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Assessment of functional ability of nonambulatory patients with obesity: after and before bariatric surgery
Surgery for Obesity and Related Diseases - (2019) 1–7
Original article
Assessment of functional ability of nonambulatory patients with obesity: after and before bariatric surgery Mohit Bhandari, M.S.*, Winni Mathur, B.P.T., M.B.A., Susmit Kosta, Ph.D., Prashant Salvi, M.S., Mathias Fobi, M.D. Mohak Bariatrics and Robotics Center, Indore, Madhya Pradesh, India Received 27 June 2019; accepted 12 September 2019
Abstract
Introduction: Functional ability is often impaired as a direct consequence of severe obesity. Bariatric surgery is the most effective treatment for severe obesity. Objective: To examine the effect of weight loss after bariatric surgery on patients with impaired functional ambulatory abilities due to obesity. Settings: A high-volume university-affiliated bariatric surgery center in India. Method: We conducted a prospective study in a cohort of nonambulatory patients with functional disabilities (bedridden, wheelchair-bound, or walker-dependent) who underwent bariatric surgery. Data on sex, body mass index, co-morbid conditions, the severity of pain, and types of limitations in functional abilities were collected at baseline and at 1 year after bariatric surgery and analyzed. Results: Forty-five patients were enrolled in this study with 100% follow-up at 1 year. The mean age and body mass index of the patients were 54.7 6 8.5 years and 54.2 6 8.6 kg/m2, respectively. Thirtyfour (75.5%) were female, 27 (60%) were walker-dependent, 14 (31.1%) were wheelchair-bound, and 4 (8.9%) were bedridden. At baseline 88.8% and 75.5% patients had severe knee and back pain, respectively. The percentage of total weight loss was 22% and 31% at 6 and 12 months, respectively. At 1 year, 37 (82.2%) patients were ambulating independently, only 1 (2.2%) patient was still bedridden, and 7 (15.5%) patients were walker-dependent. Mild, moderate, and severe classification on all functional ability scales were significantly improved. Conclusion: Weight loss after bariatric surgery results in significant amelioration of knee and/or back pain with an improvement in functional abilities and quality of life. (Surg Obes Relat Dis 2019;-:1– 7.) Ó 2019 Published by Elsevier Inc. on behalf of American Society for Bariatric Surgery.
Key words:
Functional ability; Nonambulatory; Obesity; Bariatric surgery; Weight loss
Obesity is associated with a reduction in individual mobility, aggravating a previously sedentary lifestyle [1,2]. Activities of daily living are impaired due to excessive body fat accumulation. Fat accumulation also reduces functional abilities, such as walking capacity. The ability to walk * Correspondence: Dr. Mohit Bhandari, M.S., Mohak Bariatrics and Robotics Center, SAIMS Campus, Indore-Ujjain Highway, Indore, Madhya Pradesh, India 453555. E-mail address: [email protected] (M. Bhandari).
is a simple measure of physical function and an important component of quality of life because it reflects the capacity to perform day-to-day activities [3,4]. Severe obesity is associated with mechanical and structural changes that may indirectly impact physical health and induce musculoskeletal conditions [5–7]. Severe obesity may magnify these problems, and contribute to additional problems, such as increased friction from excess gluteal fat and insufficient exercise capacity leading to rapid exhaustion, making walking even more difficult or unpleasant [8,9].
https://doi.org/10.1016/j.soard.2019.09.068 1550-7289/Ó 2019 Published by Elsevier Inc. on behalf of American Society for Bariatric Surgery.
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Mohit Bhandari et al. / Surgery for Obesity and Related Diseases - (2019) 1–7
Walking limitations are a precursor to dependency in more basic activities of daily living, such as dressing, bathing, grooming, ability to transfer from bed to a wheelchair, or getting in or out of bed [10]. Evidence suggests that weight loss causes relief of knee and/or back pain and enhances the functional ability of affected patients [11–13]. Currently, bariatric surgery is the most effective treatment for severe obesity and results in improvement in the quality of life [14]. Most studies have reported on improvement of physical function after bariatric surgery on ambulatory patients with respect to cardiovascular endurance, muscular endurance, and motor skill performance [15,16]. These improvements are a consequence of the weight loss. Though there are no studies on the changes in functional abilities after bariatric surgery in nonambulatory patients with obesity, it is obvious that these changes in the nonambulatory status are due to the weight loss. Thus, this study was initiated to assess the health-related quality of life of nonambulatory patients with severe obesity undergoing bariatric surgery at a tertiary care bariatric center. The primary aim of the study was 2-fold, (1) to assess the pre- and postoperative functional ability of nonambulatory patients by Numeric Pain Rating Scale, Western Ontario and McMaster Universities Osteoarthritis Index, Rolland Morris Scale, and KATZ scores, and (2) to determine any correlation between body mass index (BMI), sex, age, and co-morbidities to the functional abilities in these patients. These results can be used to manage the expectations of nonambulatory patients with obesity after bariatric surgery regarding their quality of life.
