved to be a significant challenge in this intervention and the patient did not experience the level of improvement that was expected. Therefore, future interventions may consider including a more holistic approach to physical therapy, as well as adopt more creative ways to incorporate a range of physical activities. According to Cup and colleagues (2007), treating deconditioning requires a combination of muscle strengthening and flexibility, aerobic exercise and lifestyle modifications. Subsequent efforts to improve these conditions may consider drawing on Cup and colleagues’ (2007) framework to adopt more evidence-based practice strategies. 

Conclusion

The purpose of this case report was to document an intervention related to an elderly female patient with severe deconditioning, morbid obesity and critical care myopathy. As a result of these conditions, this patient has experienced a number of co-morbidities that have added to the complexity of her case. For example, this patient has reported cardiomegaly and multiple pulmonary emboli. Despite these varying symptoms, this patient is relatively independent and high functioning. In addition, she has supportive relatives nearby who can help monitor intervention efforts and home treatment strategies. Therefore, the purpose of this intervention was to explore strategies for improving the level of functionality in a patient with these symptoms.

Based on the lack of research regarding these specific conditions, this intervention adopted an exploratory approach, drawing on multiple bedside physical rehabilitative strategies. These included muscles strengthening and flexibility exercises, range of motion activities, and the use of assistive devices to improve individual functioning. Major outcome measures included aerobic capacity, endurance, BMI, waist circumference, muscle performance and ROM. Results indicated that this patient experienced improvements in muscle performance and ROM but did not experience any significant gains in aerobic capacity, ventilation, BMI, or wait circumference. These findings suggest that the current intervention was effective in improving neuromuscular functioning but did not effectively target the cardiorespiratory system. Additionally, this intervention was successful in improving ASDL measures and increasing the patient’s quality of life. Unfortunately, the lack of improvement found in circulation and ventilation illustrates a significant weakness in this study.

Future research can expand on the current intervention results by employing aerobic exercise in a deconditioning and myopathy intervention for a patient with morbid obesity. While the feasibility of performing such intervention strategies may pose as a significant challenge for physical therapists, the detriments in circulation and ventilation as a result of deconditioning necessitate innovative ways for targeting these variables. Similarly, aerobic exercise may have an indirect impact on BMI and waist circumference improvements, subsequently improving circulation and ventilation. Previous research has suggested that an effective physical therapy intervention for patients with myopathy and neuromuscular disease should include aerobic exercise, as well as muscle strengthening exercises. Additionally, future research should explore the impact of various lifestyle modification strategies on specific outcomes related to myopathy and deconditioning. The current intervention incorporated education strategies into its protocol but failed to include any outcome measures for these efforts. Future interventions should evaluate the effects of such educational and assessment strategies. 

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