Physical Therapy Principles and Methods Guide

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M013/4 Revision: 02 Page: 1 of 79
NATIONAL PHYSIOTHERAPY EXAM PREP GUIDE
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MEDICINE: It’S A NOBLE PROFESSION, IT SERVES HUMANITY
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PASSAGE TO THE USA, VIA CAPE OF NPTE.
NATIONAL PHYSIOTHERAPY EXAMINATION-PART-4
SPEC. BY: Abdulrehman S. Mulla
DATE: 03/21/2009
REVISION HISTORY
REV. DESCRIPTION CN No. BY DATE
01 Initial Release PT0013 ASM 04/25/2009

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TABLE OF CONTENTS PAGE
1.0 DIABETES AND METABOLIC HEALTH: .................................................................................................................................................. 5
1.1 OVERWEIGHT HAS IMPORTANT HEALTH CONSEQUENCES IN CHILDREN:.................................................................................... 5
1.2 IMPORTANTANCE OF PHYSICAL EDUCATION IN SCHOOLS: ............................................................................................................ 6
1.3 INFLUENCE OF PHYSICAL ACTIVITY ON HEALTH OUTCOMES IN THE FACE OF INCREASED BODY MASS;.............................. 6
1.4 METABOLIC SYNDROME: ....................................................................................................................................................................... 8
1.4.1 METABOLIC SYNDROME DEFINITION:.......................................................................................................................................... 8
1.4.2 CAUSES OF METABOLIC SYNDROME: ......................................................................................................................................... 9
1.4.3 PROBLEMS ASSOCIATED WITH METABOLIC SYNDROME: ....................................................................................................... 9
A. OBESITY AND FAT: ............................................................................................................................................................... 11
B. BODY MASS INDEX (BMI}: .................................................................................................................................................... 11
I. RISK OF ASSOCIATED DISEASE ACCORDING TO BMI AND WAIST SIZE:.............................................................. 11
II. DETERMINING YOUR BODY MASS INDEX (BMI): ...................................................................................................... 12
III. HIGH BLOOD PRESSURE:............................................................................................................................................ 13
IV. BLOOD FATS:................................................................................................................................................................. 13
V. INSULIN RESISTANCE: ................................................................................................................................................. 13
1.4.4 METABOLIC SYNDROME TREATMENT:...................................................................................................................................... 14
A. DIET: ....................................................................................................................................................................................... 14
B. EXERCISE: ............................................................................................................................................................................. 15
C. COSMETIC SURGERY TO REMOVE FAT: ........................................................................................................................... 16
D. DRUGS TO CONTROL CHOLESTEROL LEVELS, LIPIDS, AND HIGH BLOOD PRESSURE:............................................ 16
E. MESSAGE:.............................................................................................................................................................................. 17
1.5 THE LINK BETWEEN OBESITY AND DIABETES:................................................................................................................................. 18
1.5.1 PREVENTION: ................................................................................................................................................................................ 19
1.5.2 TREATMENT OPTIONS: ................................................................................................................................................................ 19
1.5.3 FACTS ABOUT DIABETES:............................................................................................................................................................ 20
A. ANSWER THE FOLLOWING:................................................................................................................................................. 21
2.0 OBESITY/BARIATRICS INCLUDING BARIATRIC EQUIPMENT AND EXERCISE IMPLICATIONS FOR THE OBESE: ..................... 22
2.1 BARIATRICS: .......................................................................................................................................................................................... 22
2.2 BARIATRIC SURGERY:.......................................................................................................................................................................... 23
2.2.1 OBESITY:........................................................................................................................................................................................ 23
A. FACTS ABOUT OBESITY:...................................................................................................................................................... 24
2.2.2 CONSIDERATIONS FOR BARIATRIC SURGERY: ....................................................................................................................... 25
2.2.3 BARIATRIC EQUIPMENT AND EXERCISE IMPLICATIONS FOR THE OBESE: ......................................................................... 25
A. INDICATIONS FOR TREATMENT:......................................................................................................................................... 25
B. CHART REVIEW/MEDICAL HISTORY:.................................................................................................................................. 26
I. HISTORY OF PRESENT ILLNESS: ............................................................................................................................... 26
II. PAST MEDICAL HISTORY:............................................................................................................................................ 26
III. SOCIAL HISTORY: ......................................................................................................................................................... 26
IV. PRIOR FUNCTIONAL LEVEL:........................................................................................................................................ 26
C. EXAMINATION:....................................................................................................................................................................... 27
I. PHYSICAL STATUS: ...................................................................................................................................................... 27
II. FUNCTIONAL MOBILITY:............................................................................................................................................... 27
D. ASSESSMENT:....................................................................................................................................................................... 27
I. ESTABLISH DIAGNOSIS AND NEED FOR SKILLED SERVICE................................................................................... 27
II. PROBLEM LIST: ............................................................................................................................................................. 27
III. PROGNOSIS:.................................................................................................................................................................. 28
E. AGE SPECIFIC CONSIDERATIONS:..................................................................................................................................... 29
F. SURGICAL INTERVENTIONS:............................................................................................................................................... 29
I. ROUX-EN-Y GASTRIC BYPASS (RYGB): ..................................................................................................................... 29
II. LAP BAND:...................................................................................................................................................................... 29
III. PANNICULECTOMY:...................................................................................................................................................... 29
G. TREATMENT PLANNING / INTERVENTIONS:...................................................................................................................... 29
I. BED MOBILITY: .............................................................................................................................................................. 29
II. TRANSFER TRAINING:.................................................................................................................................................. 30
III. GAIT TRAINING/STAIRS:............................................................................................................................................... 30
IV. AEROBIC EXERCISES:.................................................................................................................................................. 30
V. RESISTED TRAINING: ................................................................................................................................................... 31
VI. PATIENT EDUCATION:.................................................................................................................................................. 31
H. FREQUENCY & DURATION:.................................................................................................................................................. 31
I. INPATIENT:..................................................................................................................................................................... 31

