Defining Moment A Snow Angel in Dayton Motivation comes in all shapes, sizes, even weather phenomena. By Janet Squiers, PT | August 2016 Listen to 'Defining Moment' "What do you want on your pizza?" I ask. "Pepperoni and mushrooms!" he answers. "Mushrooms? Ewww! I don't like mushrooms!" I respond, because I know it will make him smile and laugh. We are playing in his room on the hematology/oncology floor at Dayton Children's Hospital. He is 6 years old, with a double-lumen Hickman catheter and multiple lines connected to a minimum of 2 IV pumps. He has a nasogastric tube that provides supplemental nutrition. His IV pole is so top-heavy it could topple like an overloaded coat tree when rolling it aside to begin his physical therapy session. We play a pretend-pizza game. Magnets attach tasteless toppings to a perfectly round, stiff surface of wooden dough. He uses his hands to locate the pieces because his vision has deteriorated from cataracts after years of steroids and chemotherapy. We are sitting on his bed, to give him a sense of control over a life of which he has so little. He reaches for the wooden toppings using his oblique abdominal muscles to rotate his torso, which has become stiff from illness and inactivity. We place the pepperoni circles between his toes and reach for them to stretch his hamstrings and heel cords that have tightened from so much time spent in bed, a result of fatigue and not feeling well. These are all typical therapeutic activities carried out by the pediatric physical therapist. Strength, range of motion, and functional mobility are all part of the plan that is hiding within the pizza-making game. If I play my cards right, maybe I can address his ambulation goals today. Every patient I have ever encountered has something that motivates him or her. Through my experience as a pediatric physical therapist, I've compiled a toolbox stocked with therapeutic activities and exercises that address the goals set in my plan of care. My challenge is to identify what motivates the patient—and often the parent—to begin the work required to create change and improve function. These are the defining moments in my career. They happen again and again, day after long, often exhausting, day. I look for what makes the child "tick" and how to tap into whatever it is—a toy, a song, or an activity. On another occasion in the outpatient clinic, a 4-year-old girl diagnosed with Down syndrome demonstrates readiness for walking, but she repeatedly succumbs to gravity by lowering to the floor after only 5 or 6 steps. Somehow during her session, we discover the game of hide and seek. Her father and mother dash around a corner, then peek out and call her name. She becomes so excited about the prospect of locating her parents that she increases her walking distance by at least 50 feet in her search for the loving and forever-supportive faces poking out from the doorway down the hall. Her balance is impacted by fatigue and her base of support widens with the extra distance, but she is able to practice the skill in her session with enough repetition that it quickly becomes her own. She soon has the confidence and strength to use her once-unsteady steps as her new form of mobility—walking. Now it's the day of the big storm, as predicted by the local news team. I cross the walkway outdoors to get to the main hospital building, wondering what my young pizza-maker's mood will be today. Did he sleep last night? Have the sores in his mouth returned? Is his abdomen distended and uncomfortable? I watch the snowflakes fall and think about all the kids who are home from school on a snow day and probably outside, playing or making snow angels. I think about my little patient, confined to his room but surrounded by nurses and patient-care attendants who care for him and wait patiently as he selects his superhero costume—a daily ritual. I wonder how hard it will be to coerce him to get out of bed today to work on his ambulation, endurance, and strength exercises. In a sudden moment of inspiration—let's call it a defining moment—I run back to my rehab clinic area, empty a plastic storage bin filled with random toys, and quickly head to the once-grassy but now snow-filled area by the side entrance to the hospital. I fill the bin with snow and carry it to the fourth floor. After checking with his doctors to be sure there are no contraindications for my therapy plan, I bring the cold and icy wet modality to his room for our special activity: building a snowman! Once he figures out what we'll be doing, he readily climbs out of bed with some assistance and steps into his snow boots—a gift from the staff for dress-up days. He pulls on his hat and gloves, and we begin to play. He squats for hip and knee strength to scoop the snow, using 2 hands for bilateral integration, and lifts the heavy snowball. He rotates his trunk to move the snowball out of the bin and place it on the snow-white sheet that we use to cover the floor. He steps laterally to pick up a "bendy" straw to add arms to the snowman. Not long after we start, I can hear increased respiratory effort and a hint of wheezing. The work of standing and squatting is very fatiguing today, so I ask if he needs a rest. "Yes," he says, just a little short of breath. So he sits down. But there is no mistaking the joy and the smile behind the exhaustion of such a simple activity. It is worth it—for him and for me.