THE LINDA CRANE MEMORIAL LECTURE The Patient Puzzle: Piecing it Together

Abstract

Time precludes me from going into more detail. I used Danny's case to illustrate the fact that motor impairments are never “just” a musculoskeletal problem or “just” a neuromotor problem, etc. We were not born with a single system. We were born with systems that interact to give us the control that we need for health and for participation. If Danny's motor deficits and the immobility of his trunk was treated from a single system perspective, would he be as healthy and functional as he is today? After 34 surgeries and 15 years, Danny's story is nothing short of a miracle. The doctors never, ever, thought he would be decannulated (trach tube removed) because his airway kept rejecting all the reconstruction efforts by the surgeons, but eventually he was successful; a miracle. The fact that he ever got his G-tube removed and that he can eat by mouth is even more of a miracle. The fact that he can walk and talk and chew gum, be a normal high school freshman and go to a big public high school, I think is another miracle as well. But what about tomorrow? Look at Danny's journey. He has come so far in 15 years and if you were a teacher or a PT in his high school, you would not be able to tell that he is not just another normal boy with baggy pants that fall off his hips. But watch out, because I will soon be turning him over to you for therapy as an adult. He will still need to be assessed and treated from a multisystem perspective. He will never be a single system patient. In fact, I would challenge you to find me any patient that is a single system patient. I challenge all of you to find the problem. I used the concept of a puzzle because I wanted you to see the body's multiple systems as interlocked. Find the problem! Ask, “Why do I see that motor presentation?” Don't simply identify that someone has a shoulder problem or other motor impairment, but ask why is the shoulder problem there? Find the real impairment to the motor performance needed for participation and health. Learn to identify all the body systems, to look at their interactions and to look at which ones are contributing to the problem or the solution. As an infant, Danny's musculoskeletal and integumentary systems played a very minor role, thus, because you looked at all 5 systems, you could overtly rule out the need to treat those systems at the moment. Determine which body system is the primary limitation to motor performance initially and which one is the problem now. I want you to think about surviving and thriving. I am in pediatrics, but think about the application to patients in acute care. Most of you can tell me the day that “Mr. Jones” changed from surviving to thriving. It is usually the day that he laughed at your joke, or that he told you a joke. It is when they are no longer worried about their physiologic state and they can safely allow themselves to think about thriving. Prioritize your interventions. Integrate a multisystem perspective into your daily practice for all motor dysfunctions, low back pain, shoulder problems, spinal cord injuries, stroke… What is in the future? I think we can do even a better job at differential diagnoses and referrals for every “Danny.” We need to recognize not only where the problem is, but when it is beyond our scope. When should we refer to that plastic surgeon? When should we call in the pediatric GI doctor or when should we call in one of our colleagues who has more expertise in a specialty area than us? I would like to challenge every PT in this room to become a better problem solver, a better puzzle solver en route to becoming that autonomous practitioner. I believe that when we are good at that, the consumers will see us as the practitioners of choice. We will not need to tell them. If we are effective as diagnosticians, we will be better able to plan correct interventions. Thank you.