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II. OUTPATIENT:................................................................................................................................................................. 31
I. RE-EVALUATION: .................................................................................................................................................................. 31
J. DISCHARGE PLANNING:....................................................................................................................................................... 31
I. COMMONLY EXPECTED OUTCOMES AT DISCHARGE:............................................................................................ 31
II. TRANSFER OF CARE (IF APPLICABLE): ..................................................................................................................... 31
III. PATIENT’S DISCHARGE INSTRUCTIONS MAY INCLUDE:......................................................................................... 32
DME WEIGHT RESTRICTIONS........................................................................................................................................ 32
3.0 REHABILITATION FOR LYMPHATIC DISEASE: ................................................................................................................................... 33
3.1 DIAGNOSIS:............................................................................................................................................................................................ 34
3.2 TREATMENT OF LYMPHATIC VASCULAR DISEASES:....................................................................................................................... 35
3.2.1 DIAGNOSIS AND MANAGEMENT OF LYMPHATIC VASCULAR DISEASE: THE FUTURE PROMISE OF MOLECULAR
TREATMENT STRATEGIES: ....................................................................................................................................................................... 37
3.2.2 COMPLEX DECONGESTIVE PHYSIOTHERAPY:......................................................................................................................... 38
3.2.3 MANUAL LYMPHATIC DRAINAGE [MLD]: .................................................................................................................................... 39
A. THE HISTORY OF MANUAL LYMPHATIC DRAINAGE [MLD]: ............................................................................................. 39
B. THE BENEFITS OF MANUAL LYMPHATIC DRAINAGE: ...................................................................................................... 40
C. MLD PROCEDURE/TECHNIQUES: ....................................................................................................................................... 40
D. COMPREHENSIVE DECONGESTIVE THERAPY (CDT): ..................................................................................................... 41
4.0 TABLE OF MOTOR LEARNING AND TRAINING STRATEGIES:.......................................................................................................... 42
4.1 USE OF COGNITIVE AND METACOGNITIVE STRATEGIES IN MOTOR LEARNING:........................................................................ 42
4.2 ORGANISATION AND METHODS OF RESEARCH: ............................................................................................................................. 46
4.3 METHODS:.............................................................................................................................................................................................. 46
4.4 RESULTS: ............................................................................................................................................................................................... 47
4.5 SUMMARY: ............................................................................................................................................................................................. 49
4.6 CONCLUSIONS: ..................................................................................................................................................................................... 50
5.0 EXTENSIVE NEW GUIDELINES ON STANDARD/UNIVERSAL PRECAUTIONS:................................................................................ 51
5.1 STANDARD UNIVERSAL PRECAUTIONS POLICY: ............................................................................................................................. 51
5.2 ROLE OF STANDARD UNIVERSAL PRECAUTIONS:........................................................................................................................... 51
5.3 PURPOSE: .............................................................................................................................................................................................. 51
5.4 SCOPE: ................................................................................................................................................................................................... 51
5.5 RESPONSIBILITIES:............................................................................................................................................................................... 51
5.6 DEFINITIONS:......................................................................................................................................................................................... 52
5.6.1 SAFE WORKING PRACTICES:...................................................................................................................................................... 52
5.6.2 SPECIFIC METHODS AND PRACTICES:...................................................................................................................................... 54
5.7 TRAINING: .............................................................................................................................................................................................. 55
5.8 AUDIT TOOL FOR POLICIES AND PROCEDURES:............................................................................................................................. 56
5.9 UNIVERSAL PRECAUTIONS FOR INFECTION CONTROL AND PREVENTION:................................................................................ 58
5.9.1 INFECTION CONTROL:.................................................................................................................................................................. 58
5.9.2 BLOODBORNE PATHOGEN STANDARD: .................................................................................................................................... 58
5.9.3 TUBERCULOSIS (MTB):................................................................................................................................................................. 61
5.9.4 ISOLATION: .................................................................................................................................................................................... 61
A. ISOLATION GUIDELINES BY U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC): ............................. 62
5.9.5 RESPIRATORY ETIQUETTE PROGRAM:..................................................................................................................................... 63
A. RESPIRATORY HYGIENE/COUGH ETIQUETTE IN HEALTHCARE SETTINGS:................................................................ 63
1. VISUAL ALERTS:............................................................................................................................................................ 63
2. RESPIRATORY HYGIENE/COUGH ETIQUETTE:......................................................................................................... 63
3. MASKING AND SEPARATION OF PERSONS WITH RESPIRATORY SYMPTOMS:................................................... 64
4. DROPLET PRECAUTIONS: ........................................................................................................................................... 64
5.9.6 UNIVERSAL PRECAUTIONS/INFECTION CONTROL QUIZ: ....................................................................................................... 65
5.9.7 ABBREVIATIONS:........................................................................................................................................................................... 66
6.0 LOCOMOTOR TRAINING/BODY WEIGHT SUPPORT SYSTEMS:....................................................................................................... 67
6.1 ROBOTICS IN NEUROREHABILITATION: LOCOMOTOR TRAINING:................................................................................................. 67
6.2.1 INTENSIVE FUNCTIONAL LOCOMOTION THERAPY:................................................................................................................. 67
6.2.3 TRAINING PERIOD:........................................................................................................................................................................ 68
6.2.4 ADJUSTING THE AUTOMATED LOCOMOTOR TRAINING TO DIFFERENT PATIENTS:.......................................................... 69
6.2.5 BALANCE CONTROL: .................................................................................................................................................................... 69
6.2.6 DRIVING POWER:.......................................................................................................................................................................... 69
6.2.7 CONTROL SYSTEM: ...................................................................................................................................................................... 70
6.2.8 BODY WEIGHT SUPPORT SYSTEM:............................................................................................................................................ 70

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6.3 METHOD, APPARATUS AND SYSTEM FOR AUTOMATION OF BODY WEIGHT SUPPORT TRAINING (BWST) OF BIPED
LOCOMOTION OVER A TREADMILL USING A PROGRAMMABLE STEPPER DEVICE (PSD) OPERATING LIKE AN EXOSKELETON
DRIVE SYSTEM FROM A FIXED BASE: .......................................................................................................................................................... 71
6.2.1 ADVANTAGES OF AUTOMATED LOCOMOTOR TRAINING BASED THERAPY: ....................................................................... 77
6.3 EFFECTIVENESS OF AUTOMATED LOCOMOTOR TRAINING IN PATIENTS WITH CHRONIC INCOMPLETE SPINAL CORD
INJURY: A MULTICENTER TRIAL. ................................................................................................................................................................... 77
6.3.1 OBJECTIVE:.................................................................................................................................................................................... 77
6.5.2 DESIGN:.......................................................................................................................................................................................... 77
6.3.3 SETTING:........................................................................................................................................................................................ 77
6.3.4 PARTICIPANTS: ............................................................................................................................................................................. 77
6.3.5 INTERVENTION:............................................................................................................................................................................. 77
6.3.6 MAIN OUTCOME MEASURES:...................................................................................................................................................... 77
6.3.7 RESULTS:....................................................................................................................................................................................... 78
6.3.8 CONCLUSIONS: ............................................................................................................................................................................. 78
TOPICS COVERED:
Diabetes/metabolic syndrome
Obesity/bariatrics including bariatric equipment and exercise implications for the obese
Rehabilitation for lymphatic disease
Table of motor learning and training strategies
Extensive new guidelines on standard/universal precautions
Locomotor training/body weight support systems

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1.0 DIABETES AND METABOLIC HEALTH:
1.1 OVERWEIGHT HAS IMPORTANT HEALTH CONSEQUENCES IN CHILDREN:
Type 2 diabetes and metabolic syndrome
Incidence of type 2 diabetes is double that of Type 1 (NHANES III) in children (4.1/1000)
Undiagnosed hyperglycemia a major concern
Metabolic syndrome is present in ~ 4% of all adolescents but 30-50% in overweight children, and
for each ½ increase in BMI is associated with ~ 50% increase risk of metabolic syndrome (Weiss,
2004)
• The continued decline in the relevance of physical activity in youth
• More than 1/3 of 7-12 graders do not engage in regular physical activity
• More than 10% get no physical activity at all
• Only 16% of kindergarten programs have daily physical education.
• Almost 60% have PE once a week, 13% of schools provide PE less than once a week

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1.2 IMPORTANTANCE OF PHYSICAL EDUCATION IN SCHOOLS:
• 2 lbs of weight gain, independent of dietary change, is 7000 kcal of positive energy balance
• 7000/180 school days = 40 kcal/day
• 4 lbs = 80 kcal; 6 lbs = 120 kcal, etc.
• As importantly, what of the behavioral messages associated with decreased emphasis on
physical activity & fitness
1.3 INFLUENCE OF PHYSICAL ACTIVITY ON HEALTH OUTCOMES IN THE FACE OF
INCREASED BODY MASS;
People with diabetes are more likely to be overweight and to have high blood pressure and high cholesterol. At least one
out of every five overweight people has several metabolic problems at once, which can lead to serious complications like
heart disease. "Cardiometabolic risk" means that if you have one of these problems, you are at higher risk for having the
others.
The term "metabolic syndrome" describes cardiometabolic risk. The term has been used to describe cardiometabolic risk
factors,
• Primarily overweight,
• Type 2 diabetes,
• High cholesterol, and
• High blood pressure.
It's better to think of these factors simply as raising your cardiometabolic risk. There doesn't seem to be enough evidence
to say that these factors represent a "syndrome," and scientists don't even agree on what the various components of the
"syndrome" are. The important thing for you is to know whether you have any of these risk factors, and if so to take active
steps to improve them.

