• Defining Moment

    Two Degrees, Many Variables

    The journey of a PT/anthropologist.

    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.

    defining moment

    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.


    Mark, I loved reading your story about Rose. I have spent my professional life studying neuroscience, brain injury and especially the influence of the limbic system on motor control. As you so clearly identified, pain and anxiety (related to the limbic neurochemistry) affects motor performance and so many colleagues won't or don't want to see those relationships and its affect on the outcome of PT treatments and compliance. Thinking outside the box whether it be outside medical liiterature on disease and pathology or PT literature which should reflect movement function and dysfunction, is truly where the fun lies when being a PT and an active thinking human. Throughout my life I have been confronted with the unknowns and nothing in the literature to explain what I was seeiing and feeling, but for me in the last 30 years before I retired, it generally happened in front of 50 - 200 colleagues which didn't allow my left brain to say it didn't happen. So my right brain just stroked the left brain and said "calm down, we'll file it under unexplanable at the moment and try to figure it out later!" Those unknowns or unexplanable treatment outcomes are truly what makes PT fun and challenging, so please keep enjoying your life adventure and allowing your energy to help so many people no matter their age. darcy
    Posted by Darcy Umphred on 5/1/2020 11:52:59 AM
    Excellent presentation of your college background and your profession and expertise. Kudos to you and good luck! Stay healthy and safe!
    Posted by Napoleon A. Valdez,MD, FACS,FAAOS on 5/1/2020 3:53:44 PM
    You have 2 interesting degree material to assist you in treating patients. Good for you. Did the lady get better? Patients can be a puzzle that most therapists don't have time to evaluate and really treat... Keep up the good work...
    Posted by Vanie L. Jones DPT,MS on 5/2/2020 5:10:16 PM
    Thanks for the encouraging words Darcy! Striving to be an "active thinking human" resonates with me too. There's so much to learn and explore--to enrich what we do as therapists, including what's happening in neuroscience (e.g., neuroplasticity, etc.).
    Posted by Mark Sala -> =NW[AH on 5/5/2020 9:14:41 AM
    Thanks for the comment/kind words Napoleon! Be safe and healthy too!
    Posted by Mark Sala -> =NW[AH on 5/5/2020 9:22:08 AM
    Hi Vanie, she did improve upon safer functional mobility at home and in the community, with the help of her caregiver; we keep in touch and she's doing her best to keep up with the exercises/activities. Agree, sometimes the clues to a complex puzzle can take much longer to unfold. Thanks for the comment!
    Posted by Mark Sala -> =NW[AH on 5/5/2020 9:22:55 AM

    Leave a comment: