But today, as Amy mentioned, we're going to do a bit of an overview on cancer rehab, what is it that a cancer rehabilitation physiatrist does, and what my area within cancer rehab actually is. So, I'm an associate attending on the Rehab Medicine Service, which is in the Department of Neurology at Memorial Sloan Kettering, and I'm also the assistant program director of our Cancer Rehab Fellowship, and the last appointment that I do hold is as an assistant professor of Rehab Medicine within Weill Cornell Medical College, and within that, it has to do with how we interact with the New York Presbyterian residents who do come and spend some time with us. So, I did take a little bit of a unique background into cancer rehab. It was actually not my first area of interest. I stumbled upon it during residency. I went into physical medicine and rehab wanting to do spinal cord injury medicine, thinking I would work in a model system taking care of traumatic spinal cord injuries, but as a New York Presbyterian resident myself, I had the opportunity to rotate at Memorial Sloan Kettering, and it really opened my eyes to the idea of cancer rehab and what cancer rehab was, but it also allowed me to explore my love of spinal cord within a different way. I wanted to focus more on non-traumatic spinal cord injuries and those that are particularly cancer-related. So, what we'll do today is kind of talk a little bit about the field as a whole, and then this notion that you can sub-specialize within cancer rehab. So, I have nothing to disclose. Any time we talk about cancer and cancer care, I think we always have to start with the statistics. They are just really important for us to think about, excuse me, and, you know, when we think about cancer, it can be a very scary thing for ourselves, for our family members, for our patients, and when we talk about this idea that a little over 1.9 million new cancer cases are expected to be diagnosed in the U.S., and that's for this year. So, you know, this has been an increasing trend. A lot of it is related to the fact that people are living longer. A lot of it also has to do with the fact that we're better at screening for these type of things, but it is an uptrend, but that's not necessarily, you know, something that should have us so worried because there's a lot more that we can do as we're learning more and more about it. When we look at cancer, we can break it down by male and female. The leading number of sites for cancer in terms of men are prostate, lung, and colorectal. For women, it becomes breast, lung, and colorectal, and then in terms of the overall causes of death, lung actually becomes the highest for both men and women, and then for men, it's prostate, and for women, it's breast, again, followed by colorectal. Also, when we think about cancer, we do tend to talk about what the death rate or survival rates are going to be from these various cancers, and this year, they're estimating about 609,820 deaths will happen. This is a rather large number, but what you can see by the two graphs below, this actually has to do with cancer death rates separated by male and female, and they break it down for the top ones, but what you can notice is as time goes on from the 1930s when they were first looking until we're hitting the, you know, the 2020s or the years that we're approaching now is that the number of cancer deaths are actually going down, and what this really has to do with, again, is our early detection of various cancers and also our improvements in how we're treating these cancers. So, when we think about these new incidences of cancer and when we think about these death rates, we really have to start thinking about how we're taking care of our patients. The focus can't only be on let's diagnosis and treat your cancer, but really, what are we doing for our patients and how are we approaching this? And back in 1974, Dr. Herbert Dietz, who is actually a physiatrist here at Sloan Kettering, really started to put this notion into play. So, what does this mean? And he actually said this trend towards increased and improved life expectancy is having an important impact on concepts of caring for cancer patients. How best can we help these patients readapt to society? So, it was no longer about how do we make this diagnosis and how do we treat your tumor, but it was how do we get you back to doing the things that you want to and need to be doing? And what do we need to put into place to make that happen? He spoke about this idea of cancer rehab and having paradigms. And what he did was he took standard rehab approaches that we use in other areas such as, you know, musculoskeletal and stroke and spinal cord, and he applied them too. So, when he spoke about cancer rehab, what he envisioned was that there would be preventive rehabilitation. So, when we're thinking about prehab, and that's a topic that we talk about quite a bit, but preventive rehab, when we can predict what's going to happen to this patient, and we can really focus on reducing the severity of this and also the duration of its effect. So, if we know that you may develop a neuropathy, what can we put into place in terms of your balance, in terms of your mobility, in terms of your ADLs? What modalities? So, this idea that a lot of times for cancer patients, they're using cooling to try to see if they could prevent. So, there's different modalities that we could do, but different areas that we could focus on really to help patients improve their tolerance of treatment and improve the outcomes in the long run. His next paradigm was restorative rehabilitation. So, this idea that we don't expect a permanent impairment to be there, and how do we restore to premorbid function? So, this is really what a lot of our rehab efforts are, right? We always want to bring back that person to what their normal or what their baseline was. The next paradigm was supportive rehab. So, we know that there's going to be a permanent impairment that will exist due to this cancer or due to its treatment, but how can we maximize function despite that impairment? How can we use adaptive equipment? How can we use bracing and orthotics? What things can we put into place to help support this individual? And then the last piece, and this is not necessarily unique to cancer care alone, but, you know, where we focus the most on. So, when we're thinking about palliative or hospice, and, you know, a lot of times when we're thinking about hospice care or palliative care for patients, what we're really thinking about is, you know, their pain and keeping their pain control and helping them with just comfort care. But there's a lot that we can actually do in that time frame in terms of helping provide comfort and support. We can help in terms of positioning, in terms of bed mobility. We can help with bowel bladder. Really, what we want to do is try to reduce complications that may develop as we're expecting increasing disability due to their disease progression. Andrea Chaville nicely put this together. She is a cancer rehab physiatrist herself, and what she really did was she looked at Herbert Dietz's Paradigms for Cancer Rehab, and she plugged them in to the cancer care continuum. So, when we think about where a patient is in their cancer treatment, what needs may they have? So, everyone starts at their initial diagnosis and their initial treatments. So, you know, they may have started with an impairment, and that might have brought them in. A lot of my patients, for example, with multiple myeloma, they were brought in because they had back pain. And it was during this workup of their back pain that we found that they had the multiple myeloma. So, this is that