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1.4 METABOLIC SYNDROME:
An association between certain metabolic disorders and cardiovascular disease has been known since the
1940s. In the 1980s this association became more clearly defined and the term metabolic syndrome (also
known as syndrome X or the dysmetabolic syndrome) was coined to designate a cluster of metabolic risk
factors that come together in a single individual. In more current times, the term metabolic syndrome is
found throughout medical literature and in the lay press as well. There are slight differences in the criteria
of diagnosis - depending on which authority is quoted. Regardless, the concept of a clustering of risks
factors leading to cardiovascular disease is well accepted.
The main features of metabolic syndrome include insulin resistance, hypertension (high blood pressure),
cholesterol abnormalities, and an increased risk for clotting. Patients are most often overweight or obese.
Insulin resistance refers to the diminished ability of cells to respond to the action of insulin in promoting the
transport of the sugar glucose, from blood into muscles and other tissues. Because of the central role that
insulin resistance plays in the metabolic syndrome, a separate article is devoted to insulin resistance.
1.4.1 METABOLIC SYNDROME DEFINITION:
The definition of metabolic syndrome depends on which group of experts is doing the defining.
Based on the guidelines from the 2001 National Cholesterol Education Program Adult Treatment
Panel (ATP III), any three of the following traits in the same individual meet the criteria for the
metabolic syndrome:
1. Abdominal obesity: a waist circumference over 102 cm (40 in) in men and over 88 cm (35
inches) in women.
2. Serum triglycerides 150 mg/dl or above.
3. HDL cholesterol 40mg/dl or lower in men and 50mg/dl or lower in women.
4. Blood pressure of 130/85 or more.
Fasting blood glucose of 110 mg/dl or above. (Some groups say 100mg/dl)
The World Health Organization (WHO) has slightly different criteria for the metabolic syndrome:
1. High insulin levels elevated fasting blood glucose or elevated post meal glucose alone with at
least 2 of the following criteria:
2. Abdominal obesity as defined by a waist to hip ratio of greater than 0.9, a body mass index of
at least 30 kg/m2 or a waist measurement over 37 inches.
3. Cholesterol panel showing a triglycerides level of at least 150-mg/dl or HDL cholesterol lower
than 35 mg/dl.
4. Blood pressure of 140/90 or above (or on treatment for high blood pressure).
Note:
Metabolic syndrome is
quite common.
Approximately 20%-
30% of the population
in industrialized
countries have
metabolic syndrome.
By the year 2010, the
metabolic syndrome is
expected to affect 50-
75 million people in
the US alone.

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Metabolic syndrome results from eating a diet that has too many calories and too much saturated
fat, and not getting enough physical activity. You can lower your risk of heart disease and diabetes
by improving your eating habits, getting more physical activity and losing weight. If you smoke, you
should stop smoking.
1.4.2 CAUSES OF METABOLIC SYNDROME:
As is true with many medical conditions, genetics and the environment both play important
roles in the development of the metabolic syndrome.
Genetic factors influence each individual component of the syndrome, and the syndrome itself.
A family history that includes type 2 diabetes, hypertension, and early heart disease greatly
increases the chance that an individual will develop the metabolic syndrome.
Environmental issues such as low activity level, sedentary lifestyle, and progressive weight
gain also contribute significantly to the risk of developing the metabolic syndrome.
Metabolic syndrome is present in about 5% of people with normal body weight, 22% of those
who are overweight and 60% of those considered obese. Adults who continue to gain five or more
pounds per year raise their risk of developing metabolic syndrome by up to 45%.
While obesity itself is likely the greatest risk factor, others factors of concern include:
Women who are post-menopausal,
Smoking,
Eating an excessively high carbohydrate diet,
Lack of activity (even without weight change), and
Consuming an alcohol-free diet.
1.4.3 PROBLEMS ASSOCIATED WITH METABOLIC SYNDROME:
Metabolic syndrome is a condition that can pave the way to both diabetes and heart disease, two
of the most common and important chronic diseases.

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Metabolic syndrome increases the risk of type 2 diabetes (the common type of diabetes) anywhere
from 9-30 times over the normal population. That's a huge increase. As to the risk of heart
disease, studies vary, but the metabolic syndrome appears to increase the risk 2-4 times that of
the normal population.
Metabolic syndrome is associated with fat accumulation in the liver (fatty liver), resulting in
inflammation and the potential for cirrhosis.
The kidneys can also be affected, as there is an association with microalbuminuria -- the leaking of
protein into the urine, a subtle but clear indication of kidney damage.
CIRRHOSIS
I remember the face,
but I’ve forgotton
your name
DEMENTIA

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• Other problems associated with metabolic syndrome
• Obstructive sleep apnea,
• Polycentric ovary syndrome
• Increased risk of dementia with aging
• Cognitive decline in the elderly.
A. OBESITY AND FAT:
Being overweight or obese is a leading risk factor for type 2 diabetes. A healthy weight is
measured by your body mass index (BMI). A BMI of 25 or more is considered overweight. A
BMI of 30 or more is obese. If your BMI is over 25, you are at higher risk. In addition to how
much you weigh, where your extra fat is stored can also affect your health. Having an "apple
shaped" body (extra fat around your middle) rather than "pear shaped" body (extra fat around
your hips) raises risk for heart disease.
B. BODY MASS INDEX (BMI}:
Body mass index, or BMI, is a new term to most people. However, it is the measurement
of choice for many physicians and researchers studying obesity. BMI uses a
mathematical formula that takes into account both a person's height and weight. BMI
equals a person's weight in kilograms divided by height in meters squared. (BMI=kg/m2).
I. RISK OF ASSOCIATED DISEASE ACCORDING TO BMI AND WAIST SIZE:
BMI
Waist greater than Waist less than
or equal to
40 in. (men) or 35 in. (women)
Waist less than or equal to
40 in. (men) or
35 in. (women)
18.5 or less Underweight -- N/A
18.5 - 24.9 Normal -- N/A
25.0 - 29.9 Overweight Increased High
30.0 - 34.9 Obese High Very High
35.0 - 39.9 Obese Very High Very High
40 or greater Extremely Obese Extremely High Extremely High

