Effective physical therapy interventions are essential for helping patients manage this prevalent health risk.

Obesity is a condition that results from an imbalance between caloric input and energy output. It is associated with numerous comorbidities, including cardiovascular disease, diabetes mellitus, obstructive sleep apnea, and osteoarthritis.¹ In turn, these comorbidities may lead to serious health problems, functional limitations, and even frank disability.1,2 The rapid increase in the prevalence of obesity in America, its association with major health compromises, and the enormous costs to society associated with the condition have caused obesity to be recognized as a major public-health problem in this century. The mere prevalence of obesity in American society signals the need for every health care practitioner to be vigilant of its detrimental effects. Specifically for physical therapists (PTs), the myriad compromises to movement and function suggest the need for active intervention. This article will review elements surrounding obesity and demonstrate proposed physical therapy involvement with patients who are obese and attempting to manage its comorbidities through surgery and/or activity/exercise.

According to the National Institute for Health (NIH)2 clinical guidelines and the World Health Organization,³ “overweight” is an umbrella term signifying a body mass index (BMI: weight in kilograms divided by the square of the height in meters) equal to or greater than 25 kg/m2. Health care professionals use BMI to quantify weight across a range of body sizes and to determine risk factors for the diseases associated with obesity.⁴ Furthermore, the distribution of fat stores is also a significant indicator of health risk, as waist circumference and centrally distributed adiposity (waist circumference >40 inches in men or >35 inches in women) has been shown to be an independent risk factor for obesity-related diseases.⁴ Having a BMI >= 30 kg/m2 signifies one is obese. Obesity is further divided into three classes: Class I, BMI >30 kg/m2 but <35 kg/m2; Class II, BMI >35 kg/m2 but <40 kg/m2; and Class III, BMI >40 kg/m2.2,3 Individuals with Class II or Class III obesity (a BMI >=35 kg/m2) are considered to be morbidly obese.⁵ As one progresses to a higher class of obesity, health risk and morbidity increase. If the morbidly obese patient’s obesity level remains untreated, he or she has only a 1 in 7 chance of reaching his or her life expectancy.5,6 

In the United States, Flegal et al estimates that 65% of adults can be categorized as overweight or obese.⁷ The prevalence of being overweight (BMI >25 kg/m2) has increased from 43.3% in the 1960s to 64.5% in 2000.7 Similarly, the prevalence of obesity has more than doubled in the same time period, with 30.9% of individuals categorized as obese in 2000, as compared to 13.4% in 1960.7,8 This increase in the percentage of people who are now overweight or obese is paralleled by a documented reduction in daily energy expenditure and physical activity among Americans.^9,10 Existing evidence indicates that physical inactivity is strongly associated with body-weight gain and that the conduct of purposeful and regular exercise and maintenance of a physically active lifestyle can be effective for maintaining a healthy body weight.11-13 The resulting decrease in aerobic capacity and the ability to perform physical activities can be expected to have implications for an individual’s health and health care.

Intervention aimed at reducing body weight typically involves a combination of dietary treatment, exercise, and behavior modification.2,4,11-21 Pharmacological therapy and bariatric surgery also are used as intervention options for individuals who are overweight or obese.

Patient Assessment

Patients who are morbidly obese often report that they have a poor quality of life, problems with joint pain, decreased mobility, functional limitations, and deconditioning prior to undergoing bariatric surgery.9-10,22 Operative risks, abdominal incisions, and the complications associated with being on bedrest postoperatively often will exacerbate a patient’s impairments and functional limitations, and may create new deficits. Because physical-therapy intervention is directed toward impairments and limitations in movement and function, patients who have bariatric surgery appear to be appropriate candidates for physical therapy examination and intervention both prior to and following surgery. In addition, many of the comorbidities associated with obesity, such as diabetes, osteoarthritis, and cardiovascular disease, can be positively influenced by physical-therapy intervention, making the primary and secondary medical diagnoses appropriate targets for the PT.

A physical-therapy examination of obese clients who are obese identifies key impairments and movement faults that occur during functional mobility tasks.

Following a thorough medical-systems review and a health and exercise history assessment (pain included), the objective examination used at our facility is focused on four categories of clinical information: appearance and postural analysis; motor and sensory function; functional activities; and gait, endurance, and postural control.