time frame where they're undergoing all their workup to determine what their cancer is, you know, where it has spread to, any kind of genomics behind the cancer in terms of, you know, determining its treatment. So, we're doing all of those things, and we're starting the aggressive phase of treatment. So, this might be, you know, surgery. This might be radiation therapy. It might be a systemic treatment option. So, what we're doing is it's that early phase. And where we can come into play, you know, we're thinking about, okay, you have this diagnosis. What might you be at risk for? What can we prevent? What can we minimize in terms of outcomes? So, we can use this idea of preventative. We may also be able to use some restorative. So, if you have a patient who had, you know, a foot drop because there was a tumor that was compressing on a nerve root, and we alleviated that, you know, maybe that foot drop is actually going to get better, and our focus is going to be on improving your mobility and improving your strength and improving your, you know, overall functional status. When we look at cancer and after that initial cancer treatment, patients enter what we call an observation or a surveillance phase. So, they may have finished their initial treatment, or they may be on a maintenance type of therapy to try to keep things at bay. And they get routine scans, and they have routine check-ins with their oncologist or their surgeon or their radiation oncologist. And we can continue to watch them. They remain in their surveillance phase until they hit a time of disease recurrence, and then they'll loop back into, you know, this idea of perhaps more aggressive treatment or trying to just keep tumor under control. So, this idea of going from surveillance to disease recurrence and then going back to surveillance because we were, again, able to treat, or temporization, we're just keeping things where they are. And so, surveillance can last for a very long time. You know, we tend not to really say cure. And the reason is, is because there's always the chance that something may come back. So, patients are always referred to as having no evidence of disease, but they'll remain on observation or, you know, they'll move into more of a survivorship realm where we continue to keep track of them. When they are in that surveillance realm, we can, again, think about, you know, preventative, you know, predicting things that may come down the road for them. So, you know, a lot of times for my patients who have had spine mets, who have been radiated, who are older, who are at risk for pathologic vertebral compression fractures, a lot of my efforts are to try to minimize that. We may want to be minimizing falls for patients who might have, whether it be neuropathy symptoms or any kind of weakness, you know, from their treatments or from their tumor itself. We may also incorporate some supportive, right? So, some of our patients may continue to have weakness or some type of impairment that remains that we're not going to be able to reverse for them, but we can help them in terms of their management, and we can help them in terms of their functional status. When a patient does enter a realm, if unfortunately to disease recurrence, it's going to be the same type of rehab strategies that we are employing. If they go from the disease recurrence to this idea of keeping things at base, so in other words, we don't think that we're going to be able to treat that specific area, but we can help keep that area controlled. Our focus is again going to be more on this idea of preventing and also supporting. Patients then may go from disease recurrence to temporization onto palliation. So, no one necessarily has to follow the arrow perfectly, but we're just kind of describing the various phases where they are. If they do unfortunately enter that realm of palliation in terms of their treatment, then the focus of what we're going to do is going to be a lot more supportive. If we look back, some of the early studies that actually looked at Dr. Dietz's paradigms or this notion of using rehab care, I mean, if we think about rehab, we've been around for quite a long time. You know, when you think about World War II, when you think about polio, so this notion of rehab has been there, but these are the first time that physiatrists really started thinking about the cancer patient and what we can do for them. And so, one of the early studies came from Lehman et al., and this was back in 1978. And what they did was they looked at this Dietz model and they said, you know, we really should create a patient care model, you know, very patient-focused. We should have a nurse who's going to screen patients for any kind of functional impairments that they do have. And if a patient has a functional impairment, it's going to trigger a physiatry consultation and that us as physiatrists, we're going to serve as liaisons between the oncology team and the rehab team. And what they found was that before this patient care model was implemented, patients, about 13 patients a month were actually referred to rehab medicine. And so, over the course of, you know, this kind of idea, it was about 137 total rehab visits per month, what they were seeing at their institution. And then seven months later, after implementing it, they found that 29 patients per month were being referred in. And so, there was a total of that increase to about 548. So, it did show that when someone was screening, we were finding these impairments when someone was mentioning them and making the referral that they were actually happening. These are some extra earlier articles as well, too. So, he wasn't the only group that looked in it. The idea of general cancer rehab has been looked at. Rehab in hospice settings, rehab in spinal cord injury, in brain tumor population, and this idea of a consultation-based type of rehab service. These aren't all inclusive in terms of the articles. By no means are they the most recent articles, but this is really kind of taking a look back of where we started and where we're now going with it. So, when we look back at all these earlier articles, one of the big things that we need to notice is that majority of them were inpatient-based. So, it was patients who were being admitted to rehab units after their cancer care. And, you know, looking at this was actually very important. And why is that? When we think about the idea of the 60% or the 75% role, depending on who you're talking about or who's giving you the percentage, we talk about at any given time on a rehab unit, patients need to meet, 65% to 70% of patients need to meet these certain criteria in order to be admitted. And so, at the time, cancer wasn't actually one of them. There's a lot of diagnosis that didn't make too much sense that were, but it's about the timing that this law was put into place. But it was important for us to do these studies and to look at actually having patients go to rehab units because we could prove that it would benefit. So, we found that cancer patients actually had similar or shorter length of stays within rehab. Often the times this actually had to do with our want to get patients home so that they can maximize time at home with their families and their loved ones. They had similar rates of community discharge to patients who were admitted to rehab units for other reasons. They had similar rates of functional gains and that these patients could maintain gains during their life course after discharge. And earlier on, we found that tumor type didn't really impact functional outcome and that not an inordinate number of patients were being transferred back to acute care. And so, we're continuing