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II. DETERMINING YOUR BODY MASS INDEX (BMI):
The table below has already done the math and metric conversions. To use
the table, find the appropriate height in the left-hand column. Move across the row
to the given weight. The number at the top of the column is the BMI for that height
and weight. Or, use our BMI calculator.
BMI (kg/m2) 19 20 21 22 23 24 25 26 27 28 29 30 35 40
Height (in.) Weight (lb.)
58 91 96 100 105 110 115 119 124 129 134 138 143 167 191
59 94 99 104 109 114 119 124 128 133 138 143 148 173 198
60 97 102 107 112 118 123 128 133 138 143 148 153 179 204
61 100 106 111 116 122 127 132 137 143 148 153 158 185 211
62 104 109 115 120 126 131 136 142 147 153 158 164 191 218
63 107 113 118 124 130 135 141 146 152 158 163 169 197 225
64 110 116 122 128 134 140 145 151 157 163 169 174 204 232
65 114 120 126 132 138 144 150 156 162 168 174 180 210 240
66 118 124 130 136 142 148 155 161 167 173 179 186 216 247
67 121 127 134 140 146 153 159 166 172 178 185 191 223 255
68 125 131 138 144 151 158 164 171 177 184 190 197 230 262
69 128 135 142 149 155 162 169 176 182 189 196 203 236 270
70 132 139 146 153 160 167 174 181 188 195 202 207 243 278
71 136 143 150 157 165 172 179 186 193 200 208 215 250 286
72 140 147 154 162 169 177 184 191 199 206 213 221 258 294
73 144 151 159 166 174 182 189 197 204 212 219 227 265 302
74 148 155 163 171 179 186 194 202 210 218 225 233 272 311
75 152 160 168 176 184 192 200 208 216 224 232 240 279 319
76 156 164 172 180 189 197 205 213 221 230 238 246 287 328

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III. HIGH BLOOD PRESSURE:
High blood pressure and type (2) diabetes often go hand-in-hand. High blood
pressure, or hypertension, increases your chances for heart disease, stroke, and
kidney disease. At least 40% percent of people with diabetes have high blood
pressure, which often leads to stroke. High blood pressure may make stroke more
likely in people with diabetes.
IV. BLOOD FATS:
Your body stores fat for future use for energy. Some of these fats, or lipids, are
stored in your blood. Some are good for the body, like HDL cholesterol, which helps
protect your heart. In general the higher your HDL, and the lower your LDL, the
better. Triglycerides are another kind of blood fat that raises your chances for a heart
attach or stroke if your levels are too high.
V. INSULIN RESISTANCE:
Insulin helps the cells of the body use sugar, or glucose, as fuel. Insulin resistance
occurs when the cells no longer respond well to insulin. The cells don't get the fuel
they need and the body keeps making more insulin in an effort to lower blood
glucose levels. Insulin resistance may be a key component of cardio-metabolic risk,
and may cause problems to develop.

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1.4.4 METABOLIC SYNDROME TREATMENT:
The major goals are to treat both the underlying cause of the syndrome, and also to treat the
cardiovascular risk factors if they persist. As has been discussed, the majority of people with
metabolic syndrome is overweight and led a sedentary lifestyle.
Lifestyle modification is the preferred treatment of metabolic syndrome. Weight reduction usually
requires a specifically tailored multifaceted program that includes diet and exercise. Sometimes
medications may be useful.
A. DIET:
A detailed discussion of diet therapies, pros and cons of various diets etc. is
beyond the scope of this article. However, there is now a trend toward the use of a
Mediterranean diet -- one that is rich in "good" fats (olive oil) and contains a reasonable
amount of carbohydrates and proteins (such as from fish and chicken).
The Mediterranean diet is palatable and easily sustained. In addition, recent
studies have shown that when compared to a low fat diet, people on the Mediterranean
diet have a greater decrease in body weight, and also had greater improvements in
blood pressure, cholesterol levels, and other markers of heart disease -- all of which
are important in evaluating and treating metabolic syndrome.

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B. EXERCISE:
A sustainable exercise program, fore example 30 minutes five days a week is
reasonable to start, providing there is no medical contraindication. (If you have any
special concerns in this regard, check with your doctor first.) There is a beneficial effect
of exercise on blood pressure, cholesterol levels, and insulin sensitivity, regardless of
whether weight loss is achieved or not. Thus, exercise in itself is a helpful tool in
treating metabolic syndrome.
AMPK activation, such as occurs in
many tissues during exercise or
glucose deprivation, phosphorylates
ACC and inhibits its activity.
Conversely, a sustained excess of
glucose, and possibly inactivity,
decrease AMPK phosphorylation
and activity and cause ACC
activation. In muscle, the pancreatic
beta-cell, and probably in other cells,
glucose availability also determines
the concentration of cytosolic citrate,
an allosteric activator of ACC and a
precursor of its substrate, cytosolic
acetyl-CoA. Such changes in citrate
occur rapidly (min) and may be
responsible for early changes in
malonyl-CoA concentration and for
sustained changes in malonyl-CoA
under conditions in which assayable
AMPK activity is not altered. ACC,
acetyl-CoA carboxylase; AMPK,
AMP kinase.

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C. COSMETIC SURGERY TO REMOVE FAT:
Some people may ask: Why not just have liposuction of the abdomen and remove
the large amount abdominal fat, which is a big part of the problem? Data thus far
shows no benefit in liposuction on insulin sensitivity, blood pressure, or cholesterol. As
the saying goes, "If it's too good to be true, it probably is." Diet and exercise are still the
preferred primary treatment of metabolic syndrome.
D. DRUGS TO CONTROL CHOLESTEROL LEVELS, LIPIDS, AND HIGH BLOOD PRESSURE:
If someone has already had a heart attack, his or her LDL ("bad") cholesterol
should be reduced below 100mg/dl. (Some experts now say it should be under
70mg/dl.) A person who has diabetes has a heart attack risk equivalent to that of
someone who has already one and so should be treated in the same way. What
remains controversial is whether metabolic syndrome should be considered a coronary
equivalent or not. If you have metabolic syndrome, a detailed discussion about lipid
therapy is needed between you and your doctor, as each individual is unique.
Blood pressure goals are generally set lower than 130/80. Some blood pressure
medications offer more than simply lowering blood pressure. For example, a class of
blood pressure drugs called ACE inhibitors has been found to also reduce the levels of
insulin resistance and actually deter the development of type 2 diabetes. This is an
important consideration when discussing the choice blood pressure drugs in the
metabolic syndrome.
The discovery that a drug prescribed for one condition, and has other beneficial
effects is not new. Drugs used to treat high blood sugar and insulin resistance may

17
have beneficial effects on blood pressure and cholesterol profiles. A class of drugs
called thiazolidinediones [pioglitazone (Actos) and rosiglitazone (Avandia)] also
reduces the thickness of the walls of the carotid arteries.
Metformin (Glucophage), usually used to treat type 2 diabetes, also has been
found to help prevent the onset of diabetes in people with metabolic syndrome. Indeed,
in my practice, I routinely discuss metformin with my patients who have metabolic
syndrome. Many of my patients who have insulin resistance associated with metabolic
syndrome opt for metformin therapy. However, there are currently no established
guidelines on treating metabolic syndrome patients with metformin if they do not have
overt diabetes.
E. MESSAGE:
• Part of our responsibility and commitment as health care professionals;
• Prevention in children and adolescents is critical; think families;
• Volume of physical activity and increased fitness have a synergistic effect on
weight loss and health outcomes;
• We typically under prescribe the volume of activity necessary for weight loss and
maintenance of weight loss;
• Fitness significantly improves health outcomes even in those who do not lose
weight or achieve ‘normal’ weight.
• Be an advocate - in the schools and in the community – programs, parks, trails and
access for all;

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1.5 THE LINK BETWEEN OBESITY AND DIABETES:
The prevalence of obesity is rising to epidemic proportions worldwide. In some countries, an
astonishing half of the population is overweight. Being overweight or obese seriously increases an
individual’s risk of developing other health problems such as type 2 diabetes, coronary heart disease, and
some forms of cancer.
In both men and women, the more overweight an individual is, the greater the risk of developing type 2
diabetes. The means by which excessive body fat causes type 2 diabetes is not clearly defined, but it
appears that excess fat increases insulin resistance, raising blood glucose levels and the likelihood of
developing diabetes. People with a greater amount of abdominal fat have a higher risk of developing the
condition.
Diabetes is the most preventable consequence of the obesity epidemic. Figures from the International
Obesity Task Force (IOTF) suggest that up to 1.7 billion of the world’s population are already at a
heightened risk of weight-related non-communicable diseases such as type 2 diabetes and cardiovascular
disease. In fact, the risk in type 2 diabetes appears to be mainly related to the increasing prevalence of
overweight and obese individuals worldwide. One in three Americans born today is predicted to develop
diabetes as a consequence of obesity.