Methods Study design We prospectively collected data on nonambulatory patients with 3 functional disabilities, being bedridden, wheelchair-bound, or walker-dependent who had weight loss surgery at Mohak Bariatric and Robotic Surgery Center, Indore, MP, India. Indications for weight loss procedures were based on the 1991 National Institutes of Health criteria with modifications for patients in the Asia pacific region (at least BMI .28 kg/m2 with co-morbidities after previous failed attempts to lose weight conventionally). Bariatric procedures were contraindicated in patients with certain gastric lesions, neoplastic findings, or family history of gastric cancer. Individuals with mental health disorders, significant medical co-morbidities precluding sedation, or coagulopathies were also excluded. In addition to a preprocedural consultation with the surgeon, patients also underwent evaluations by a bariatric physician, physiotherapist, and dietician. All patients also underwent routine laboratory, radiologic, and cardiopulmonary evaluations. Preoperatively, all patients provided written informed consent for their operation and to have de-identified data analyzed for
presentation or publication. The institutional review board approved this study. The choice of procedure was made by the patient in conjunction with the surgeon after proper education and discussion of technical aspects, risks, and costs. Data on sex, BMI, co-morbid conditions, type of limitation of functional ability, and the severity of knee and/or back pain were collected at baseline and at 1 year after bariatric surgery and analyzed. Outcome assessment The baseline and follow-up characteristics included the analysis of weight, height, and BMI. The resulting changes in BMI and percentage of total weight loss were measured during scheduled follow up visits at 1, 3, 6, and 12 months postprocedure. The categories of mobility (bedridden versus walker-dependent, versus wheelchair-bound) were determined by physical assessment and by self-reporting of the patients. Further outcomes included postprocedure hospital length-of-stay. Pain scores and co-morbidities remissions were assessed at 12 months postprocedure. Assessment of functional ability Pre- and postsurgery outcome parameters of functional ability were assessed using the following scales: Numeric pain rating scale. To assess the subjective intensity of pain. A composite pain intensity score was calculated from 0 to 10 numeric rating scale [17,18]. Where, 0 5 no pain, between 1 and 3 5 mild pain, 4 and 7 moderate pain, and 8 and 10 5 extreme pain. Western Ontario and McMaster Universities Osteoarthritis Index. To asses proprietary set of standardized questionnaires used by health professionals to evaluate the condition of patients with osteoarthritis of the knee and hip, including pain, stiffness, and physical functioning of the joints. It measures for 5 items for pain (0–20), stiffness (0–8), functional limitation (0–17) [19,20]. Where, 0 5 no pain, between 1 and 17 5 mild pain, 18 and 34 moderate pain, and 35 and 68 5 extreme pain. Rolland Morris Scale (numeric pain scale for low back pain). The questionnaire includes 24 questions regarding Assessment of Activities of Daily Living maximum of 24 points, minimum of 0 [21,22]. Where, 0 5 no pain, between 1 and 6 5 mild pain, 7 and 12 moderate pain, and 12 and 24 5 extreme pain. KATZ. To assess the function and detect problems in performing activities of daily living and to plan care accordingly. The index ranks adequacy of performance in the 6 functions of bathing, dressing, toileting, transferring, continence, and feeding. Patients were scored yes/no for independence in each of the 6 functions. A score of 6 indicates full function, 4 indicates moderate impairment, and 2 indicates severe functional impairment [23,24]. Where, 0 5 no pain, between 1 and 2 5 mild pain, 3 and 4 moderate pain, and 5 and 6 5 extreme pain.
Mohit Bhandari et al. / Surgery for Obesity and Related Diseases - (2019) 1–7 Table 1 Baseline characteristics of nonambulatory patients who had bariatric surgery Baseline characteristics Mean age, yr (SD) Sex (F:M), n (%) Mean height, cm 6 SD Mean weight, kg 6 SD Mean preoperative BMI, kg/m2 (SD) Preoperative co-morbidities T2D, n (%) HTN, n (%) SA, n (%) Back pain, n (%) Knee pain, n (%) Back and knee pain, n (%)
54.7 (8.5) 34 (75.5):11 (24.5) 154.1 6 8.8 128.6 6 20.8 54.2 (8.6)
and reposted Pearson’s coefficient of correlation. All P values presented are 2-tailed, and statistical significance was defined a priori as P , .05. Data analyses were performed using IBM-SPSS statistics 20 (IBM Corp, Armonk, NY, USA). Results Patients characteristics
23 (51.1) 33 (73.3) 28 (62.2) 34 (75.5) 40 (88.8) 29 (64.4)
SD 5 standard deviation; BMI 5 body mass index; T2D 5 type 2 diabetes; HTN 5 hypertension; SA 5 sleep apnea.
