Defining Moment Two Degrees, Many Variables The journey of a PT/anthropologist. By Mark G. Sala, PT, DPT, MA | May 2020 Listen to 'Defining Moment' Rose was just into her eighties when she became my home care patient. Both she and her daughter were confused and frustrated by her growing list of physical ailments, including pain and stiffness in her lower left leg, difficulty walking, and anxiety. This was a woman who had travelled the world in her 70s, having been to the Taj Mahal and the Great Wall of China. She'd trekked into the African bush to encounter gorillas at age 80! Now, however, she barely was able to walk from her bedroom to her bathroom some 20 feet away. A recent hysterectomy, emesis due to a liver cyst, interventional radiology, prolonged hospital and short-term rehabilitation stays — something or everything was causing her to stumble and fall in her home. She also had a host of comorbidities, including gastroesophageal reflux disease, chronic low back pain, and spinal stenosis. After going over my evaluation, we immediately set out to identify her most pressing impairments in order to address her falls risk and maximize her functional mobility and safety. I suspected from the start, though, that this wasn't going to be a straightforward case. That turned out to be true. Over the course of her physical therapy, specialist after specialist gave Rose diagnosis after diagnosis — a litany of reasons why her body was changing or malfunctioning. Some simply chalked it up to old age. Eventually, the possibilities of left knee arthritis or Parkinson disease were proposed — by an orthopedist and a neurologist, respectively — as the main cause of her walking difficulties. My responsibility as her physical therapist was to help Rose figure things out — to help alleviate her pain and to work with her to improve her balance, endurance, and strength. We went to work on the immediate goals of safe mobility and reduced falls risk in the home. Still, I felt strongly that there was something amiss with the whole scenario. I wanted to dig deeper. As humans, we're all complex, and factors such as disease and environment can add layers of complication to cases like Rose's. Fortunately, I had two hats available to me as I tackled these complexities: those of the physical therapist and of the anthropologist. All physical therapists encounter medically complex patients who force us to think harder and outside the box. This challenge is one of the reasons I joined the profession, graduating from New York University's baccalaureate program in 1995. Our professors equipped us to see the big picture while homing in on myriad details for further investigation. Over time, I developed the ability to tell what might be occurring among different physiological systems, and to pay close attention to such factors as the home environment and the patient's medications. Continuing education and experience further sharpened my skills at pattern recognition. I saw that Rose did not fit neatly into the patterns consistent with a diagnosis of knee osteoarthritis, spinal stenosis, or Parkinson disease. So, I needed to explore other possible pathologies that better fit her overall picture. I knew that I needed to consider the factor of variation — the variability of disease presentation, symptoms, and age-related issues of individuals within the geriatric population. I've always enjoyed working with older adults and addressing the health challenges that accompany aging; it's why I became a board-certified clinical specialist in geriatric physical therapy. My physical therapy knowledge and training provide me with many tools to address aging's complications. But I have another scientific bent, as well. Might the answers to some of my questions about human variation lay in the field of anthropology? Physical therapists are musculoskeletal experts. We treat people who come in all shapes and sizes. I was looking for the "why" behind such variation. I found it in the subfield of physical anthropology — also known as biological anthropology — at Hunter College in New York City. It's a broad field that includes primatology (think Jane Goodall) and forensic anthropology (think television's "Bones"). Many anthropologists teach gross anatomy at medical schools. I zeroed in on the areas of genetics, functional morphology, and comparative anatomy. I graduated from Hunter with my master's degree in 2008 with a thorough appreciation of the array of influences on biological variation. My thesis, for example, involved investigating thoracolumbar osteoarthritis patterns among a specific group of primates and determining what factors — vertebral position, biomechanics, living in the wild versus captivity, and others — might be associated with those patterns. The study found that spinal osteoarthritis among my sample group varied according to such factors as sex, body size, and age. Interestingly, more arthritic changes were seen in primates that weren't just older but also were in captivity or had larger body masses. I thought about how my physical therapy patients might similarly be shaped by their genes and environment, and how their diseases or conditions might be influenced by those factors. In Rose's case, the physical therapist in me explored the connections between her symptoms — including ataxic gait, pain and stiffness in the lower anterior compartment of her leg, and anxiety — and the possible diagnoses. It's the kind of detective work I enjoy as a diagnostician. Meanwhile, the anthropologist in me was mindful of the ways in which natural variation can muddle things — producing variable responses to medications and different presentations of the same disease. One also must consider each person's unique trajectory in life — family history, employment, culture, and lifestyle. Such factors shape all of us in different ways. It was clear that Rose's symptoms were not due to Parkinson disease. Nor could they be fully explained by osteoarthritis. The fact that her sister had posterior lateral sclerosis — a rare neuromuscular disease — led me to explore the possibility that Rose had inherited it. Research revealed that PLS is not hereditary, but two other conditions are — familial amyotrophic lateral sclerosis and pure hereditary spastic paraplegia. Pertinently, both FALS and PHSP are characterized by gait ataxia, unilateral lower leg symptoms (worsened by anxiety in the case of PHSP), and late-adulthood onset. I relayed this theory to Rose's neurologist and her geriatrician for further consideration. With that diagnostic possibility in mind, Rose and I carried on — focusing on alleviating her pain, improving her balance and gait, and meeting her physical therapy goals. (Rose's family members and specialists agreed not to mention FALS or PHSP to her, given her easily triggered and debilitating anxiety.) My work with Rose illustrated why I became a physical therapist, and what motivated me to supplement those skills with knowledge and training in biological anthropology. Human beings are molded by their genes, culture, and environment. When individuals present with mysterious and confusing symptoms that cause discomfort and real risks for injury, I try to piece together that puzzle. I may not always succeed. What I can and do always provide, however, is compassion and caring. I strive to convey — straightforwardly and without medical jargon — the fact that I'm steadfastly listening, and that my patients are not alone in their struggle and their search for answers. As a clinical scientist and anthropologist equipped with a holistic approach to rehabilitation, I continue to serve others — ever observant and always curious about the variables that make us uniquely ourselves. Maybe, in the end, it's all about helping people who are in pain feel human again — in all of their complexity. Mark G. Sala, PT, DPT, MA, a home care physical therapist with Fox Rehabilitation, is a board-certified clinical specialist in geriatric physical therapy. He lives in Staten Island, New York.