to look at this. And sometimes we have to think about tumor type and prognosis and what that's meaning in terms of outcomes from rehab. There's some studies that have actually shown that patients with given tumor types actually do better if they receive rehab or they're admitted to rehab units. The other thing is looking at patients we are transferring back. This is something that we're always arguing about or always trying to push for that, you know, we're going to send our patient is going to stay there and we're hoping they're not going to continuously bounce back. We also try to do what we can on the front end when patients are admitted to the hospital to try to minimize any complications that might come up while they're on a rehab unit. So, we've talked about this idea that patients are living longer, that we understand this cancer continuum, and that we have to help patients adapt and we have to really change how we're delivering care. But what are we really talking about? And so, you've heard me give some examples already, but we're first referring to this idea of the direct effect of a tumor. So, where the tumor is, what the tumor is putting pressure on, and what impairments a patient has as a result. We refer to treatment-related effects. So, if this patient's having surgery or a systemic treatment or radiation, what adverse effect are they having in relationship to that? It's important to note patients can actually experience impairments from both. So, they're not mutually exclusive. There are indirect effects, which we're not going to touch so much about, but I do want to make you aware of them. So, this is when we're thinking about, you know, patients in terms of their weight, fatigue, muscle loss, just because of cancer's catabolic state. We're thinking about their nutritional status. So, all of these, it's not directly from my tumor, but it's because I have cancer, these effects are happening. And then there's perineoplastic effects, and this in itself could be an entire lecture, but it's really how a tumor is impacting the endocrine system or the neurological system for a patient. So, it's not necessarily that the tumor is located there, but it can cause impairments to other muscle systems or, excuse me, other body systems just due to the nature of the tumor itself. So, thinking a little bit about direct tumor effects. So, we can start with the brain. I think it's a pretty intuitive area, right? So, we know a lot about the brain in terms of strokes or other brain injuries that patients are having, and we know that in the brain, it's all about location, location, location, right? So, depending on where the tumor is, we can predict what type of impairments a patient has. So, patients with brain tumors, they may experience headaches, they may experience seizures, fatigue, personality changes, vision or hearing impairments, sensory changes, motor weakness, motor apraxia, or kind of difficulty with their coordinating their movements, language dysfunction, they may experience neglect, so this idea, you know, that they don't realize that part of their body does exist, and they only pay mind to the part that they're still aware of. Ataxia are in coordination of their movements. They may have cognitive decline, they may have difficulty swallowing, they may have gait and balance impairments. Similar, when we think about the spine and the spinal cord, I do list them as separate, but together. Tumors oftentimes will go to the spinal column, not necessarily the spinal cord, or there are some tumors that will arise from the spinal cord itself or metastasize to the spinal cord, and you can kind of see a little bit of both here. So if you look at the bony spinal column anatomy, and you can kind of see there's a collapse, and there is a, you know, tumor that looks like it's pushing up against the spinal cord. So this is a lesion that did go to the spinal column that grew beyond the level of the vertebral body and started to grow into the epidural space, compressing on the cord. So this would be idea of epidural cord compression or epidural metastasis. So it's going into that area. And then if you look up higher in the thoracic spine, you can kind of see a little white blip in an otherwise fairly dark spinal cord. So this is actually a lesion that is more in the intradural space, so kind of the inner protective coating when we're talking about the spinal cord. And then, you know, we have to do a little bit more of a detailed study to see if it's within the spinal cord itself or it's in that kind of supportive space, you know, between the dura and the spinal cord itself. But we talk about these impacts on both. So regardless of where a tumor is within the spine or the spinal cord, patients may have pain. And we define these classic types of pain when it comes to the spine, whether it's tumor related, when it's mechanical, because this patient has a fracture, whether it's putting pressure on a nerve. When we talk more about radicular, kind of like we would do with someone who has a disc who's putting pressure on a nerve root. And so we can really define where this area of pain is based on where in the spinal cord or spinal column someone has involvement. Spine fractures and instability is a lot of what I actually see patients for. And this is the notion that when a tumor is going to the spinal column, each tumor has a different kind of quality to it. So we have osteolytic lesions such as multiple myeloma that can actually, you know, eat up bone and make that bone unstable. Other tumors are more blastic where they're laying down bone. But the importance about this idea that they're laying down bone is it's very immature bone that doesn't go through the natural maturation cycle of bone. So it's not hard. And then you can have some mixed tumors. And why this is so important is if we impact the bone density from a tumor itself, we're weakening the integrity of that area within the spinal column. And so we're predisposing this patient for a fracture. And so that's if you've ever heard of it or you see it on a read when they're referring to a pathological fracture that has to do with that tumor that's there. Why these fractures are so concerning isn't just because of the pain area, but also this idea that these patients can become unstable. So when I was a fellow, my program director always told me that the spinal column is a suit of armor that protects the spinal cord, right? It's made up of vertebral bodies and posterior elements that are all bony. It has the discs in between the shock absorbers, and it has ligaments. Anything that disrupts the pull on the ligaments, so, you know, idea of someone has collapsed a vertebral body, those ligaments become a lot more floppy. So think about a rubber band pulled tight, not too much movement, bring that rubber band together, it flops over a lot more. So that now means that this spine is moving more than it should. And that pain that people are getting is telling us that they're at risk for further injury or even injury to their cord. With these spine fractures, or even with pain, patients may have postural changes, and we should be aware of them because they usually tell us that there's something going on. If there's pressure on a specific nerve root or there's pressure on the spinal cord itself, we think about more classic neurological impairments, so weakness, sensory impairments, bowel impairment, balance impairments, bowel, bladder, sexual dysfunction, other forms of autonomic dysfunction, or even some spasticity, although I would argue that spasticity is more common with brain involvement than it is with spine involvement. We can move on to the peripheral nervous system. You