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1.5.1 PREVENTION:
Although obesity can affect anyone, the main risk factors are high-fat, high-energy dense diets
and physical inactivity. Growing trends in many countries portray an ‘obesogenic’ society where
the consumption of high-fat, high energy dense food is preferred to healthy fresh fruit and
vegetables, and where the level of physical activity has dramatically been reduced or substituted
by the constant usage of motor vehicles.
The importance of eating a low-fat, low-energy dense diet and participating in physical activity
should be greatly promoted in order to reduce the risks of becoming overweight or obese. If these
habits are introduced in children, there is a greater chance that they will continue into adulthood.
Public health programmes should stress the importance of a healthy environment, promoting
improved diet and activity throughout communities. National programmes should be especially
aimed at improving education and awareness of obesity and its consequences in schools and in
youth recreational centres.
1.5.2 TREATMENT OPTIONS:
Weight management is the best strategy to prevent the development of type 2 diabetes.
Research has shown that even a small amount of weight loss can decrease or slow down the
risk of developing type 2 diabetes. Group therapy is advised to improve the psychological
approach to weight loss, and to maintain an appropriate weight. Drugs to assist weight loss
play a role in individuals for whom lifestyle changes alone may be insufficient to produce the
required weight loss.
“If exercise could be purchased in a pill, it
would be the single most widely
prescribed and beneficial medicine in
the nation.”
—Robert H. Butler

20
1.5.3 FACTS ABOUT DIABETES:
• There is an emerging global epidemic of diabetes that can be traced back to rapid
increases in overweight, obesity and physical inactivity.
• Total deaths from diabetes are projected to rise by more than 50% in the next 10 years.
Most notably, they are projected to increase by over 80% in upper-middle income
countries.
• It is important for people with diabetes to keep their long-term blood glucose levels (A1C)
below 7%, blood pressure below 130/80 and cholesterol below 200 to help stay healthy.
Few people with diabetes in this study kept these measures at healthy levels.
• The prevalence of obesity is rising to epidemic proportions at an alarming rate in both
developed and developing countries worldwide.
• Overweight and obesity affect over half the world’s population and diabetes rates are
climbing to 20% of all adults in many Middle Eastern, Asian, and Latin American
countries.
• Type 1 diabetes is characterized by a lack of insulin production and type 2 diabetes
results from the body's ineffective use of insulin.
• Type 2 diabetes is much more common than type 1 diabetes, and accounts for around
90% of all diabetes worldwide.
• Reports of type 2 diabetes in children - previously rare - have increased worldwide. In
some countries, it accounts for almost half of newly diagnosed cases in children and
adolescents.
• It is estimated that at least half of all diabetes cases would be eliminated if weight gain in
adults could be prevented.
• A third type of diabetes is gestational diabetes. This type is characterized by
hyperglycaemia, or raised blood sugar, which is first recognized during pregnancy.
• In 2005, 1.1 million people died from diabetes. The full impact is much larger, because
although people may live for years with diabetes, their cause of death is often recorded
as heart diseases or kidney failure.
• 80% of diabetes deaths are now occurring in low- and middle-income countries.
• Non-communicable diseases such as diabetes now account for more deaths each year
worldwide than AIDS.
• Lack of awareness about diabetes, combined with insufficient access to health services,
can lead to complications such as blindness, amputation and kidney failure.
• The twin epidemics of obesity and diabetes already represent the biggest public health
challenge of the 21st century.
• Diabetes can be prevented. Thirty minutes of moderate-intensity physical activity on most
days and a healthy diet can drastically reduce the risk of developing type 2 diabetes.

21
A. ANSWER THE FOLLOWING:
• Describe the prevalence and other important health trends associated with
cardiometabolic and chronic vascular disease across differing gender and ethnic
groups.
• Describe the association of metabolic risk factors for chronic disease risk, with
particular reference to cardiometabolic and vascular disease.
• Evaluate the evidence for exercise and nutritional strategies in the prevention or
remediation of cardiometabolic and vascular risk. (1), (2),
• Identify and evaluate practical clinical approaches in the assessment of exercise
endurance, body mass, and composition to optimize patient/client outcomes at risk
for, or diagnosed with metabolic disease. (click here for the best ), (1), (2), (3)

22
2.0 OBESITY/BARIATRICS INCLUDING BARIATRIC EQUIPMENT AND EXERCISE
IMPLICATIONS FOR THE OBESE:
2.1 BARIATRICS:
Bariatrics is a branch of medicine, created around 1965, that deals with the causes, treatment,
and prevention of obesity. Bariatrics may include such treatments as dietary counseling, exercise
programs, psychological approaches, or in cases of extreme health risk, bariatric surgery.
Medical bariatric treatments usually include diet and exercise regimens. A bariatric physician
diagnoses and treats medical conditions that accompany obesity, such as type-2 diabetes. Bariatric
physicians safely supervise weight loss using very low calorie diets and/or medications.
Two types of medication are currently available for the treatment of obesity. Bariatric physicians
may prescribe appetite suppressants, which are usually some type of amphetamine, and fat blockers,
like orlistat. Fat blockers keep fats from being absorbed in the intestines. When fat is present, food
moves more quickly through the intestines and other nutrients, including vitamins and minerals, are
not absorbed well.
Bariatric surgery is another option for the treatment of obesity. In the past, bariatric surgery was
risky and required permanent lifestyle changes of the people who had it. Bariatric surgery caused
malabsorption of essential vitamins and minerals. Without supplementation, nutritional deficiencies
and health problems such as anemia and osteoporosis developed. A new type of bariatric surgery,
gastric banding, is safer and easier.
Both obesity and treatment for obesity are associated with vitamin B12 deficiencies. Bariatric
physicians diagnose and treat vitamin B12 deficiencies before, during and after treatment. Most
bariatric surgeons instruct their patients to have vitamin B12 injections once a month after surgery.
It has declared obesity to be a worldwide epidemic, with nearly all developed nations reporting a
high incidence of obesity. Bariatric research is trying to discover the causes of obesity, and to identify
more effective treatments.
Bariatric research has uncovered some interesting vitamin deficiencies associated with obesity. It
is not known whether these deficiencies are the cause of obesity, or if they occur because of poor
diets among the obese. Vitamin D deficiency is frequently associated with obesity. In children,
Vitamin B12 deficiency occurs at least twice as often in obese children as in normal weight children.
In fact, the higher a child's BMI (body mass index), the more likely he or she is to have a vitamin B12
deficiency. It is not yet known if this also holds true with adults.

