I was nervous in 1989 during the first of my three six-week physical therapy internships. This one was at a pediatric clinic located in a minimall in Orange County, California. The woman who ran the place, Jessica, was an extremely talented and knowledgeable therapist who was totally compassionate with her young clients and their parents, but who was hard as nails with everyone else.
         The children, whose ages ranged from less than a year old through the teens, were often severely disabled. Many had been victims of near-drowning accidents in southern California swimming pools--accidents that left them brain-damaged. Jessica said: “No one with a small child should live in a house with a swimming pool.”
         In addition to disabilities in language and cognition, these children often had severe motor problems--especially if they had abnormal muscle “tone.” With abnormal tone, one set of muscles can be very weak--while an opposing set goes berserk, tenses up, and won’t let go. Older people who have had strokes often get abnormal tone on the affected side--arms can draw up at the elbow while wrists curl and fingers clench; legs can go stiff with the toes pointing down and the heelcords developing fixed contractures. Many of the near-drowners at Jessica’s clinic had abnormal tone in their trunk extensors--the muscles that enable you to arch back and look at the ceiling. Physical therapy techniques, including good positioning practices, can help to reduce abnormal muscle tone.
         Abnormal tone in an adult is bad enough, but in a child it can totally derange the course of development. Subjected to the constant unbalanced pull of muscles, bones grow crooked. I saw one man in his thirties, who had nearly drowned at the age of two. He had grown with such extreme extensor tone that the back of his head almost touched his buttocks, and he was stuck there--that’s how his skeleton was shaped. That horrendous outcome could probably have been improved with good positioning when he was young. But now, he was bedbound in an institutional care facility, and dependent on others for personal hygiene, for eating, for repositioning to prevent bedsores, and for all his other basic needs.
         Abnormal tone can prevent a child from rolling, crawling, or sitting up. This in turn causes still more disability, because these skills are prerequisite for learning other skills--skills that in turn are prerequisite for still more advanced skills, and so on. As Jessica taught me, children learn to move--and move to learn. The child sees a bright toy. She rolls or crawls over to it, shakes it, explores it, and learns from it--but that learning doesn't happen if she can’t move.
         Still, abnormal tone is not itself the problem; the problem lies in the results of that tone. I’ve seen therapists obsessed with addressing the flexor tone in a patient’s undeniably nonfunctional arm, when there were much more practical things they could have been working on.
         My favorite story from the pediatric internship is when Jessica put me on the spot, really making me sweat. “What’s wrong with this child?” she demanded, as we stood over the small boy on the mat below. My head was swimming with technical information from physical therapy school, and this sounded like another test. “Asymmetric tonic neck reflex?” I tried. “No,” she shot back. “Weak abdominals?” No again. “Trunk extensor tone?” “No!” she nearly shouted this time. “OK, Jessica,” I said, “I give up. What’s wrong with this child?” After a dramatic pause with penetrating eye contact, she gave me the answer: “This child is two years old, but he can’t roll, he can’t sit up, he can’t stand or walk, and he can’t hold anything in his hands.” Then she walked away, leaving me to work with the boy, my head still spinning.
         “I knew all that,” I muttered silently, thinking, she probably does this with all her interns; what the hell is she trying to prove? Then came the sudden and unforgettable realization that I’m sure she wanted to elicit: The Big Picture. Don’t forget the big picture. All those details might (or might not) be relevant when you’re working out your plan to address the real problems, but the details themselves aren’t what’s important. Keep your focus on the things that really matter.