can see here, the big orange arrow is actually pointing at a pancreas tumor. And if you think about the anatomy up in this area, we have to think about the brachial plexus and even their nerve roots as they're leaving the cervical spine. And we also have to think about how that tumor would grow in and potentially invade into the epidural space. But these patients also may have pain. This pain might be localized to where the tumor is. It may also be more in a dermatomal pattern, matching areas of the plexus or the nerve roots that are involved. They may have sensory impairments, they may have weakness. Depending on what kind of peripheral nerve is involved, they may also have balance impairments. But you can usually localize their impairments back to the area that is actually involved. We can look at the remainder of the musculoskeletal system and think about patients who might get primary or secondary bone tumors. These also would be painful. They may result in joint abnormalities such as sublocations or dislocations. If you look at the x-ray on the top, you can see a small pathological fracture just at the ball at the top of the humerus. These are things that we're always thinking about as a source of pain, but also as a source of impairments and difficulty with weight bearing. They might have muscle injuries. You can kind of see that down below where there's tumor that is actually within muscle. It might cause a lot of inflammation, it might cause weakness in that area. We might see some necrosis that happens and scarring in that muscle. Because of these tumors, patients may require amputations in terms of having them removed or other kind of surgical abnormalities. For pediatric patients who have any kind of bone tumors, it does impact how the bone grows. We have to think about different types of growth abnormalities. Moving on from just the direct effects of the tumor itself, but this idea of treatment related effects. Just to highlight, and I've mentioned a few of them, but a lot of different cancer treatments do exist. We've come a long way from traditional chemotherapy and surgeries and radiation therapies to depending on cancer type, such as breast or prostate, we might think about hormone-based therapies. For some patients, and we think a lot about this in terms of the myeloma population, but bone marrow transplantation is used for some other cancers as well. And what is that going to mean for a patient when we're making them immunosuppressed and also how are they accepting the graft that we're now putting in? We're moving more into the realm of targeted therapies, really looking at the genomics of a cancer. What's the tumor's DNA itself? And what's the best way to treat this? And also immunotherapy, so this idea of letting your immune system actually attack the cancer itself. Just to highlight and thinking about some of the treatment related effects that you might see, if you take a look at the top left of the screen, and if I were to tell you what did it look like it was missing, I would hope you would tell me that on the right side, there's part of the pelvis and also that the femur is missing. So this is a patient that had a hemipelvectomy. Sometimes when patients are having these surgeries, they can actually make a prosthesis and put that into place and do a hip replacement at the same time to try to maintain more structure. But here is a patient who now has a portion of their pelvis and also their lower extremity that has been removed. So if you think about this from a pain, from a mobility, from a functional standpoint, this is a pretty big treatment related effect. Similarly, if you look at the scan on the top right of the screen and I asked you what was missing or what did this now look like, I would hope you would tell me that it looks like the surgical hardware coming from the lumbar spine looks like it's being attached to the pelvis and that there is no sacrum. So this is actually a patient who had what we call the sacrectomy for tumor resection. So the sacrum was removed. In doing this, not only do we change your anatomy in terms of your bony landmarks, but we also removed a good portion of her sacral nerve roots. And so now we had to think about how did that impact bowel, bladder types of function, her sexual function, also thinking about what this meant in terms of her mobility and also pain. On the bottom, I'm showing this as an example, not so much of a tumor resection, but as a surgical procedure that was done. So this is idea of using the latissimus dorsi to do a breast reconstruction. So we actually take a portion of skin, fat, and muscle from that area and move it to the breast. And this is the idea of doing this type of reconstruction as opposed to some of the other type of breast reconstruction that we can do with artificial components. But when you think about this, think a lot about discomfort, what does this now mean for shoulder and scapula mechanics? What does this mean for upper extremity function for this patient? So we have to always think about, try to help prevent if we know that this is something that may come after. But really making sure we're having conversations with patients beforehand so that they feel comfortable with what is going to happen. Another treatment-related effect, and this can also be a tumor-related effect, is this idea of lymphedema. We hear about this most in patients who have breast cancer, who have lymph nodes removed as part of their surgical process. And so with this, we can see pitting or non-pitting edema. We might see skin changes where the skin looks very shiny, it might look very red, you know, or discolored just in terms of how blood is moving in that area. Because of the stretch in the nerve endings in the skin, we might see sensory impairments that may arise. This limb may feel very heavy. And because we oftentimes see the swelling around joints, we also think about range of motion. Not only can we see this in the upper extremity, we can see it in the face, we can see it in the neck, we can see it in the lower extremities. So we think a lot about not only cosmesis and discomfort, but really how is this impacting, you know, someone in terms of their function. And when you think about individuals who may have also potentially had a nerve injury or cord compression, and now you add lymphedema, just that weight and what that means to them in terms of, you know, their function. I feel like one area we think a lot about when we think about treatment-related effects has to do with more of the traditional chemotherapies. And we talk about this idea of a chemotherapy-induced peripheral neuropathy. We can see nerve injuries, not only to peripheral nerves, but to the plexus and even to the cord with some of the newer treatments that we're looking at as well. I did put this picture down on the bottom of a peripheral neuropathy just because I really liked how it broke it down with this idea that if the sensory nerve was damaged, you might feel unusual sensations. You might have numbness. You might have tingling. You might have burning. You might have freezing cold sensations. It may impact your balance. We might see muscle cramping or twitching. We might see reflex abnormalities or weakness if a motor nerve is damaged. And just to remind everyone that, you know, peripheral nerves do play a role in our autonomic function. And so whenever we have a peripheral neuropathy, autonomic function may be impacted as well. And what does that mean for a patient? The picture of the hands on the right side of the screen, this is a specific area within the idea of using chemotherapies and a nerve type of involvement. But these are pictures of a patient who