Phone: 866-782-6258

Bariatric Apple Pannus and Apple Ascities Body Types: Relation to Mobility and Therapy

Rina Pandya, PT, DPT

June 1, 2023



What is the difference in apple body types of apple ascites and apple pannus, and what should we know regarding transfers and applicability to practice? 


Apple Ascities and Apple Pannus

  • Apple ascites: weight is carried high; the abdomen may be rigid
  • Apple pannus: weight carried high; abdomen mobile (apron) and hanging down

Figure 1 shows the apple body type.

Figure 1

Figure 1. Apple body type.  Image: Continued (licensed from Getty Images)

Identifying these different body types is crucial as your handling and transfer techniques will change with each.

Apple Ascites

Those with an apple ascites shape have a high waist-to-hip ratio. These patients have trouble tolerating any supine or prone position. Why do you think that is? The rigid abdomen causes restricted chest wall movement, poor ventilation (O2 sats < 90%), and decreased diaphragmatic activity. Postural adaptation is associated with hypertrophy of accessory muscles, jugular vein distention, and elevated clavicles.  They will be very uncomfortable if you want them to lie down in treatment.

The size of their legs may be relatively normal, with intact hip and knee flexion. However, they may display limited trunk flexion, ambulation, and wheelchair propulsion. If their hips and knees are intact, they should be able to walk around. Ask them what they can do and make them use their legs when doing a transfer. Chances are, they have found a way to work around their large abdomen. Again, they may not be able to bend too far forward, have limited ambulation, and have difficulty propelling a wheelchair due to the large abdominal mass. 

As far as mobility is concerned, they may be able to prop on their elbows and do a flat spin to bring their hips closer to the edge of the bed. Then, they may be able to push up their upper body and bring their legs over the edge of the bed for you. If you see this body type and they can move their legs up and down while supine in bed, you can instruct them to push up on their arms and spin around. They may tolerate rolling but may not be able to lay supine for a log roll.

Apple Pannus

Figure 2

Figure 2. Example of apple pannus. Image: by FatM1ke, Public domain, via Wikimedia Commons

Here the belly button is mobile, and the abdomen does hang a little bit. When the abdomen is stabilized, the patient can tolerate the supine position.

Figure 3 shows a large pannus.

Figure 3

Figure 3. Example of a large pannus. Image: Muybridge, Eadweard, 1830-1904, Public domain, via Wikimedia Commons

In the case of an apple pannus shape, the hips and knee flexion remain intact, and the leg size may be normal.

There is also a pannus classification.

  • Grade 1 pannus covers the pubic hairline but not the entire mons pubis.
  • Grade 2 pannus covers the entire mons pubis.
  • Grade 3 pannus covers the upper thigh.
  • Grade 4 pannus extends to midthigh.
  • Grade 5 pannus extends to the knee and beyond. 

Figure 3 shows a grade-four pannus. 

Regarding positioning and transfers, these clients can turn on their side for ventilation and improved diaphragmatic excursion. You can place the pannus on some soft pillows while lying on their side. Typically, they can ambulate distances.

Some patients with the apple pannus distribution use a supine flat spin, and they pop themselves perpendicularly to sit up at the edge of the bed. They are the guys who scootch sideways and then prop themselves on their arms to sit up. The easier way for these guys to get on and off the bed is using a prone quadruped technique.

For more information on bariatric transfers and manual handling, see course 4352 Guide to Bariatric Transfers and Manual Handling, by Rina Pandya, PT DPT. 

rina pandya

Rina Pandya, PT, DPT

Dr. Rina Pandya, PT, DPT, has an extensive physical therapy career that spans over 20 years, through the UK, the USA, and the Middle East. She has worked in NHS (National Health Service), American health care providing PT services in acute care, in-patient rehab, skilled nursing facility, home healthcare, and outpatient clinic. In addition to being a clinician, she has developed specialty programs based on evidence-based practice in her role as a project manager. She has also managed a Physical Therapy department as Department Head in a premier private hospital in Oman. Currently, Dr. Rina is a senior lecturer of physiotherapy (musculoskeletal physiotherapy) at the University of West England, Bristol, UK, and an author of a pocket book series titled Orthopedic Assessments Made Easy.  

Rina graduated from Manipal University, India, in 2000, as well as the University of Michigan, in 2018 with a Doctor of Physical Therapy. Rina is a member of the APTA, HCPC-UK, and OAP-Oman. 

Related Courses

Upper Extremity Fractures and Stages of Fracture Healing
Presented by Rina Pandya, PT, DPT
Recorded Webinar


Rina Pandya, PT, DPT
Course: #4653Level: Introductory2 Hours
  'I liked the incorporation of the X-rays with the anatomy and clinical presentation'   Read Reviews
Based on the latest evidence of fracture healing and complications responsible for impaired healing, this course also includes the classification of fractures, stages of healing, and case studies.

Rehab Professionals Guide to Diaphragm Rehabilitation After Mechanical Ventilation
Presented by Rina Pandya, PT, DPT
Recorded Webinar


Rina Pandya, PT, DPT
Course: #3957Level: Intermediate3 Hours
  'Easy to follow'   Read Reviews
The clinical relevance of strength and function of the diaphragm as a core stabilizer and its role as a thoracoabdominal pump is covered in this course. This course walks through the positive effects of diaphragmatic breathing which is integral for both mental and physical recovery of a patient after mechanical ventilation. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

A Physical Therapist Guide to Exercise Prescription for the Diabetic and Pre-diabetic Population
Presented by Rina Pandya, PT, DPT
Recorded Webinar


Rina Pandya, PT, DPT
Course: #4483Level: Advanced3 Hours
  'Instructor was passionate and ready to teach'   Read Reviews
This course equips the physical therapist to identify pre-diabetes and type 1 diabetes in their patients based on history and clinical signs and symptoms. Exercise Prescription, the interaction of other medications, and modulation of a current exercise program for patients with diabetes as a co-morbidity are also included. This course also includes the management of diabetes from a Covid-19 perspective.

Editor's Note: Regarding Pennsylvania credits, this course is approved by the PA State Board of Physical Therapy for 3 hours of Direct Access CE credit.

Guide to Bariatric Transfers and Manual Handling
Presented by Rina Pandya, PT, DPT
Recorded Webinar


Rina Pandya, PT, DPT
Course: #4313Level: Intermediate3 Hours
  'Very thorough'   Read Reviews
This course addresses different manual handling techniques, considerations, and safety for patient transfers for the patients, clinicians, and caregivers. This aids in staff retention, reduces workplace injuries, and prolongs a clinician's career in their chosen field of healthcare. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

Groin Pain: Etiology, Differential Diagnosis, and Treatment Strategies
Presented by Rina Pandya, PT, DPT
Recorded Webinar


Rina Pandya, PT, DPT
Course: #4869Level: Advanced3 Hours
  'Very very detailed'   Read Reviews
Delve into the intricacies of groin pain as we unravel its causes, discuss effective differential diagnoses, and explore cutting-edge treatment approaches. Don't miss this opportunity to enhance your understanding and refine your clinical strategies in addressing this common yet complex medical concern.

Our site uses cookies to improve your experience. By using our site, you agree to our Privacy Policy.