23
If you are or have been obese, you may have a vitamin B12 deficiency, whether or not you have
had bariatric surgery or taken bariatric medications. The B12 Patch is an easy and painless way to
get the vitamin B12 you need.
2.2 BARIATRIC SURGERY:
When weight increases to an extreme level, it is called morbid obesity. Obesity is associated with
diabetes, heart disease, high blood pressure, some types of cancer, and other medical problems.
Bariatrics is the field of medicine that specializes in treating obesity. Bariatric surgery is the term for
operations to help promote weight loss. Bariatric surgical procedures are only considered for
people with severe obesity and not for individuals with a mild weight problem. The October 19,
2005, issue of JAMA includes several articles about bariatric surgical procedures for the treatment
of obesity.
2.2.1 OBESITY:
The body mass index (BMI) is a standard way to define overweight, obesity, and morbid
obesity. The BMI is calculated based on a person's height and weight—weight in kilograms
(2.2 pounds per kilogram) divided by the square of height in meters (39.37 inches per
meter). A BMI of 25 or more is considered overweight; 30 or more, obese; and 40 or more,
morbidly obese. Bariatric surgery may be offered to patients with severe obesity when
medical treatments, including lifestyle changes of healthful eating and regular exercise,
have not been effective.

24
A. FACTS ABOUT OBESITY:
• Globally, there are more than 1 billion overweight adults, at least 300 million of
them obese.
• Obesity and overweight pose a major risk for chronic diseases, including type 2
diabetes, cardiovascular disease, hypertension and stroke, and certain forms of
cancer.
• The key causes are increased consumption of energy-dense foods high in
saturated fats and sugars, and reduced physical activity.
Obesity has reached epidemic proportions globally, with more than 1 billion adults
overweight - at least 300 million of them clinically obese - and is a major contributor to
the global burden of chronic disease and disability. Often coexisting in developing
countries with under-nutrition, obesity is a complex condition, with serious social and
psychological dimensions, affecting virtually all ages and socioeconomic groups.
Increased consumption of more energy-dense, nutrient-poor foods with high levels
of sugar and saturated fats, combined with reduced physical activity, have led to
obesity rates that have risen three-fold or more since 1980 in some areas of North
America, the United Kingdom, Eastern Europe, the Middle East, the Pacific Islands,
Australasia and China.The obesity epidemic is not restricted to industrialized societies;
this increase is often faster in developing countries than in the developed world.
Obesity and overweight pose a major risk for serious diet-related chronic diseases,
including type 2 diabetes, cardiovascular disease, hypertension and stroke, and certain
forms of cancer. The health consequences range from increased risk of premature
death, to serious chronic conditions that reduce the overall quality of life. Of especial
concern is the increasing incidence of child obesity. Calling out firefighters to help with
obese patients has costed £4m in the past five years, claim the Conservatives.

25
2.2.2 CONSIDERATIONS FOR BARIATRIC SURGERY:
Individuals considering bariatric surgery must discuss risks and possible benefits with their
doctor. Bariatric surgery has associated risks and long-term consequences and should be
considered only one part of an approach to treating obesity. Most bariatric surgeons think
that the operations work best when they help promote lifelong behavioral and dietary
changes. Long-term follow-up with doctors experienced in the care of patients having these
procedures, as well as lifelong vitamin supplementation, is essential to avoid life-
threatening complications.
2.2.3 BARIATRIC EQUIPMENT AND EXERCISE IMPLICATIONS FOR THE OBESE:
Physical therapy services may include therapeutic exercise and techniques to facilitate
increased functional mobility levels, increased walking ability and activity tolerance and
also for initiating a home exercise program and cardiovascular training safely.
This standard of care will address the specific musculoskeletal and mobility needs for the
bariatric population as well as the need for screening for additional services. Implications
for physical therapy, contraindications and interventions that are reviewed in other
standards of care, (e.g. ICU, Pulmonary or General Surgery) apply to this population as
well.
A. INDICATIONS FOR TREATMENT:
• The indication for inpatient physical therapy intervention in the bariatric patient can
include: new weakness, difficulty with functional mobility and decreased
endurance, which may be related to prolonged hospitalization, surgery or traumatic
injury.

26
• The indication for physical therapy intervention in the outpatient setting may
include: new musculoskeletal pain or injury, gait training or balance deficits.
• The APTA practice patterns that are applicable in this population should be based
on the impairments and functional limitations present (e.g. musculoskeletal,
cardiopulmonary).
• Please refer to other standards of care for specific contraindications/precautions
for treatment related to recent surgery (e.g. cardiac, orthopedic) or any other
medical procedures.
• Due to increased upper extremity girth, it is important to use large adult blood
pressure cuffs or thigh cuffs on patients with an upper-arm circumference greater
than 34 cm to avoid a false high or low blood pressure reading. Also, heart rate
may be difficult to palpate due to excessive adipose tissue.4, 5
• It is important that the health care provider choose the correct equipment with
regards to weight limitations and correct height and width. Please refer to Appendix
I for weight limitations for commonly used equipment.
B. CHART REVIEW/MEDICAL HISTORY:
As per departmental standards for minimum data set
I. HISTORY OF PRESENT ILLNESS:
1. Reason for admission to the hospital: e.g. exacerbation of illness such as
COPD, CHF, plans for surgical intervention
2. Reason for referral to outpatient PT services: e.g. DJD, weight loss, status post
surgical intervention
3. Patient’s admission weight and height
4. If admitted for gastric bypass surgery, any prior interventions/treatments
patient received
II. PAST MEDICAL HISTORY:
1. Sleep apnea,
2. Osteoarthritis,
3. DM,
4. Cardiac history,
5. Prior surgeries
III. SOCIAL HISTORY:
1. Support systems
2. Roles within the home and community
3. Patient’s expectations
4. Professional role/occupation
5. Hobbies/recreational activities
IV. PRIOR FUNCTIONAL LEVEL:
1. Baseline ambulation (distance)
2. Assistive device (if used)
3. Environmental modifications to their home (e.g. ramp, stair lift, etc.)
4. Home O2 use/BiPAP/CPAP

27
5. Exercise program
6. Use of wheelchair or power scooters if not ambulatory
7. Sleeping arrangements (e.g. HOB elevated, using a recliner chair)
C. EXAMINATION:
I. PHYSICAL STATUS:
1. Vital signs (refer to Contraindications/Precautions for Treatment above)
2. Pain (VAS scale)
3. Strength (functional, MMT)
4. ROM (functional, often limited by body habitus)/flexibility
5. Posture
6. Body type (upper body obesity vs. lower body obesity)
7. Sensation (neuropathy, sensory loss, hypersensitivity)
8. Aerobic capacity and endurance (use of RPE scale or Six minute walk test)4
9. Respiratory status (may be limited by body habitus)
10. Balance
11. Skin Integrity (friction, shearing, ulcers, infections, weeping drainage, heat
dissipation, surgical incisions)
II. FUNCTIONAL MOBILITY:
1. Bed mobility
2. Transfers
3. Gait (level and stairs)
D. ASSESSMENT:
I. ESTABLISH DIAGNOSIS AND NEED FOR SKILLED SERVICE:
1. Musculoskeletal issues
2. Specific impairments related to disease process or surgical intervention,
prolonged bedrest or hospitalization
3. Deconditioning (baseline or due to hospitalization)
4. Need for referrals to other health care professionals (e.g. registered dietician,
occupational therapy for adaptive equipment as needed, social work)
II. PROBLEM LIST:
1. Potential Impairments
a. Decreased:
i. Endurance/aerobic capacity
ii. Balance, strength
iii. ROM
iv. Skin integrity
v. Patient knowledge including but not limited to correct body mechanics,
use of assistive device, energy conservation techniques
b. Altered hemodynamic response to exercise
c. Increased pain
2. Potential Functional Limitations:

28
a. Decreased bed mobility, transfers, gait, stairs, ADLs
III. PROGNOSIS:
Please refer to specific standard of care related to patient’s admitting diagnosis or
disease process (e.g. pulmonary, vascular, etc) for guidelines regarding prognosis.
E. Goals (Measurable parameters and specific timelines to be included on eval
form)
1. Short Term Goals:
a. Goals should be related to impairments and functional limitations that are
identified during the initial evaluation.
b. Goals should consider admitting diagnosis and type of referral. An
inpatient may be referred to PT to address conditioning while at BWH. The
inpatient PT role is to address an independent walking and exercise
program and offer referrals to outpatient services as needed including but
not limited to outpatient physical therapy or personal trainers.
c. For patients admitted to the hospital for musculoskeletal needs or general
surgical interventions, please refer to the specific standards of care for
departmental guidelines.
d. For patients referred to outpatient physical therapy for specific
musculoskeletal needs or for continued post-surgical PT, please refer to
the specific departmental guidelines.
e. For patients admitted to the hospital for gastric bypass surgery, the typical
length of stay is 3 days. Some examples of appropriate goals may include:
i. Independent bed mobility.
ii. Independent transfers with appropriate assistive device.
iii. Independent ambulation greater than 100 feet with appropriate
assistive device.
iv. Maintain O2 saturation > 92% on least supplemental O2.
v. Verbalize understanding of HEP, activity progression, body mechanics
and energy conservation techniques.
vi. If above short term goals are not met or appropriate support systems
are not in place, the patient should consider ECF placement or
outpatient services as appropriate.
f. Because the length of stay for patients who have gastric bypass surgery is
short, long-term goals should be addressed with further PT intervention in
an extended care facility or outpatient setting as appropriate.

29
E. AGE SPECIFIC CONSIDERATIONS:
Normal age related changes will occur in this population; however a patient who is
defined as obese may have an earlier onset of certain comorbidities (e.g. OA, heart
disease, CHF).
F. SURGICAL INTERVENTIONS:
Indicated for patients with BMI >40 or BMI >35 with associated risk factors/diseases
I. ROUX-EN-Y GASTRIC BYPASS (RYGB):
The upper portion of stomach is stapled to create a small reservoir that attaches to
the jejunum. This combines limited food intake with malabsorption (because of
attachment of small intestine to proximal stomach).
1. Incision sites-vertical midline incision from xyphoid to umbilicus
2. Laparoscopic surgery with multiple small incisions6
II. LAP BAND:
A small band is placed around the upper portion of stomach and a balloon is
inflated to limit the capacity of the stomach, the opening can be adjusted as
needed via port in the skin of the stomach
III. PANNICULECTOMY:
The excess skin and fat is removed from the abdominal area.
Complications from procedures can include but are not limited to: post operative
bleeding, bowel perforation or obstruction, leak at the anastomosis (in RYGB),
wound infections, bleeding, DVT, nausea and vomiting.7, 8
G. TREATMENT PLANNING / INTERVENTIONS:
Established Pathway ___ Yes, see attached. _X_ No
Established Protocol ___ Yes, see attached. _X_ No
Interventions most commonly used for this case type/diagnosis:
This section is intended to capture the most commonly used interventions for this case
type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate
interventions.
I. BED MOBILITY:
1. Use of friction reducing sheets, Trendelenburg position, bed rails/trapeze,
airflow mattress (deflated for transfers)
2. Suggestions based on body type 9, 10, 11
a. Apple ascites: immobile abdominal wall, intolerant to supine/prone,
respiratory issues due to tissue bulk, utilize the supine flat spin technique,
then push up at EOB with elbows, may require wider bed

30
b. Apple pannus: dominant pannus, variable tolerance to supine, depending
on mobility of pannus, supine flat spin or prone flat spin (to perpendicular
with EOB) with trunk push-up
c. Pear shape abducted: majority of tissue is located on the medial aspect
of the thighs, difficulty rolling due to abducted position of B LEs, supine to
long to short sit technique
d. Pear shape adducted: majority of adipose tissue on lateral aspect of
thighs, allows patient to perform logroll technique, supine to long to short
sit or side lying to sitting with rail
e. Pear shape with bulbous gluteal region: may have increased LBP due
to excessive posterior tissue bulk causing pelvis to push anterior in relation
to trunk
II. TRANSFER TRAINING:
1. Patient’s hips and knees must be in 90 degrees of flexion; will help reduce the
risk of patient sliding off the edge of the transfer surface
2. Egress Test: to determine if patient is safe to transfer (please refer to article for
full explanation).12 Briefly the test consists of three parts:
a. Test 1: three repetitions of sit to stand (to test weight-bearing and function)
b. Test 2: marching in place (to test endurance)
c. Test 3: advance one step and return each foot (two trials, to test function
and endurance)
3. Gait belt
a. Can only be used for improved grip
b. Must have appropriate length of belt
i. If appropriate length cannot be achieved, the sheet technique can be
utilized
4. Patient moves towards the stronger side during transfer
5. Utilize appropriate number of staff
6. If a patient was not previously mobile, utilizing mechanical lifts (e.g. ceiling lifts;
Liko lifts) will prevent injury to patient and healthcare provider, with care taken
to choose the correct size sling
III. GAIT TRAINING/STAIRS:
1. Correct musculoskeletal/postural abnormalities
2. Correct assistive device prescription
IV. AEROBIC EXERCISES:
1. Walking program
2. Low impact exercises
3. Exercises in sitting
4. Stationary bike/restorator
5. Swimming program (if appropriate due to any incisions, per post operative
instructions)4
LOGROLL TECHNIQUE

31
V. RESISTED TRAINING:
1. Utilizing resistance bands, weights, body weight to perform therapeutic
exercise programs in supine, sitting or standing as tolerated and as
appropriate based on healing of incision sites
a. Positions of certain exercises may need to be modified due to body habits
VI. PATIENT EDUCATION:
1. Body mechanics
a. Especially important for post-surgical patients re: logrolling technique to
minimize stress on incisions sites
b. Upright posture with ambulation for improved respiratory capacity, normal
alignment
2. Energy conservation
3. Pacing
4. Aerobic and strengthening home exercise program13, 14
a. Importance of 30-60 minutes of exercise/physical activity throughout the
day
b. Exercise can be divided into several sessions during the day
c. Equipment needs: please refer to Appendix I for weight limitations
H. FREQUENCY & DURATION:
This is based upon patient’s impairments, tolerance to treatment and medical stability
as per departmental guidelines.
I. INPATIENT:
1. Functional mobility: 3-5x/week
2. Musculoskeletal needs: 2-3x/week
3. Screening: 1x visit or several visits to address walking and exercise/stretching
program
II. OUTPATIENT:
Based on specific needs, typically for musculoskeletal or endurance issues, 1
2x/week
I. RE-EVALUATION:
The patient should be re-evaluated every 10 days throughout the length of inpatient
stay or when a change in status occurs, or every 30 days for outpatient visits.
J. DISCHARGE PLANNING:
I. COMMONLY EXPECTED OUTCOMES AT DISCHARGE:
The patient will return to their home environment with improved functional mobility,
endurance, decreased O2 requirement, and more appropriate assistive
devices/mobility aides.
II. TRANSFER OF CARE (IF APPLICABLE):
If the above goals are not met during the inpatient stay, discharge to a
rehabilitation hospital may be appropriate.