has hand-foot syndrome where we actually see changes in the nails and in the skin as well. And oftentimes they do have an accompanied peripheral neuropathy. I also put chemo brain here. And I put chemo brain in parentheses because there is very mixed views as to is chemo brain really a thing. So there are some people who really do believe that after certain types of cancer treatment, patients may have cognitive impairments. They may experience changes in their visual and verbal memory and language and their processing speeds and executive functioning and motor in their mood. And the reason I put it in parentheses is because before we do label that that's what it is, it's really important to rule out other potential causes for these cognitive changes. But it is fairly well documented in the literature and it is something that patients really do struggle with. Moving on from more of the systemic treatments to radiation therapy, when we talk about radiation therapy, we have to think about it from a neuromuscular standpoint and a non-neuromuscular standpoint. I put a focus on the neuromuscular standpoint here. Things that would fall in the non-neuromuscular may be swallowing difficulties, cardiomyopathy, it's pulmonary fibrosis that may happen. There are still things that we're dealing with and we need to help patients with. But for the purpose of this, I focus more on the neuromuscular. So thinking about patients, if they've been radiated to the spine or to a bone, we're really impacting bone turnover. So we might impact growth and might see skeletal growth arrest. You might see, because of this, abnormalities in someone's posture and their alignment. We may inadvertently cause osteoporosis because we're not allowing these bones to turn over as they should and mature as they should. And so now we're increasing the risk of fractures for these patients. We may see osteonecrosis or this kind of ischemia of the bone in an area or even in muscle. We might impact different nerves depending on if they were in the area of the tumor itself. We can see a lot of scarring within the skin, within muscles. We may see lymphedema if lymph nodes are radiated. If the spinal cord is involved in an area of radiation, there is a risk for a spinal cord injury to occur. Radiation oncologists try very hard to make sure we're minimizing the amount of radiation that someone is experiencing and that we're really trying to, you know, be mindful of the approach and make sure that there's a good gap for the cord itself and a good space so that we can minimize this. But there are myelopathies that can present. Some of them might be just transient where we lose some of the coating or myelin to the spinal cord and those get better. And then there's the delayed, which we really worry about because those tend not to improve as well. You might see a lot of fatigue. You might see focal brain radiation necrosis where, you know, a patient did have an area where there was a tumor and we found that for a while they were doing well and now we're starting to notice neuro deficits in that same area again. We might see that we impact the brain as a whole, so more of an encephalopathic type of picture. We might impact cognitive function depending on, you know, how much radiation is received to the brain. And unfortunately, there are studies that have shown that particularly in children and when we radiate the entire neural access that we can see some secondary tumors that develop in the areas that were radiated. So just to show you what this actually looks like. So on the top, you can kind of see that red area between the neck and the shoulder itself. So radiation itself creates a burn and that's that redness that you are seeing. And within that, we can get a lot of scar tissue that forms. We can actually get that scar tissue within muscle. We have to think about the bones in those areas, the nerve roots in that area. So this is the earlier things that we can see. And then if you look down at the bottom, this is also a patient who is radiated and you can still kind of see some of the skin changes that still do exist, but you can actually see the effect of the scar tissue on the front where the neck looks like it's flexing forward and the chin is coming closer to the chest because the patient is being pulled. And because of the impact on that muscle itself, we can see the weakness that is developing. And so this inability to hold our head up, this is something we saw a lot with patients who got mantle field radiation for Hodgkin's and we can also see a lot in head and neck. And this is an important area for us to try to prevent, to make sure that during their course of treatment, we are addressing this because radiation unfortunately is a gift that keeps on giving. So it's constant maintenance for them. And we want to try to catch them earlier as opposed to when their head is dropped or they have a lot of impairments from this. This is actually an MRI of the cervical spine of a patient of mine who was radiated. She has been radiated for Hodgkin's, she was radiated for breast cancer, she was also radiated for head and neck. So you can think about it as multiple treatments in the same area. You can kind of just see where she started to collapse down in terms of bone, where her ligaments have started to buckle. And a lot of this just really had to do with the bone that fell due to the osteoporosis and all the scar tissue that did develop and weakness that she did have in terms of her musculature. So it really not only on the surface had an impact, but it had an impact deeper as well. All of the things that I've been talking about now to this point has really been, what do we see as the provider? What are we perceiving that's happening to patients? But what do patients notice? And a lot of times when I'm seeing patients, I can tell them what their impairments are, I can tell them where it's coming from, but what they really want to know is what I'm going to do about it and that what they really want to express is what it means to them. So if we think about some of these impairments, and by no means, this is an inclusive list, but think about it, right? You're now weak. You may have difficulty moving your upper and lower extremities. Now it's impacting your bed mobility. It's impacting your transfers in and out of a chair, on and off the toilet. It's impacting your mobility, how you're using any kind of adaptive equipment if you needed it, or you may need it now. If you were someone who is going to operate a wheelchair, would you be able to? And how it's impacting your activities of daily living. Similarly for sensory impairments, and sensory impairments are actually a lot harder to treat than motor impairments because it's one thing to help someone compensate for weakness, but if they just don't know where they are in space, it's a lot harder to teach them that and to get them to understand that. So they really lose an awareness of their environment. They're unable to tell where their limbs are, where their joints are, it impacts their balance quite a bit. It's gonna impact a lot of the same things that weakness did. But in addition to that, they may actually have a lot of pain from it. And what I always try to liken it to is, when we think about someone who's had an amputation and we talk about phantom limb, well, why did we get phantom limb? Because we cut the nerve ending. The brain still perceives that the limb should be there. And all this discomfort is related to the brain not getting the information that it's looking for. So patients who have sensory impairments, whether it be from cord compression or whether it be from chemotherapy, experience a similar type