Statement of informed consent Informed consent was obtained from all individuals undergoing all procedures and included in our study. No identifying information is included in our study. Statement of ethical rights and human rights (as no animal experiments were conducted in this study) All procedures performed in our study were in accordance with the ethical standards of the institutional and national research committee. Statistical analysis Descriptive analyses of the variables were performed using the test of proportions for qualitative variables and measurements of central tendency (mean) and measures of dispersion (standard deviation [SD]) for quantitative variables. To assess demographic variables (such as age, height, sex, initial weight, and BMI, etc.) that may have contributed to better response rates, we employed the student’s t test for independent samples (continuous variables) and the c2 test (qualitative variables). We also correlated bassline BMI and co-morbidities with bassline scores on the functional ability and change in BMI and resolution of comorbidities with effectiveness in functional ability scores
Forty-five patients, 34 (75.5%) female and 11 (24.5%) male, with a mean age of 54.7 years (SD 8.5; range, 30–73) were enrolled in this study. They had an average weight of 128.6 kg (SD 20.8; range, 94.5–169.5) and a mean BMI of 54.2 kg/m2 (SD 8.6; range, 37.4–75.3). Of the 3 surgical procedures performed, the majority 21(43.8%) underwent sleeve gastrectomy followed by 19 (39.6%) who underwent one-anastomosis gastric bypass, and 8 (16.6%) who underwent Roux-en-Y gastric bypass. None had a history of any previous bariatric surgery or any surgical intervention for weight loss. Baseline characteristics and incidence of preoperative co-morbidities of the study cohorts are summarized in Table 1. Walking/functional disabilities according to age and BMI Four (8.9%) patients were bedridden, 14 (31.1%) were wheelchair-bound, and 27 (60%) were walker-dependent. There was a significant trend with BMI (P 5 .001) and with age (P 5 .004) group for each walking ability measure (Table 2), such that more obese and older adults reported more walking limitations compared with less obese and younger adults, respectively. At 1 year, 37 (82.2%) patients were ambulating independently, only 1 (2.2%) patient was still bedridden and 7 (15.5%) patients were walkerdependent (3 previously bedridden and 4 previously wheelchair-bound). (Table 2) Adverse effects and weight loss pattern There were no major postoperative complications. Minor adverse events included 14.5% with epigastric pain, 18.7% patients with nausea, 12.5% with vomiting, 12.5% with bloating symptoms, and 16.6% complained of a generalized
Table 2 Distribution of nonambulatory patients /functional disabilities according to age and BMI
Preoperative Number, n (%) Age, yr, (SD) BMI, kg/m2 (SD) Postoperative Number, n (%) BMI, kg/m2 (SD)
3
Bedridden
Walker-dependent
Wheelchair-bound
P value
4 (8.9) 61.50 (2.6) 65.25 (5.2)
27 (60.0) 50.12 (8.0) 51.60 (7.2)
14 (31.1) 53.81 (9.6) 54.25 (8.3)
.004 .001
1 (2.2) 60.0
7 (15.5) 42.86 (6.9)
-
.001
SD 5 standard deviation; BMI 5 body mass index.
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Mohit Bhandari et al. / Surgery for Obesity and Related Diseases - (2019) 1–7
Fig. 1. Weight loss pattern.
weakness. These events resolved spontaneously with minor interventions. The average length of stay was 4 days (range, 3–7 d) The percentage of total weight loss was 7%, 15%, 22%, and 31% at 1, 3, 6, and 12 months (Fig. 1). Effectiveness of functional ability scoring Applying the Numeric Pain Rating Scale, Western Ontario and McMaster Universities Osteoarthritis Index, Rolland Morris Scale, and KATZ scores and dyspnea grading to this cohort, at baseline 40 (88.8%) patients had knee pain with a rating of 7.6 6 1.4 and 34 (75.5%) had back pain with a rating of 7.3 6 1.4. After 1 year 10 (25.0%) patients had 100% resolution in knee pain and reduction of the scores to 2.9 6 1.7 in 30 (75.0%). Similarly, there were 9 (26.5%) patients with 100% resolution of back pain and reduction of the scores to 2.3 6 1.4 in 25 (73.5%) patients with back pain (Table 3). Table 4 demonstrates the mild, moderate, and severe classification for all scales before and after surgery. There was significant (P 5 .001) improvement in functional ability after the bariatric surgery in nonambulatory patients.
Discussion Walking is often prescribed to retain and improve physical function in performing various activities of daily life, such as doing light housework, crossing a street, or grocery shopping. Walking margins are an ancestor to dependency in more basic activities of daily life [10]. Thus, walking capacity is often impaired as a direct consequence of obesity, through excess weight bearing, and reduced flexibility of movement. Severe obesity can also impact walking capacity indirectly via destructive back and joint pain [6,7] and loss of muscle mass due to the proinflammatory state associated with adiposity and related co-morbidities. To the best of our knowledge, our study is the first to assess various functional ability scales with BMI and co-morbidities at baseline and after bariatric surgery in a specific nonambulatory cohort of patients. The advantage to this objective assessment is that these results could be used to manage expectations of nonambulatory patients with obesity after bariatric surgery regarding their quality of life. This study sample, ranging in mean age (54.7 6 8.5) from 30 to 73 years, enabled examination of functional disabilities who were bedridden, wheelchair-bound, or walker-
Correlation between BMI and obesity-specific functional ability scoring/co-morbidities Table 5 shows a correlation of the functional ability scores. There was weak correlation between baseline BMI and baseline co-morbidities with different functional ability scoring. In contrast, there was a significant correlation (P 5 .001) of enhancement of functional ability scoring with a change in BMI and resolution co-morbid conditions. At 1 year the rate of co-morbidities remission was 73.9%, 78.8%, and 71.4% for type 2 diabetes, hypertension, and sleep apnea, respectively (Fig. 2).
Table 3 Effectiveness of knee/back pain
Preoperative Pain, n (%) Score mean 6 SD Postoperative 100% resolution, n (%) Pain reduction, n (%) Score mean 6 SD
Knee pain
Back pain
40 (88.8) 7.6 6 1.4
34 (75.5) 7.30 6 1.4
10/40 (25.0) 30/40 (75.0) 2.9 6 1.7
9/34 (26.5) 25/34 (73.5) 2.3 6 1.4
Mohit Bhandari et al. / Surgery for Obesity and Related Diseases - (2019) 1–7
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Table 4 Validation of the effectiveness of all scales (Functional Ability Scoring) Functional ability scoring
NPRS (for back pain) NPRS (for knee pain) WOMAC RMS KATZ Dyspnea grading
Preoperative
Postoperative
P value
Mild n (%)
Moderate n (%)
Severe n (%)
Mild n (%)
Moderate n (%)
Severe n (%)
15 (33.3) 6 (13.3) 6 (13.3) 12 (26.7) 24 (53.3) 3 (6.6)
19 (42.2) 16 (35.6) 3 (6.7) 5 (11.1) 14 (31.1) 34 (75.6)
11 (24.5) 23 (51.1) 36 (80.0) 28 (62.2) 7 (15.6) 8 (17.8)
39 (86.7) 31 (68.9) 28 (62.2) 33 (73.4) 43 (95.6) 42 (93.3)
5 (11.1) 10 (22.2) 9 (20.0) 6 (13.3) 2 (4.4) 3 (6.7)
1 (2.2) 4 (8.9) 8 (17.8) 6 (13.3) 0 0
.001
NPRS 5 Numeric Pain Rating Scale; WOMAC 5 Western Ontario and McMaster universities osteoarthritis index; RMS 5 Rolland Morris Scale.