Appearance and postural analysis are examined to identify the clients’ excessive fat-accumulation pattern (apple or pear, and its impact on function), their static postural faults, and their faulty movement patterns. Motor and sensory function is evaluated to identify the impairments of decreased strength, flexibility, sensation, and proprioception that can impact the client’s ability to be independent with functional activities and ambulation. Functional activities (rising from sit to stand, climbing stairs, lifting, bathing, toileting, and dressing/grooming) and gait are assessed to identify functional limitations that the client may present. Based on the outcome of the examination, various forms of adaptive equipment, such as a handheld showerhead, a long-handled scrub brush, a raised toilet seat, or a tub bench, may be needed to decrease effort and increase or maintain the client’s level of independence.

Next, a measure of endurance is obtained through a 6-minute walk, a 3-minute step test, or a bicycle or treadmill test. During the examination of endurance, baseline and activity vital signs are obtained for screening purposes and to help develop an appropriate exercise prescription. According to the American Heart Association and the American College of Sports Medicine (ACSM) guidelines for exercise testing and training, exercise or activity should produce a change in heart rate (HR) and blood pressure (BP) as follows: HR should rise 10 bpm/MET, systolic  should rise 7–10 mm Hg/MET, and diastolic BP may fluctuate +10 mm Hg/MET.²³ Lastly, postural control is analyzed to assess the individual’s ability to correctly align himself or herself during static and dynamic activities so that movement is efficient, safe, and occurs with the least amount of pain possible.

Corbeil et al theorize that obese individuals may have a higher fall risk.²⁴ He proposes that two physical consequences of obesity—an increased mass to stabilize over the base of support and an anterior position of the body’s center of mass relative to the ankle joint—and potential health-related factors, such as muscular atrophy/weakness or aging, are likely to exacerbate the risk of falling in an individual who is obese.²⁴ For these reasons, the patient’s postural control needs to be assessed. I examine elements of postural control using components of the Functional Balance Scale developed by Berg.25,26 

Physical-Therapy Intervention

Intervention in this client group must be broad-based and multidisciplinary to address medical comorbidities, nutritional needs and eating habits, and exercise and physical-activity patterns.27,28 Because movement in obese clients can be challenging and even risky for both the cardiovascular and musculoskeletal systems, PTs are key individuals trained to provide intervention focusing on safe and efficient movement, correction of impairments (flexibility, balance, strength, and endurance), alleviation of musculoskeletal pain syndromes, and functional independence. When prescribing exercise, it is important to assess and pay attention to the client’s likes, motivation, and readiness to adhere to an exercise program. Programs can be recommended that allow for resistive and aerobic exercise to be done individually or in groups. Groups often are very useful to help maintain motivation levels and promote adherence to programs.

At our facility, we have developed a group-exercise program, On the Move™, that is led by PTs with assistance from PTs in training. Participants have the opportunity to attend 60-minute exercise sessions held one to four times per week. Prior to entering and exiting the program, each participant has an individualized assessment of their musculoskeletal status with regard to flexibility, strength, endurance, and balance. This enables the exercise-session leaders to screen each participant and tailor exercise sessions to the needs of the individuals in each class. The On the Move program uses various types of programming and educational materials to improve musculoskeletal status: low-impact aerobics in sitting and standing for endurance; exercise balls for balance and coordination; resistive bands and free weights for strengthening; self-stretching for flexibility; and slow, controlled movement for posture and body control. Education is provided during class sessions as take-home materials, and we email participants weekly to promote interactive education and communication.

Prescribing an exercise program for clients may be challenging initially because of musculoskeletal pain, medical comorbidities, and the distribution of excess weight. The exercise prescription may also be complicated by the client’s deconditioned state and abnormal vital-sign responses displayed during the examination. Frequently, alternative modes of activity and exercise, such as aquatics and chair aerobics, need to be prescribed for this client population and should be determined based on the individual’s limitations in gait, the complaints of musculoskeletal pain, and the demonstrated deficits in postural control.

Obesity is a significant public health problem in the United States. Following the 1996 NIH Consensus Conference statement that “surgery is the only effective treatment for morbid obesity,” many class III obese individuals are seeking and being counseled to have bariatric surgery as a treatment intervention.^20,29 In light of the increasing prevalence of obesity, PTs will need to educate themselves on specific and effective examination components for the obese client.

Tamara L. Burlis, PT, DPT, CCS, is an assistant professor at the Program in Physical Therapy at Washington University School of Medicine, St Louis. She has pursued clinical practice and administrative roles in the acute care, cardiopulmonary, and vascular divisions of Barnes-Jewish Hospital in St Louis. Currently, she is on the clinical education team and maintains a clinical practice in the area of obesity—specifically, gastric bypass surgery, and exercise and fitness for the obese patient. Her current research activities focus on functional and exercise therapy for the obese patient, and the measurement of vital signs by physical therapists.

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