of thing. I put spasticity here. Again, like I said, we see it more with brain tumor. But this idea of a velocity dependent increase to muscle tone, again, gonna be a potential source of pain for patients, really impacting their mobility pieces of function and also their activities of daily living, may also impact a lot about how they're positioned in a chair, whether it be a chair that they're normally sitting in or their wheelchair, really just trying to get them in a good position. And then thinking about musculoskeletal abnormalities. We can see everything from scoliosis to kyphosis to pelvic tilts, to joint subflexations and dislocations, to fractures, to amputations, areas of primary metastatic disease where the patients aren't allowed to bear the same weight that they could before and how that's gonna impact. And so these are the things that patients are gonna describe and these are the things that they want us to fix. So it's really important for us to have a good knowledge. And, you know, I put this here because it's, you know, oftentimes patients are like, well, you're a physical therapist or an occupational therapist, or my primary doctor tried to address this, but what do we do as cancer physiatrists? And why is it this physician perspective and this patient perspective was so important for our area of medicine? And it's because cancer patients are complicated. And so whenever I talk to patients or I talk to trainees who are with me, and we talk about this idea of a spinal cord injury and then a cancer-related spinal cord injury. Yes, patient has a spinal cord injury and we can address their spinal cord injury, but at the same time, it's their cancer that makes it special and it's their cancer that that's that added piece that we really have to focus on. And so it's important for us to remember, you know, where their symptoms are coming from. Is it from cancer? Is it from treatment? Do we have to talk to a treating team about their treatment and what these symptoms really mean in terms of their tolerance? It's important to remember that patients bring more than just cancer to the table. If you think about men with prostate cancer, majority of them are over 70. And when you think about all the hosts of other things that come along with them, they have arthritis, they have disc disease, they may have already had surgeries, they may have diabetes, COPD, peripheral vascular disease. What was that, that pre morbid comorbidity that they brought to the table? Is that doing anything? Is that causing their symptoms? Is that something that we can work on? Is that getting worse because of their cancer treatment? What precautions do we need to put into place for them? So a lot of ones that I recommend have to do with spine precautions in terms of different movements. We may think about extremity precautions, blood counts, blood pressures, falls, sensory impairments. So all of these things, anyone who is going to provide exercise or activity recommendations, these patients need to be aware of them. We really need to find a good balance. We wanna find a balance for patients who spend a lot of time in treatment, who wanna be home with their family, and now you're adding on rehab management. How can we make sure that they could do both? And how can we make it something that's digestible for them? And it does require us to have some oncologic knowledge. We don't necessarily need to know every treatment that exists, but we need to know the classifications of different treatments, what potentially may happen. We really have to understand what oncologists are thinking, what they wanna do next, how this may impact someone. So we have to have a little bit of an understanding or an open dialogue with treating teams so that we can understand the cancer components when we're providing any kind of rehabilitation interventions. So what is it that we think we do? Hopefully by now you've heard me start to lay some of that out, but we can do a lot in terms of diagnosing symptoms. Where are things coming from? And that's not just from the pre-morbid to the now, but if you have a patient who has a spinal cord injury who may now have a plexus injury or neuropathy on top of it, trying to tease out what they're more symptomatic for, or if they have multiple areas of spine mess, which one might be the symptomatic one, helping treating teams understand where things are coming from. We can also help to relieve symptoms, improve quality of life, enhance functional independence. We wanna prevent further complications from happening for these patients. And the last piece of thing that we can do is oftentimes we can actually help improve tolerance to treatment. So there's a lot of functional decision-making that goes into someone qualifying for a clinical trial or a given treatment protocol where they have to function at a certain level. And so oftentimes we can help get the patient to that level or we could advocate for that patient, but also we can just make sure that we're doing that preventative, that restorative, that supportive that helps them get through their treatments. These are different ways that we do it. Again, I'm listing a lot of the diagnosis that we may make for these patients, but these are the different things that we can intervene, right? If they're having bowel and bladder dysfunction, we might be able to prescribe therapy, we might be able to help them with any kind of casting that they would need to do, any kind of medications or stimulation that they would need for a bowel program. If they're having pain, helping with medication management or referring to one of our colleagues who does any kind of procedures for this or working with our anesthesia pain or supportive or palliative care providers to make sure that we're giving appropriate medications. We might choose to use physical therapy or occupational therapy or speech therapy, really writing a thorough prescription of the precautions, the things that we want these therapists to actually work on for our patients, or even giving patients exercise recommendations or activity recommendations ourselves. We may prescribe prosthetics or orthotics, kind of more of that supportive, right? Thinking of the patient who might've had an amputee or the person who might have weakness due to their brain tumor, we can help with adoptive equipment. We can help using EMG in some of the diagnosis. Sometimes we will do it at the baseline to understand someone's neurological function or to help determine doing the EMG in conjunction with some labs. Is this something that is a diabetic neuropathy versus their chemo? Can we pick up a trend? Or is this a plexus versus a peripheral nerve lesion? So a little bit of the diagnosis, but then again, tying into the different prescriptions that we can make for the management. And then we do a good job in dispo planning, right? Thinking about what the patient's goals are, what the treating team's goals are, what treatment requirements may be and what the most appropriate setting for their rehab is. And so now kind of tying into what it is that I do. So I am probably one of the few that has found a way to subspecialize in cancer rehab. And I think I'm very fortunate in that I do work for Sloan Kettering. So we are a little bit different, whereas a lot of times in a lot of other institutions, you think about a rehab department and all the various components of a rehab department working in a bigger hospital system. For us, all of our patients, for the most part, do have a carrier cancer diagnosis. And we've actually built a rehab department in a cancer hospital, right? So instead of cancer rehab having to be more general, we do have generalists, but