dependent and limitations from young adulthood to older age. As expected, age was positively associated with walking limitations. However, many young bariatric candidates experience walking limitations generally associated with older age. The 60% that were walker-dependent had a mean age 50.1 6 8.0, the 31.1% who were wheelchairbound had a mean age 53.8 6 9.6, and 8.9% who were bedridden had a mean age 61.5 6 2.6. Sex was not significantly associated with higher odds of walking aid use or reporting physical discomfort [25–27]. Osteoarthritis is a very common problem in weightbearing joints, especially in the aging population and obesity has been identified as the main modifiable risk factor [11–13]. In this study we found a significant decrease in pain and significant improvement in the ambulatory status with weight loss after bariatric surgery. Table 4 shows the comparison and validation (effectiveness of mild, moderate, and severe classification) for various scales (functional ability scoring) pre- and postbariatric surgery in this study. The significant (P 5 .001) improvement in functional abilities after bariatric surgery in this study are consistent with other studies related to pain and walking limitations. There are
systematic reviews of the literature that reports bariatric surgery significantly improving quality of life over the long term [28–30]. The incidence of co-morbidities were significantly related to disability during obesity and all measures of walking scales. However, specific co-morbidities (type 2 diabetes, hypertension, sleep apnea, and back/knee pain) had better resolution with a change in BMI and enhancement of functional ability scores after bariatric surgery. All the patients but 1 had an improvement in their ambulatory status. The 1 patient that was still bedridden at 1 year had bilateral above the knee amputation. He could not independently transfer to a wheel chair at 1 year. However, currently with more weight loss he is able to independently transfer to a wheel chair. Follow-up of all these patients is planned and there obviously will be further improvement as the patients lose more weight. This study has 2 main limitations. The first limitation is that it is not a randomized study. Although all data were prospectively collected, the level of evidence provided is not as strong as that from a well-designed, randomized, prospective control study. Second, there is very limited literature
Table 5 Correlation between BMI and obesity specific functional ability scoring and co-morbidities
NPRS (for back pain) NPRS (for knee pain) WOMAC RMS KATZ Dyspnea grading T2D HTN SA
Correlation between baseline BMI and baseline functional ability scoring/comorbidities*
Correlation between change in BMI at after 1-yr functional ability scoring/comorbiditiesy
r 5 2.29 (P 5 .004) r 5 2.24 (P 5 .006) r 5 2.02 (P 5 .83) r 5 2.16 (P 5 .2) r 5 2.30 (P 5 .004) r 5 2.34 (P 5 .008) r 5 2.33 (P 5 .009) r 5 2.22 (P 5 .006) r 5 2.26 (P 5 .8)
r 5 .40 (P 5 .002) r 5 .32 (P 5 .003) r 5 .38 (P 5 .003) r 5 .42z (P 5 .005) r 5 2.47z (P 5 .001) r 5 .41z (P 5 .005) r 5 .49z (P 5 .001) r 5 .48z (P 5 .001) r 5 2.38 (P 5 .007)
BMI 5 body mass index; NPRS 5 Numeric Pain Rating Scale; WOMAC 5 Western Ontario and Mcmaster universities osteoarthritis index; RMS 5 Rolland Morris Scale; T2D 5 type 2 diabetes; HTN 5 hypertension; SA 5 sleep apnea. * The negative coefficients of correlation are form the higher functional ability scores. y Difference between BMI measured at baseline and after 1 year. z Significant correlation after 1 year.
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References
Fig. 2. Co-morbidities remission.
