Shirley Aparecida Fabris de Souza

Gait Cinematic Analysis in Morbidly Obese Patients

Background: Functional co-morbidities of excess body weight such as gait problems are never life-threatening like those associated with certain metabolic sequelae. Nevertheless, they may interfere with quality of life and also act as a mirror of muscle, bone and joint stress. In this prospective study, the goal was to document dynamic aspects of gait in severely obese subjects. Methods: An outpatient population (age 47.2 ± 12.9 years, 94.1% females, BMI 40.1 ± 6.0 kg/m2, n= 34) had their gait analyzed by an experienced physical therapist. Variables included speed, cadence, stride, support base and foot angle, which were compared to reference values for the Brazilian population. Results: All variables were significantly lower in the obese patients, except for support base which was increased. Speed was 73.3±16.3 vs 130 cm/s, cadence was 1.4±0.2 vs 1.8 steps/s, stride was 106.8±13.1 vs 132.0 cm, and support was 12.5±3.5 vs 10.0 cm (P<0.05). Conclusions: 1) Widespread cinematic impairment was the rule in the studied population. 2) These findings are consistent with poor skeletal muscle performance, high metabolic expenditure and constant physical exhaustion. 3) Attention should be paid not only to the metabolic management but also to the physical rehabilitation required in cases of advanced obesity.

Pulmonary function and aerobic capacity in asymptomatic bariatric candidates with very severe morbid obesity

PURPOSE Aerobic capacity and respiratory function may be compromised in obesity, but few studies have been done in highly obese bariatric candidates. In a prospective study, these variables were documented in the preoperative period, aiming to define possible physiologic limitations in a apparently healthy and asymptomatic population. METHOD Forty-six consecutively enrolled adults (age 39.6 +/- 8.4 years, 87.0% females, body mass index /BMI 49.6 +/- 6.3 kg/m2) were analyzed. Ventilatory variables were investigated by automated spirometry, aerobic capacity was estimated by a modified Bruce test in an ergometric treadmill, and body composition was determined by bioimpedance analysis. RESULTS Total fat was greatly increased (46.4 +/- 4.6% of body weight) and body water reduced (47.3 +/- 4.6 % body weight), as expected for such obese group. Spirometric findings including forced vital capacity of 3.3 +/- 0.8 L and forced expiratory volume-1 second of 2.6 +/- 0.6 L were usually acceptable for age and gender, but mild restrictive pulmonary insufficiency was diagnosed in 20.9%. Aerobic capacity was more markedly diminished, as reflected by very modest maximal time (4.5 +/- 1.1 min) and distance (322 +/-142 m) along with proportionally elevated maximal oxygen consumption (23.4 +/- 9.5 mL/kg/min) achieved by these subjects during test exercise. CONCLUSIONS 1) Cardiopulmonary evaluation was feasible and well-tolerated in this severely obese population; 2) Mean spirometric variables were not diminished in this study, but part of the population displayed mild restrictive changes; 3) Exercise tolerance was very negatively influenced by obesity, resulting in reduced endurance and excessive metabolic cost for the treadmill run; 4) More attention to fitness and aerobic capacity is recommended for seriously obese bariatric candidates;

Computerized baropodometry in obese patients.

Background: Few studies have investigated the influence of obesity on the structural and functional performance of the feet, and its potential implications for the musculoskeletal system. Computerized baropodometric analysis (CPA) is a new investigation for the center of pressure, plantar surface area and plantar pressure while standing on the platform of a specialized apparatus. CPA is relevant to gait and posture, and may be important as well for postoperative musculoskeletal disorders. We investigated the biomechanical dysfunctions of foot pressure by means of CPA in bariatric and non-bariatric subjects. Methods: Subjects (n=67, 71.6% females, age 40.8 ± 13.8 years, BMI 31.4 ± 11.0 kg/m2) included obese (BMI 30.0-60.0 kg/m2, n=27), overweight (BMI 25.0-29.9 kg/m2, n=12) and normal-weight controls (BMI 20.0-24.9 kg/m2, n=28) of equivalent age and gender. Variables included center of pressure location, plantar ground contact area and pressure, and pressure patterns (maximum and average) in different regions of the foot, during quiet standing on the platform of the baropodometer. Results: A significant increase was detected for peak pressure on forefoot and plantar ground contact area in the obese group, compared to control and overweight cases, during quiet standing. Conclusion: Excessive forefoot pressure and enlarged support area were a consequence of obesity, mirroring the efforts of the obese subject to acquire a wider and stronger support base. Although this is originally a physiological change, it may result in maladaptative and degenerative musculoskeletal consequences. Re-education exercises may be advised, in combination with bariatric surgery in the morbidly obese, aiming at restoration of normal gait and posture, as well as at minimization of stress damage to bones and joints in the axial skeleton.

Disability in the Post-Obese Bariatric Patient: Old and New Problems

Sustained and lifelong weight loss for severely obese people is not anymore an impossible dream, and a Swedish journal has described bariatric surgery as the fairy tale about the ugly duckling (Olbers 2011). Of course this is a bittersweet remark, because although for millions such is an advantageous and even life-saving intervention, all of them have to cope with the post-obesity status. Obesity is a chronic incurable disease and the postobesity status is an attenuated albeit ongoing illness, not a mere sequela. Appropriate follow-up and secondary interventions, be they surgical, clinical, physiatric, dietary, or psycho-social, may be demanded. Obesity entails widespread disorders involving as far away organs, structures, needs and abilities as the teeth, the central nervous system, the gut microbiome, the susceptibility to cancer, the performance at the workplace, and the demand for health care resources. Subsequent weight gain and comorbidity relapse is a permanent possibility, as endogenous and environmental obesogenic stimuli are not suppressed, only weakened. Gastrointestinal restriction and bypass are highly successful maneuvers when correctly indicated and conducted, however, they do not signal the end of the battle. Patients have to be educated and followed for life. It is hoped that such experience along with general public-health initiatives will eventually trickle down to their families, their offspring, and society in general, so that the new generations might be born and nurtured with obesity prevention in mind.

Bariatric Surgery: Current Techniques and Results

Half a century ago obesity was not a public health problem, however, gastroduodenal ulcers were ubiquitous. Many gastrectomies were conducted at that time and patients eventually lost weight. That is how bariatric surgery commenced, naturally expanding to a variety of techniques and accesses. Success has been both bigger and smaller than expected. Yes, bariatric operations became so popular that they already represent one of the five most performed major operations in some countries. They are followed by strong secondary benefits particularly concerning diabetes remission, to the point that a new subspecialty has arisen, metabolic surgery for diabetes. No, they are not carefree and they have not solved the problem of severe obesity, at least from the epidemiological point of view. They were actually not designed to be a mass treatment. The pursuit of new therapeutic avenues and the reinforcement of old ones is still mandatory, if the worldwide obesity epidemic is to be curtailed.