we can also be more specialized. So it allows me to actually use my background in spinal cord medicine to help cancer patients. So this is actually an image, although some of the providers have moved on, but this is actually an image of our multidisciplinary spine team, which I am an active part of, which is made up of neurosurgery, orthospine, radiation oncology, interventional radiology, and anesthesia pain. And we actually have made spine our organ, and we all focus together on treating anyone who has a primary or metastatic spine tumor. And so this is really nice, and this idea of can I sub-specialize in cancer rehab? And there was an article that came out in 2017 in the Lancet Oncology, and it had to do with the management of patients with spinal tumors. And they actually said that physiatry is important to be part of this multidisciplinary team, and that our role had a lot to do with the evaluation of patients, understanding their neuroimpairments, and helping them manage it. And so when we think about spinal oncology itself, and what type of things do I look at when I'm thinking about relieving symptoms, I'm thinking about pain, bowel, bladder, spasticity, if it does occur, sexuality and fertility, not so much the fertility piece, but more of sexual function. I think about complications that I can prevent in terms of bone health, spine instability, long bone fractures, pressure injuries, DVTs in terms of how we're mobilizing patients, enhancing functional dependence, right? Thinking about their neuroimpairments, their functional impairments, any kind of needs that they have from an adaptive equipment standpoint, and what can we do to put that into place. I do a lot of treatment decision-making, and I help our oncology teams really kind of figure out where symptoms are coming from, or help them manage the things that they're unsure of. I do a lot in terms of deciphering things for patients, so discussing with their treating team, what we're seeing, what they're experiencing, and then helping them understand what that means to them. I don't do electrodiagnostic testing, but I have some colleagues who do. I do help with cardiovascular management when patients may have autonomic dysreflexia or hypotension, two things that are common in spinal cord injury, which not everyone necessarily has a good understanding in management, and we can help pulmonary-wise, not so much from an oxygen standpoint, but from a ventilation standpoint, and I do help manage pressure injuries and wounds should they occur. And we do all of these things to improve quality of life, and in addition to the things that you see here, there's a lot of education that happens and a lot of psychosocial support. And so just to kind of show you a little bit of what this assessment looks like, you know, we think a lot about history of present illness, past medical medications. We think a lot on social history, so what someone's role, you know, is in their home, what was their role in the community, how did they function prior to their diagnosis, what's their support system, who's with them, and also financially. And then really taking a lot of what we know from traumatic spinal cord injury and how we're evaluating patients. So the idea of using the INSCE or the ASIA exam to determine neural levels of injury, motor, sensory overall, I don't use it in terms of prognosticating because we don't have enough data on that, but we do have information about a neural level of injury, what to expect, how complete or incomplete they are, checking other sensory modalities, taking a look at their joints, their cognition, their blood pressure and fluid status, looking at their skin, looking to see if there's any skeletal abnormalities that might impact their overall function and having them walk if they're able. So really taking all these pieces together to help understand what's happening, to help the patient understand what they're experiencing and what we can do, and then doing the same thing. And then where my recommendations, being that I practice in such a multidisciplinary approach, I'm forever collaborating with our neurosurgeons, with our orthopedic surgeons who focus in spine, with the medical oncologist, the radiation oncologist, the interventional radiologist and the pain doctors, because it's really about all of us looking at this patient together and what we can all do and making sure that we're addressing all the different facets of their care. I do a lot of education on spine precautions. I always tell people to think about the dishwasher and the overhead bin and how you put your dishes in and your luggage up. How are we moving? Are we protecting ourselves by muscle? Are we moving with only our spine? Are you gonna do something that's gonna get into trouble? Is your therapist gonna do something? How many times patients come in and they're like, well, I had back pain and I went to see a therapist and then my back pain got worse because no one knew I had cancer and I didn't have any kind of precautions. So putting it out there. We do a lot of work with postural bracing. I put it as postural bracing here and not bracing for stability because oftentimes if our patients are unstable, they're gonna be treated by the surgeon. There is medication management, bowel, bladder pain that I might do. I do a lot of education on home exercises. Historically, it was a lot more therapy recommendations, but during COVID, a lot of that did shift. So it's a little bit of both. I do incorporate our therapist, different ideas in terms of core strengthening, strengthening the muscles of the back, weight bearing, different types of exercises that are safe for our patients. I focus a little bit on nutrition as well too. And I consider referring when we need to, making sure that patients have what they need for bone health, also for muscle health and making sure that they could achieve their rehab goals. And I work very closely with vendors who do adaptive equipment and also who do bracing just to make sure that they have a good understanding and we're able to get the patients what they need. So just obviously various types of adaptive equipment we do have from wheelchairs to walkers to different types of prosthetics that we can use for our patients. And just to kind of highlight the whole idea of spine precautions one last time, because I always think these help and I think they're just good for all of us to follow. We always hear no bending, lifting, twisting, but what does that really mean? So what I always tell patients is, like I said, the overhead bin and the dishwasher, you can flex and you can extend where you can comfortably. If you're at 90 in flexion, please bend your knees, never twist when you're bent over or when you're extended. So if you're putting dishes away, you should be facing your dishwasher when you're flexing, you should be rotating towards your dishes while you're standing upright. And when you put your luggage in the overhead bin, put your luggage in front of you and then overhead. And really educating patients on these kind of easier ways to understand things than bending, lifting, twisting, because that doesn't necessarily mean the same thing for everyone, but always trying to keep our patients safe. And so with that, I'm going to stop sharing my screen and I'm going to open for any questions that you may have. I know I ran a little bit over. What is my usual day like? So I am very spoiled. I actually work in the land of outpatient and consults so we do not have an inpatient rehab service at MSU. My colleagues will joke I don't know how to practice alone, and it's because I don't. I actually see patients whenever, you know, our neurosurgeons and