Tuesday, March 29, 2011


Evelyn by Susan Jansen

As people struggle with the challenge of physical disabilities, what part does feeling good about their appearance factor into their ability to work towards regained function?

We like to envision ourselves striding into a conference or social gathering with it “all together”: the clothes, the hair, the pose and the savoir-faire. Whether in informal business attire or street chic we love the power of looking good.

One day at a residential and out-patient specialty center I was introduced to an attractive and very well dressed mother and daughter seeking therapy services. The daughter who was 21 years of age had sustained a head injury during a motor vehicle accident the year before. As the mother spoke her daughter nodded with “yes, yes”. She had been attending a local private university and it seemed was on track for a very good life. Now the mother just wanted her daughter to appear pretty.

Seeing the young woman walk I understood the concern. She walked with a cane, a flexed arm and a stiff leg. From their point of view, like an ‘old person’. Not vibrant, attractive, sexy, not like a prospective wife and mother. Although treatment strategies have evolved since then, the desired results would still be unattainable.

Today I confine my clinical practice to those who are 85 years or older - the elderly. If you haven’t reached that age yet, you might think folks should be pleased if they could walk at all. You would be wrong. There are several reasons older persons start to withdraw and become isolated – how they appear is part of that progression.

Currently I work with a delightful 88 year-old who has had several joint replacements, continuing degenerative joint disease and a few other assorted conditions. She is well educated, continues to be involved intellectually, a wonderful take charge and let’s do it sort of person. But she doesn’t like to mix and mingle much. She has been relegated to using a 4-wheel walker, useful but not elegant. She’d like to use a cane “more practical” she says out loud, but “more acceptable” to herself. To meet this concern, periodically, I have her perform walking trials with a cane – not only borderline unsafe, but inefficient, taxing and ungainly.

This past week when I greeted her with the requisite “how are you doing”, she responded “Fine, but. . .” and described how someone - a gentleman - she regards highly mentioned that her last knee replacement had not worked because she was “walking so badly”! Even with prompting about the accolades from neighbors - all women - who believe she is doing well, to her she is not doing well enough.

Although not a typical candidate I gave her instruction in using two canes (which luckily she had) and within the first 3 feet of using them she positively radiated. She wanted to walk down the hall, walk all the way down and back. Frankly, she looked aristocratic. She then enthusiastically performed the strength exercises she is supposed to be doing on her own; and willingly made an appointment to re-see her orthopedic surgeon about a lingering knee problem.

This is not a miracle or a feel good story. Physical therapists are frequently involved with gait training interventions. Sometimes the person has no residual impairment or altered pattern. But many develop a new pattern of walking and some find that acceptable and may even be grateful. Others will want to look good, as well. I was not able to help the college student twenty-five years ago. Today I have given my elder patient some hope, something to look forward to.

What I can’t control or even anticipate is the audience that each of these young and elderly woman have in their lives. There is a complicated interaction we have as we move through our day with those around us. Until we are good at something we may prefer to be by ourselves, but once proficient we want to show off. Trying to look good for others when one has a physical disability may be part performance, part learning. The late Robert Zajonc (1) put forward a literature review on social facilitation theory in the mid-sixties. It might be time to dust off this topic again. We have increasing numbers of people living with physical disabilities for longer periods of time. To face this challenge we need durable understanding about the person and their audience.

(1) Zajonc, RB, Social Facilitation, Science, New Series, Vol. 149, No. 3681. (Jul. 16, 1965) pp. 269-274.

Art courtesy of Susan Jansen. Ms. Jansen may be contacted at susanjansen@gmail.com.

Monday, March 21, 2011

Take It Easy

I spent my Sunday afternoon with 15 delightful women, most over the age of 80. I had been asked to speak on the importance of muscle strength as one gets older. The audience was attentive. I had handouts in large print, big photos - almost posters - to pass around and a portable microphone. They appreciated all of it. After the introduction, I reviewed the value of muscle strength training for older persons. Good review for this group.

Then I started with muscle strength and posture – it was a palpable response. I have an uncanny ability to alter my posture to exemplify altered function. When I “stooped” the group leaned forward, nodded their heads and some exclaimed under their breath “why, that’s me”, or “that’s how I look”. I demonstrated the muscles that control that part of our posture and immediately the attendees felt they’d gotten their monies worth (the session was free!).

There was more to the seminar: a self-assessment of functional decline to use when visiting their MD; physical assessment related to specific strength exercises; and tips on strength training itself. One of the first to break the ice asked “but my doctor told me to take it easy”. “How long ago?” I asked. “Years ago”.

Frankly the person asking the question didn't know how to interpret what was easy and what wasn't. Would they hurt themselves, do damage, set back their functional level, get sicker, or need more treatment? Better yet, could they self-determine what was their threshold for: motion, exercise, and amount of resistance?

With demonstration, feedback and guidance several of the women experimented with their ability to perform a movement with and without resistance. They were able to detect their limits and what they could do on their own. It took a few minutes.

We clinicians do not know how people will interpret our cautionary instructions. One of my elderly patients was told to keep her head straight due to extensive degenerative changes in her cervical spine. She heard “keep your neck stiff” and she complied. This resulted in reduction in head turning, muscular tightness and lingering pain. She thought it came with the territory.

We can not, nor should not, abandon the use of precautions. We can give simple tips. We can explain that this instruction should be reviewed. This is one of the times I recommend that a physical therapist’s input should be sought.

Monday, March 7, 2011


My town is embarking on an opportunity for change. But we have been misled before. So much so, that we aren’t easily swayed. We want change, and we want to work on it now. But underneath and all around us are those damn crevices, towers of great information that are difficult to break down or break through, systems that prevent serendipity. (1)

There is nothing like a really good idea. An idea that makes sense, builds on itself, allows for adaptation. I start with an idea trail. It begins with one thought, and then another. Some link, some don’t. Eventually I apply smart program development criteria. But in the mean time, I talk it up with folks from different paths and places. Then I suggest we have coffee somewhere near where the idea has the greatest meaning. Frankly, here is the secret. With putting the right folks together, a wonderful set of ideas will be created which can become a working concept. Inclusion of all these disparate sectors results in: buy-in, feedback and self-evaluation and, of course, best methods of implementation.

Here is an idea. A pediatric specialist changed positions. She worked at a community based center providing needed and (essentially) free services to children with developmental and orthopedic problems. Now she works in the neo-natal intensive care unit (NICU) literally down the street where all the kids she had been working with started out in life. Right away she was able to share with them what ‘what happens if’ feedback, e.g. prolonged position of the child for feeding and airway protection causes residual impairments. This interaction should be going on without large-scale initiatives.

The idea trail. Given information about the local healthy community initiative, I wondered along with my dear colleague that there might be a connection not only between high risk NICU infants and lifelong disability but societal problems as well. Without hesitation, a list was generated: post-traumatic stress syndrome (PTSD) of the parents, the emotional delays and latent inappropriate teen drug use, severe funding cuts along with a void of strategic education and support for the high risk infants’ ‘first responders’ - their parents. Well, she shared the opportunity with her colleagues and they got inspired and the trailhead is established.

Now let’s apply some creative analytic thinking. What information might help the idea? Discard it, embrace it, or change it? It would be great if we could answer some assumptions, such as, is parental PTSD also related to income and residence or culture? How about the social sequelae of having been in the local NICU? Do most of the kids go to college, or have families of their own? What are the essential needs of the child after discharge, and are these services accessible and affordable, or even used? There are more questions, and questions beget questions. What would families of the children share? Why, the teachers in pre-school! As is turned out, the rehab facility down the road hadn’t shared their insights with their nearby colleagues until happenstance occurred.

This process doesn’t cost much, if anything. It certainly can happen quickly. Many who sit in organizational charts are comforted by lots and lots of detailed data; others just know the problem and need for it to be articulated. But we all suffer from lack of connectedness.

(1) Meyers, Morton A.: Happy Accidents: Serendipity in Modern Medical Breakthroughs, New York: Arcade Pub., Distributed by Hachette Book Group, c2007.