available on functional ability assessment specifically on nonambulatory patients with obesity and co-morbidities remission after metabolic surgery to compare our results with because we did not determine or evaluate the physical functions that are usually evaluated in ambulatory patients, such as cardiovascular endurance, muscular endurance, and motor skill performance. However, because follow-up of these patients is planned, there will be further improvement as patients lose more weight, and we will thus be able to evaluate the physical functions that are usually evaluated in ambulatory patients, such as cardiovascular endurance, muscular endurance, and motor skill performance. These limitations might substantially limit the statistical power of our assumptions. The strength of this study is the correlation of the data pre- and postoperatively by various functional ability scales and co-morbidities. To the best of our knowledge, our study is the first to assess various functional ability scales with BMI and co-morbidities at baseline and after bariatric surgery in a specific nonambulatory cohort of patients. There is a need for the performance of multicenter prospective studies with larger series and a longer term of follow-up. Conclusion Bariatric surgery is safe and effective for treatment of severe obesity and its co-morbidities. Weight loss after bariatric surgery results in significant alteration in the ambulatory status of nonambulatory patients resulting in improvement of functional abilities and quality of life. Acknowledgments Authors acknowledge the follow-up multidisciplinary bariatric team who actively contributed to this study. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
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Original article
Assessment of functional ability of nonambulatory patients with obesity: after and before bariatric surgery Mohit Bhandari, M.S.*, Winni Mathur, B.P.T., M.B.A., Susmit Kosta, Ph.D., Prashant Salvi, M.S., Mathias Fobi, M.D. Mohak Bariatrics and Robotics Center, Indore, Madhya Pradesh, India Received 27 June 2019; accepted 12 September 2019
Abstract
Introduction: Functional ability is often impaired as a direct consequence of severe obesity. Bariatric surgery is the most effective treatment for severe obesity. Objective: To examine the effect of weight loss after bariatric surgery on patients with impaired functional ambulatory abilities due to obesity. Settings: A high-volume university-affiliated bariatric surgery center in India. Method: We conducted a prospective study in a cohort of nonambulatory patients with functional disabilities (bedridden, wheelchair-bound, or walker-dependent) who underwent bariatric surgery. Data on sex, body mass index, co-morbid conditions, the severity of pain, and types of limitations in functional abilities were collected at baseline and at 1 year after bariatric surgery and analyzed. Results: Forty-five patients were enrolled in this study with 100% follow-up at 1 year. The mean age and body mass index of the patients were 54.7 6 8.5 years and 54.2 6 8.6 kg/m2, respectively. Thirtyfour (75.5%) were female, 27 (60%) were walker-dependent, 14 (31.1%) were wheelchair-bound, and 4 (8.9%) were bedridden. At baseline 88.8% and 75.5% patients had severe knee and back pain, respectively. The percentage of total weight loss was 22% and 31% at 6 and 12 months, respectively. At 1 year, 37 (82.2%) patients were ambulating independently, only 1 (2.2%) patient was still bedridden, and 7 (15.5%) patients were walker-dependent. Mild, moderate, and severe classification on all functional ability scales were significantly improved. Conclusion: Weight loss after bariatric surgery results in significant amelioration of knee and/or back pain with an improvement in functional abilities and quality of life. (Surg Obes Relat Dis 2019;-:1– 7.) Ó 2019 Published by Elsevier Inc. on behalf of American Society for Bariatric Surgery.
Key words:
Functional ability; Nonambulatory; Obesity; Bariatric surgery; Weight loss
Obesity is associated with a reduction in individual mobility, aggravating a previously sedentary lifestyle [1,2]. Activities of daily living are impaired due to excessive body fat accumulation. Fat accumulation also reduces functional abilities, such as walking capacity. The ability to walk * Correspondence: Dr. Mohit Bhandari, M.S., Mohak Bariatrics and Robotics Center, SAIMS Campus, Indore-Ujjain Highway, Indore, Madhya Pradesh, India 453555. E-mail address: [email protected] (M. Bhandari).
is a simple measure of physical function and an important component of quality of life because it reflects the capacity to perform day-to-day activities [3,4]. Severe obesity is associated with mechanical and structural changes that may indirectly impact physical health and induce musculoskeletal conditions [5–7]. Severe obesity may magnify these problems, and contribute to additional problems, such as increased friction from excess gluteal fat and insufficient exercise capacity leading to rapid exhaustion, making walking even more difficult or unpleasant [8,9].
https://doi.org/10.1016/j.soard.2019.09.068 1550-7289/Ó 2019 Published by Elsevier Inc. on behalf of American Society for Bariatric Surgery.
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Mohit Bhandari et al. / Surgery for Obesity and Related Diseases - (2019) 1–7
Walking limitations are a precursor to dependency in more basic activities of daily living, such as dressing, bathing, grooming, ability to transfer from bed to a wheelchair, or getting in or out of bed [10]. Evidence suggests that weight loss causes relief of knee and/or back pain and enhances the functional ability of affected patients [11–13]. Currently, bariatric surgery is the most effective treatment for severe obesity and results in improvement in the quality of life [14]. Most studies have reported on improvement of physical function after bariatric surgery on ambulatory patients with respect to cardiovascular endurance, muscular endurance, and motor skill performance [15,16]. These improvements are a consequence of the weight loss. Though there are no studies on the changes in functional abilities after bariatric surgery in nonambulatory patients with obesity, it is obvious that these changes in the nonambulatory status are due to the weight loss. Thus, this study was initiated to assess the health-related quality of life of nonambulatory patients with severe obesity undergoing bariatric surgery at a tertiary care bariatric center. The primary aim of the study was 2-fold, (1) to assess the pre- and postoperative functional ability of nonambulatory patients by Numeric Pain Rating Scale, Western Ontario and McMaster Universities Osteoarthritis Index, Rolland Morris Scale, and KATZ scores, and (2) to determine any correlation between body mass index (BMI), sex, age, and co-morbidities to the functional abilities in these patients. These results can be used to manage the expectations of nonambulatory patients with obesity after bariatric surgery regarding their quality of life.