our radiation oncologists are in clinics. So I have outpatient clinics Monday, Tuesday, and Thursdays. And in those, I'll see patients who are slated to see me, but I'll also see patients who are slated to see the other providers there. And I work very closely in terms of giving them recommendations. I do take a turn at the consult service. All of the providers we have do, we take a week every so many months, but in addition to that, I staff any spinal cord consults that do come into MSK. And then on Wednesdays and Fridays are my admin days where I spend time thinking and catching up on all the documentation that I am supposed to do and do things like get to lecture to you guys. Do I see rehab becoming a big part of our specialty? Well, I do. And you know, I look at it from different perspectives. My first generation of cancer rehab really looked at it as kind of more of a generalized approach in what we could do. My generation of cancer rehab, we ran in totally different directions. Each one of us had a different interest and we decided to run with that. I've also been a big advocate of bringing cancer rehab to other subspecialties. So really talking to my spinal cord colleagues about why it's so important for us to think about non-traumatics and why it's so important for us to think about cancer patients. And I have colleagues who are doing that with other subspecialties as well. I do think that cancer rehab will continue to grow. And I do think that we will continue to infiltrate all areas of our specialty. Oh, prehab. Oh, yes. So no worries. So prehab. Prehab is actually really important. The biggest challenge to prehab is insurance coverage and just getting insurance coverage for someone who doesn't have an impairment. But I think it's important and particularly the older populations who we know have, you know, disc problems or arthritis or someone who may have a baseline neuropathy, really making sure that we're focusing on those symptoms before we start any treatment. There's a huge push. Julie Silver, I think, leads the charge in a big way. But there's a lot of others who have as well. But I think you're going to hear about it more and more because we are all acknowledging why and how important it is. I appreciate that you guys found cancer rehab so rewarding. And hopefully you enjoyed my lecture. So when we talk about, and I think that's important when we think about, so the last question in terms of limited number of beds, right? Why is your patient, why are you making this case for your patient to go to rehab, right? So if you just say, oh, well, they have breast cancer, maybe they're not going to be prioritized. But if you say that this is a patient who had breast cancer, who had a brain metastasis, and as a result of her brain metastasis, she has non-traumatic brain injury. And these are all the reasons that we should send her to an inpatient rehab or we should send her to a brain injury unit. It really actually helps make that case. And that's where we as cancer physiatrists need to really make sure we're advocating and writing that diagnosis. So my patients who have cord compression or spinal cord tumors, I always write that they have a non-traumatic spinal cord injury, and I advocate as much as I can to get them based on their needs into either acute rehab or onto a spinal cord injury unit. So I think a lot has to do with what impairments do they have, where is that tumor, and what diagnosis is this like, because that's how you actually plead that case to get patients in. So I do appreciate that question. I don't think I missed any today. I don't see any other questions. Oh, why did I pick PM&R as a specialty? Okay. I wanted to be an orthopedic surgeon, not going to lie. When I was nine, I fractured my ulnar and radius. At the same time, I had an ORIF, and I thought it was the coolest thing ever that you could put people back together again. When I was in college, I worked at Woodward Camp. I was a competitive gymnast, so I was coaching gymnastics for the summer, and I met Silvia Matova, who was a survivor of a traumatic spinal cord injury, and it was the first time that I had met someone with a spinal cord injury who was walking, coaching gymnastics, pregnant, and married, and I wanted to be a spine surgeon because I thought it was amazing that someone saved her, and this is what she could do. When I got to medical school, I had an attending tell me I didn't strike him as a surgeon, and he thought I should be a physiatrist. I had no idea what it was, but I was rotating at Kings County at the time, and I signed up for a two-week PM&R elective, and I stayed for 12 weeks, and I just never looked back, and I completely just embraced the idea of rehab and what rehab offered, and it initially really enhanced my wanting to do spinal cord injury, and like I said, when I came over to Sloan Kettering and realized that there was more to rehab than I had ever known or ever thought about, and this idea of non-traumatic injuries and really that someone needed to stand up for them and really advocate for them, it just kept me going in the same direction, and I'm happy to say that I don't think I would have picked anything else. So when I prescribe outpatient physical or occupational therapy, do I provide a specific plan or instruct things, and I rely on the therapist for appropriate application? It depends. Oftentimes, I am very strict in my precautions that I want, and I think I put a bigger emphasis on my precautions. I don't necessarily tell them the exact exercises they have to do for core strengthening. I might say something like I want core strengthening in supine or supported, but I do try to let the therapist, you know, be able to be a little bit creative and have some flexibility in what they are, you know, doing with patients. That being said, I really like feedback from the therapist, and I like to hear from them, and if I do have any concerns, then I probably do get more specific about the things that I want them to focus on. I will say one other thing I really harp on is that, you know, I want therapy to be exercise and less modalities. Massages and ice and all that feels nice, but I really want the patients to be focusing on the exercise components of things. I hope that answered your question. All right. Well, I know we are at the top, and you have my, oh, I am glad you thought it was sensible. You have my email, and you had contact information. I know Amy was going to share the PowerPoint, so everyone has access to it. I am always happy to answer questions. Reach out if you, you know, just need advice or there is something you are curious about. I am pretty good at answering emails, so feel free to always reach out. I hope this was a nice overview for you and insightful for you. Thank you so much. I think this was great. It was really interesting to me as well. I just want to remind everybody tomorrow we have our first small group discussion case, so we have a variety of faculty and residents and fellows who are going to lead those discussion groups for you all, so you will get to meet some additional people through that tomorrow, and we are going to actually be discussing cancer and spinal cord injury cases tomorrow, so we are going to combine the two, so that will be tomorrow's small group discussion, so I hope to see you all there, and I think that is it for today, so thank you for everybody and also to Dr. Rupert for helping us out today. You are so welcome. Thank you. Have a great day, everybody.

cancer rehabilitation

quality of life

pain

weakness

sensory impairments

chemotherapy-induced peripheral neuropathy

radiation therapy side effects

cognitive changes

multidisciplinary care