32
III. PATIENT’S DISCHARGE INSTRUCTIONS MAY INCLUDE:
• Effective equipment prescription
• Referrals to other healthcare professionals:
o Outpatient PT
o Occupational therapy
o Exercise physiologist
o Nutrition
o Wellness centre.
DME WEIGHT RESTRICTIONS
EQUIPMENT WEIGHT (lbs)
Standard size canes 250
Heavy-duty straight cane 500
Heavy-duty quad cane 500
Forearm crutches 300
Axillary crutches/Guardian crutches (metal) 250
Crutches with platform attachment 250
Standard wooden crutches 250
Extra tall wooden crutches 250
Bariatric crutches 550
Lumex adult walker 300
Lumex imperial walker (wide) 400
Heavy-duty extra wide walker 500
Hemiwalker 250
Junior and pediatric walkers 250
Platform walker 300
Rolling walker (Guardian) 300
Standard walker (Guardian) 300
Standard wheelchair 250
Recliner wheelchair 250
Extra wide heavy duty wheelchair 450
Overhead bed frame/trapeze 300
Foot stool 250
Sliding board 400
Tilt table 400
Gait belt
Length-at least
60 inches

33
3.0 REHABILITATION FOR LYMPHATIC DISEASE:
The lymphatic system consists of lymph nodes (or lymph glands) and lymphatics (small vessels that link the
lymph nodes). The system returns excess fluid to the circulation and helps fight infection and cancer.

34
3.1 DIAGNOSIS:
• The diagnosis of lymphatic vascular disease relies heavily on the physical examination.
Lymphedema, even when superimposed upon a more complex vascular presentation, is most
often readily identified by its physical characteristics, including edema, peau d'orange,
cutaneous fibrosis, and positive "Stemmer sign" (the inability of the examiner to "tent" the skin
at the base of the digits in the involved extremity). While pitting edema may be absent, it is a
common misconception that the presence of pitting precludes a lymphatic origin of limb
swelling. However, in all cases, the hallmark of lymphedema is the presence of cutaneous and
subcutaneous thickening, which uniquely identifies the lymphatic pathogenesis of edema
formation.
• If the diagnosis remains in question, the presence of lymphatic vascular insufficiency can be
ascertained through imaging. Direct contrast lymphography has largely been abandoned, in
favor of the use of indirect radionuclide lymphoscintigraphy. The procedure requires
intradermal or subcutaneous injection of an appropriate radiolabeled tracer (99mTc-antimony
sulfide colloid, 99mTc-sulfur colloid, 99mTc-albumin colloid, or 99mTc-labeled human serum
albumin). Criteria for the diagnosis of lymphatic dysfunction include delayed, asymmetric or
absent visualization of regional lymph nodes, asymmetric visualization of lymphatic channels,
collateral lymphatic channels, interrupted vascular structures, and visualization of the lymph
nodes of the deep lymphatic system. The presence of "dermal back-flow" is abnormal, and is
generally interpreted to represent the extravasation of lymph from the vasculature into the
interstitium as a consequence of lymphatic venous hypertension.
• Beyond lymphoscintigraphy, clinically relevant imaging modalities include magnetic resonance
imaging and computerized axial tomography. These imaging techniques permit objective
documentation of the structural changes occasioned by the presence of lymphedema,
inasmuch as the presence of edema within the epifascial plane, along with cutaneous
thickening, is characteristic of a lymphatic cause for edema. Magnetic resonance imaging has
complementary utility. Recent advances in the magnetic resonance approach have vastly
facilitated the anatomic and functional visualization of lymphatic vascular anomalies, in both
nonenhanced and contrast-enhanced applications. The latter approach has been investigated
directly for the evaluation of lymphedema of the limb.
• Bioelectric impedance analysis is an emerging diagnostic technique for the clinical evaluation
of lymphatic edema. The technique facilitates the noninvasive quantification of extracellular
fluid in the extremities; given its sensitivity and reproducibility, it is likely to find increasing
application in the early detection and management of lymphatic edema.

35
3.2 TREATMENT OF LYMPHATIC VASCULAR DISEASES:
• The state-of-the-art therapeutic approach to lymphatic edema relies upon physiotherapeutic
techniques. Complex decongestive physiotherapy (CDPT) is an empirically derived,
effective, multicomponent technique designed to reduce limb volume and maintain the health of
the skin and supporting structures. There is some evidence that this approach stimulates
lymphatic transport and facilitates the dispersal of retained interstitial proteins.
• CDPT relies heavily upon an empirically derived, lymphatic-specific massage technique termed
manual lymphatic drainage (MLD). A mild degree of manually delivered tissue compression
serves to enhance filling of the cutaneous initial lymphatics and augments dilation and
contractility of the lymphatic conduits. MLD is believed to facilitate the recruitment of watershed
pathways for lymph flow through its attempts to stimulate the edema-free zones of the trunk
and uninvolved extremities. It is also postulated that the technique enhances the development
of accessory lymph collectors.
• In addition to MLD, the CDPT approach integrates skin care, exercise, and the use of externally
applied compression. In the initial management of a previously untreated patient, this
compression takes the form of repetitively applied short stretch bandaging, in order to create a
multilayer compartment that, during muscular activity, augments the physiological mechanisms
that regulate lymphatic contractility and flow. In addition, during active tissue compression,
there is a reduction in the abnormally increased ultrafiltration which, in turn, leads to improved
fluid reabsorption. Eventually, with repetitive physical interventions and bandage applications,
edema volume will achieve its nadir; at this point, maintenance of the therapeutic benefits will
require the use of fitted elastic garments for use during nonrecumbency. In smaller numbers of
patients, nocturnal compression may also be required. Relatively inelastic sleeves and
underwear that transmit high-grade compression (40 to 80 mm Hg) will prevent reaccumulation
of fluid after successful CDPT. Garments must be fitted properly and replaced every 3 to 6
months.
• The therapeutic efficacy of CDPT has been validated. When examined in a series of patients
with either upper or lower extremity lymphedema, with an average follow-up of 9 months,
average volume reductions of 59% and 68% were observed in the upper and lower limbs,
respectively; maintenance self-management techniques are effective in sustaining the majority
of this benefit in compliant patients.
• While CDPT affords benefit to the majority of patients with lymphedema, the fact that the
interventions are labor-intensive, time-consuming, and expensive cannot be refuted.
Furthermore, the potentially uncomfortable and very visible impact of the requisite garments
may erode the patients' quality of life. Furthermore, the interventions are not uniformly
successful. Most patients achieve adequate edema control, but some will require the input of
adjunctive devices. Notably, intermittent pneumatic compression has been shown to augment
the decompressive effects of standard therapies, especially in the context of cancer-associated
lymphedema. More recently, an adaption of intermittent pneumatic compression has been
introduced that, while delivering minimal, phasic external compression, endeavors to simulate
the effects of MLD; this device, when used adjunctively in the maintenance phase of therapy,
appears to augment the beneficial impact of the standard modalities of CDPT. Other adjunctive
approaches, including the external application of hyperthermia and low-level laser, continue to
be investigated. Surgical approaches to improve lymphatic flow through vascular
reanastomosis have been, in large part, unsuccessful, but over the last 15 years there has
been consistent evidence for the beneficial effect, in the appropriately selected patient, of
controlled liposuction when coupled with the requisite, sustained aggressive post-operative
compression; this approach will restore and maintain normal limb volume and contour after the

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