Methods Study design We prospectively collected data on nonambulatory patients with 3 functional disabilities, being bedridden, wheelchair-bound, or walker-dependent who had weight loss surgery at Mohak Bariatric and Robotic Surgery Center, Indore, MP, India. Indications for weight loss procedures were based on the 1991 National Institutes of Health criteria with modifications for patients in the Asia pacific region (at least BMI .28 kg/m2 with co-morbidities after previous failed attempts to lose weight conventionally). Bariatric procedures were contraindicated in patients with certain gastric lesions, neoplastic findings, or family history of gastric cancer. Individuals with mental health disorders, significant medical co-morbidities precluding sedation, or coagulopathies were also excluded. In addition to a preprocedural consultation with the surgeon, patients also underwent evaluations by a bariatric physician, physiotherapist, and dietician. All patients also underwent routine laboratory, radiologic, and cardiopulmonary evaluations. Preoperatively, all patients provided written informed consent for their operation and to have de-identified data analyzed for
presentation or publication. The institutional review board approved this study. The choice of procedure was made by the patient in conjunction with the surgeon after proper education and discussion of technical aspects, risks, and costs. Data on sex, BMI, co-morbid conditions, type of limitation of functional ability, and the severity of knee and/or back pain were collected at baseline and at 1 year after bariatric surgery and analyzed. Outcome assessment The baseline and follow-up characteristics included the analysis of weight, height, and BMI. The resulting changes in BMI and percentage of total weight loss were measured during scheduled follow up visits at 1, 3, 6, and 12 months postprocedure. The categories of mobility (bedridden versus walker-dependent, versus wheelchair-bound) were determined by physical assessment and by self-reporting of the patients. Further outcomes included postprocedure hospital length-of-stay. Pain scores and co-morbidities remissions were assessed at 12 months postprocedure. Assessment of functional ability Pre- and postsurgery outcome parameters of functional ability were assessed using the following scales: Numeric pain rating scale. To assess the subjective intensity of pain. A composite pain intensity score was calculated from 0 to 10 numeric rating scale [17,18]. Where, 0 5 no pain, between 1 and 3 5 mild pain, 4 and 7 moderate pain, and 8 and 10 5 extreme pain. Western Ontario and McMaster Universities Osteoarthritis Index. To asses proprietary set of standardized questionnaires used by health professionals to evaluate the condition of patients with osteoarthritis of the knee and hip, including pain, stiffness, and physical functioning of the joints. It measures for 5 items for pain (0–20), stiffness (0–8), functional limitation (0–17) [19,20]. Where, 0 5 no pain, between 1 and 17 5 mild pain, 18 and 34 moderate pain, and 35 and 68 5 extreme pain. Rolland Morris Scale (numeric pain scale for low back pain). The questionnaire includes 24 questions regarding Assessment of Activities of Daily Living maximum of 24 points, minimum of 0 [21,22]. Where, 0 5 no pain, between 1 and 6 5 mild pain, 7 and 12 moderate pain, and 12 and 24 5 extreme pain. KATZ. To assess the function and detect problems in performing activities of daily living and to plan care accordingly. The index ranks adequacy of performance in the 6 functions of bathing, dressing, toileting, transferring, continence, and feeding. Patients were scored yes/no for independence in each of the 6 functions. A score of 6 indicates full function, 4 indicates moderate impairment, and 2 indicates severe functional impairment [23,24]. Where, 0 5 no pain, between 1 and 2 5 mild pain, 3 and 4 moderate pain, and 5 and 6 5 extreme pain.
Mohit Bhandari et al. / Surgery for Obesity and Related Diseases - (2019) 1–7 Table 1 Baseline characteristics of nonambulatory patients who had bariatric surgery Baseline characteristics Mean age, yr (SD) Sex (F:M), n (%) Mean height, cm 6 SD Mean weight, kg 6 SD Mean preoperative BMI, kg/m2 (SD) Preoperative co-morbidities T2D, n (%) HTN, n (%) SA, n (%) Back pain, n (%) Knee pain, n (%) Back and knee pain, n (%)
54.7 (8.5) 34 (75.5):11 (24.5) 154.1 6 8.8 128.6 6 20.8 54.2 (8.6)
and reposted Pearson’s coefficient of correlation. All P values presented are 2-tailed, and statistical significance was defined a priori as P , .05. Data analyses were performed using IBM-SPSS statistics 20 (IBM Corp, Armonk, NY, USA). Results Patients characteristics
23 (51.1) 33 (73.3) 28 (62.2) 34 (75.5) 40 (88.8) 29 (64.4)
SD 5 standard deviation; BMI 5 body mass index; T2D 5 type 2 diabetes; HTN 5 hypertension; SA 5 sleep apnea.
Statement of informed consent Informed consent was obtained from all individuals undergoing all procedures and included in our study. No identifying information is included in our study. Statement of ethical rights and human rights (as no animal experiments were conducted in this study) All procedures performed in our study were in accordance with the ethical standards of the institutional and national research committee. Statistical analysis Descriptive analyses of the variables were performed using the test of proportions for qualitative variables and measurements of central tendency (mean) and measures of dispersion (standard deviation [SD]) for quantitative variables. To assess demographic variables (such as age, height, sex, initial weight, and BMI, etc.) that may have contributed to better response rates, we employed the student’s t test for independent samples (continuous variables) and the c2 test (qualitative variables). We also correlated bassline BMI and co-morbidities with bassline scores on the functional ability and change in BMI and resolution of comorbidities with effectiveness in functional ability scores
Forty-five patients, 34 (75.5%) female and 11 (24.5%) male, with a mean age of 54.7 years (SD 8.5; range, 30–73) were enrolled in this study. They had an average weight of 128.6 kg (SD 20.8; range, 94.5–169.5) and a mean BMI of 54.2 kg/m2 (SD 8.6; range, 37.4–75.3). Of the 3 surgical procedures performed, the majority 21(43.8%) underwent sleeve gastrectomy followed by 19 (39.6%) who underwent one-anastomosis gastric bypass, and 8 (16.6%) who underwent Roux-en-Y gastric bypass. None had a history of any previous bariatric surgery or any surgical intervention for weight loss. Baseline characteristics and incidence of preoperative co-morbidities of the study cohorts are summarized in Table 1. Walking/functional disabilities according to age and BMI Four (8.9%) patients were bedridden, 14 (31.1%) were wheelchair-bound, and 27 (60%) were walker-dependent. There was a significant trend with BMI (P 5 .001) and with age (P 5 .004) group for each walking ability measure (Table 2), such that more obese and older adults reported more walking limitations compared with less obese and younger adults, respectively. At 1 year, 37 (82.2%) patients were ambulating independently, only 1 (2.2%) patient was still bedridden and 7 (15.5%) patients were walkerdependent (3 previously bedridden and 4 previously wheelchair-bound). (Table 2) Adverse effects and weight loss pattern There were no major postoperative complications. Minor adverse events included 14.5% with epigastric pain, 18.7% patients with nausea, 12.5% with vomiting, 12.5% with bloating symptoms, and 16.6% complained of a generalized
Table 2 Distribution of nonambulatory patients /functional disabilities according to age and BMI
Preoperative Number, n (%) Age, yr, (SD) BMI, kg/m2 (SD) Postoperative Number, n (%) BMI, kg/m2 (SD)
3
Bedridden
Walker-dependent
Wheelchair-bound
P value
4 (8.9) 61.50 (2.6) 65.25 (5.2)
27 (60.0) 50.12 (8.0) 51.60 (7.2)
14 (31.1) 53.81 (9.6) 54.25 (8.3)
.004 .001
1 (2.2) 60.0
7 (15.5) 42.86 (6.9)
-
.001
SD 5 standard deviation; BMI 5 body mass index.
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Mohit Bhandari et al. / Surgery for Obesity and Related Diseases - (2019) 1–7
Fig. 1. Weight loss pattern.
weakness. These events resolved spontaneously with minor interventions. The average length of stay was 4 days (range, 3–7 d) The percentage of total weight loss was 7%, 15%, 22%, and 31% at 1, 3, 6, and 12 months (Fig. 1). Effectiveness of functional ability scoring Applying the Numeric Pain Rating Scale, Western Ontario and McMaster Universities Osteoarthritis Index, Rolland Morris Scale, and KATZ scores and dyspnea grading to this cohort, at baseline 40 (88.8%) patients had knee pain with a rating of 7.6 6 1.4 and 34 (75.5%) had back pain with a rating of 7.3 6 1.4. After 1 year 10 (25.0%) patients had 100% resolution in knee pain and reduction of the scores to 2.9 6 1.7 in 30 (75.0%). Similarly, there were 9 (26.5%) patients with 100% resolution of back pain and reduction of the scores to 2.3 6 1.4 in 25 (73.5%) patients with back pain (Table 3). Table 4 demonstrates the mild, moderate, and severe classification for all scales before and after surgery. There was significant (P 5 .001) improvement in functional ability after the bariatric surgery in nonambulatory patients.
Discussion Walking is often prescribed to retain and improve physical function in performing various activities of daily life, such as doing light housework, crossing a street, or grocery shopping. Walking margins are an ancestor to dependency in more basic activities of daily life [10]. Thus, walking capacity is often impaired as a direct consequence of obesity, through excess weight bearing, and reduced flexibility of movement. Severe obesity can also impact walking capacity indirectly via destructive back and joint pain [6,7] and loss of muscle mass due to the proinflammatory state associated with adiposity and related co-morbidities. To the best of our knowledge, our study is the first to assess various functional ability scales with BMI and co-morbidities at baseline and after bariatric surgery in a specific nonambulatory cohort of patients. The advantage to this objective assessment is that these results could be used to manage expectations of nonambulatory patients with obesity after bariatric surgery regarding their quality of life. This study sample, ranging in mean age (54.7 6 8.5) from 30 to 73 years, enabled examination of functional disabilities who were bedridden, wheelchair-bound, or walker-
Correlation between BMI and obesity-specific functional ability scoring/co-morbidities Table 5 shows a correlation of the functional ability scores. There was weak correlation between baseline BMI and baseline co-morbidities with different functional ability scoring. In contrast, there was a significant correlation (P 5 .001) of enhancement of functional ability scoring with a change in BMI and resolution co-morbid conditions. At 1 year the rate of co-morbidities remission was 73.9%, 78.8%, and 71.4% for type 2 diabetes, hypertension, and sleep apnea, respectively (Fig. 2).
Table 3 Effectiveness of knee/back pain
Preoperative Pain, n (%) Score mean 6 SD Postoperative 100% resolution, n (%) Pain reduction, n (%) Score mean 6 SD
Knee pain
Back pain
40 (88.8) 7.6 6 1.4
34 (75.5) 7.30 6 1.4
10/40 (25.0) 30/40 (75.0) 2.9 6 1.7
9/34 (26.5) 25/34 (73.5) 2.3 6 1.4
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Table 4 Validation of the effectiveness of all scales (Functional Ability Scoring) Functional ability scoring
NPRS (for back pain) NPRS (for knee pain) WOMAC RMS KATZ Dyspnea grading
Preoperative
Postoperative
P value
Mild n (%)
Moderate n (%)
Severe n (%)
Mild n (%)
Moderate n (%)
Severe n (%)
15 (33.3) 6 (13.3) 6 (13.3) 12 (26.7) 24 (53.3) 3 (6.6)
19 (42.2) 16 (35.6) 3 (6.7) 5 (11.1) 14 (31.1) 34 (75.6)
11 (24.5) 23 (51.1) 36 (80.0) 28 (62.2) 7 (15.6) 8 (17.8)
39 (86.7) 31 (68.9) 28 (62.2) 33 (73.4) 43 (95.6) 42 (93.3)
5 (11.1) 10 (22.2) 9 (20.0) 6 (13.3) 2 (4.4) 3 (6.7)
1 (2.2) 4 (8.9) 8 (17.8) 6 (13.3) 0 0
.001
NPRS 5 Numeric Pain Rating Scale; WOMAC 5 Western Ontario and McMaster universities osteoarthritis index; RMS 5 Rolland Morris Scale.
dependent and limitations from young adulthood to older age. As expected, age was positively associated with walking limitations. However, many young bariatric candidates experience walking limitations generally associated with older age. The 60% that were walker-dependent had a mean age 50.1 6 8.0, the 31.1% who were wheelchairbound had a mean age 53.8 6 9.6, and 8.9% who were bedridden had a mean age 61.5 6 2.6. Sex was not significantly associated with higher odds of walking aid use or reporting physical discomfort [25–27]. Osteoarthritis is a very common problem in weightbearing joints, especially in the aging population and obesity has been identified as the main modifiable risk factor [11–13]. In this study we found a significant decrease in pain and significant improvement in the ambulatory status with weight loss after bariatric surgery. Table 4 shows the comparison and validation (effectiveness of mild, moderate, and severe classification) for various scales (functional ability scoring) pre- and postbariatric surgery in this study. The significant (P 5 .001) improvement in functional abilities after bariatric surgery in this study are consistent with other studies related to pain and walking limitations. There are
systematic reviews of the literature that reports bariatric surgery significantly improving quality of life over the long term [28–30]. The incidence of co-morbidities were significantly related to disability during obesity and all measures of walking scales. However, specific co-morbidities (type 2 diabetes, hypertension, sleep apnea, and back/knee pain) had better resolution with a change in BMI and enhancement of functional ability scores after bariatric surgery. All the patients but 1 had an improvement in their ambulatory status. The 1 patient that was still bedridden at 1 year had bilateral above the knee amputation. He could not independently transfer to a wheel chair at 1 year. However, currently with more weight loss he is able to independently transfer to a wheel chair. Follow-up of all these patients is planned and there obviously will be further improvement as the patients lose more weight. This study has 2 main limitations. The first limitation is that it is not a randomized study. Although all data were prospectively collected, the level of evidence provided is not as strong as that from a well-designed, randomized, prospective control study. Second, there is very limited literature
Table 5 Correlation between BMI and obesity specific functional ability scoring and co-morbidities
NPRS (for back pain) NPRS (for knee pain) WOMAC RMS KATZ Dyspnea grading T2D HTN SA
Correlation between baseline BMI and baseline functional ability scoring/comorbidities*
Correlation between change in BMI at after 1-yr functional ability scoring/comorbiditiesy
r 5 2.29 (P 5 .004) r 5 2.24 (P 5 .006) r 5 2.02 (P 5 .83) r 5 2.16 (P 5 .2) r 5 2.30 (P 5 .004) r 5 2.34 (P 5 .008) r 5 2.33 (P 5 .009) r 5 2.22 (P 5 .006) r 5 2.26 (P 5 .8)
r 5 .40 (P 5 .002) r 5 .32 (P 5 .003) r 5 .38 (P 5 .003) r 5 .42z (P 5 .005) r 5 2.47z (P 5 .001) r 5 .41z (P 5 .005) r 5 .49z (P 5 .001) r 5 .48z (P 5 .001) r 5 2.38 (P 5 .007)
BMI 5 body mass index; NPRS 5 Numeric Pain Rating Scale; WOMAC 5 Western Ontario and Mcmaster universities osteoarthritis index; RMS 5 Rolland Morris Scale; T2D 5 type 2 diabetes; HTN 5 hypertension; SA 5 sleep apnea. * The negative coefficients of correlation are form the higher functional ability scores. y Difference between BMI measured at baseline and after 1 year. z Significant correlation after 1 year.
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References
Fig. 2. Co-morbidities remission.
available on functional ability assessment specifically on nonambulatory patients with obesity and co-morbidities remission after metabolic surgery to compare our results with because we did not determine or evaluate the physical functions that are usually evaluated in ambulatory patients, such as cardiovascular endurance, muscular endurance, and motor skill performance. However, because follow-up of these patients is planned, there will be further improvement as patients lose more weight, and we will thus be able to evaluate the physical functions that are usually evaluated in ambulatory patients, such as cardiovascular endurance, muscular endurance, and motor skill performance. These limitations might substantially limit the statistical power of our assumptions. The strength of this study is the correlation of the data pre- and postoperatively by various functional ability scales and co-morbidities. To the best of our knowledge, our study is the first to assess various functional ability scales with BMI and co-morbidities at baseline and after bariatric surgery in a specific nonambulatory cohort of patients. There is a need for the performance of multicenter prospective studies with larger series and a longer term of follow-up. Conclusion Bariatric surgery is safe and effective for treatment of severe obesity and its co-morbidities. Weight loss after bariatric surgery results in significant alteration in the ambulatory status of nonambulatory patients resulting in improvement of functional abilities and quality of life. Acknowledgments Authors acknowledge the follow-up multidisciplinary bariatric team who actively contributed to this study. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
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