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Virtual Didactic- Safety Considerations in Cancer ...
Virtual Didactic- Safety Considerations in Cancer ...
Virtual Didactic- Safety Considerations in Cancer Rehabilitation Led by Susan Maltser, DO
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All right, let's go ahead and get started. I want to welcome everybody to AAP Virtual Didactics today. We're excited about today's lecture. As always, we want to recognize and appreciate those who have been more affected by the COVID-19 pandemic than the rest of us. We recognize that those difficulties have not been equally spread, so we appreciate those of you who have been most affected. A couple of housekeeping things. First, the goals of this are to augment didactic curricula that are ongoing at your home institutions to offload overstretched faculty due to some of the logistical difficulties associated with this pandemic. To provide additional learning opportunities to off-schedule residents, again, some of the logistical challenges of this have required changes in resident scheduling. We recognize that. And then provide more digital learning resources and support for psychiatrists in general during COVID-19. Further, we're going to keep everybody's audio and video muted. As always, if you have any questions, you can find me on the list. My name is Sterling Herring. I'm a PGY-3 at Vanderbilt. If you click on participants, you should see me up near the top. Again, my name is Sterling Herring. You can double-click me and send me a message. And at appropriate times, I will ask those questions to our presenter. If you have any general questions, suggestions, or concerns, there's an email address for Candace at AAP, or you can find us on Twitter. So without further ado, we're super excited to have Dr. Maltzer here today with us. Dr. Maltzer, welcome. Hi everyone, thank you for having me. Sterling, can you hear me? I can. Okay. So I'm really excited to talk to you guys today. I'm coming to you from New York City, from Long Island, technically. So this will be a really nice break from all the COVID-related planning and executing that's happening here in New York. I wanted to talk to you guys today about cancer rehab. Hold on one second. I just want to share my screen. Give me one second. Okay, I wanted to talk to you guys about safety considerations in cancer rehab. Cancer rehab is something I'm very passionate about. And I find that the biggest questions that people ask me who are non-cancer rehab physiatrists are when is it safe to do therapy? When is it safe to do exercise? And I think no matter what kind of physiatrist you are, whether you do inpatient and you do outpatient, you will touch cancer patients. And cancer patients will come to your practices in your hospitals. And I think having answers to some of these questions is very helpful because very frequently, the therapists are gonna come to us asking, is it safe to do this? And unfortunately, there's been a lot of dogma and a lot of misinformation that's kind of been passed out over the years without sound data to back it up. So I'm hoping that with this talk, we can kind of look at some evidence-based guidelines to make our recommendations be what our patients need them to be. So let's get started. So I have no disclosures. And like I said, I wanna talk about how do we deliver rehabilitation safely to cancer patients? And this talk could be three hours long if I hit everything, but I wanted to focus specifically on three things. One is bone metastasis, second is lymphedema, and three is modalities. I find that these are probably the number, the highest number of questions that I get asked by outpatient physical therapists and outpatient physiatrists. So as we know that the number of cancer survivors is actually increasing every year because of the way that we're delivering oncological care. So as the targeted therapies, chemo, radiation, and surgery are getting better and better, death rates are going down. And as a result, more people are living longer and longer with what we call survivorship. Survivorship happens from the day you're diagnosed with cancer and continues for the rest of your life. So we as physiatrists have to figure out a way how to take care of the disabilities that these patients have as a result of their cancer or cancer treatment for much longer than they will be following with their surgical oncologists. So I wanna jump right into it and talk about bone metastasis. So bone metastasis is very prevalent in advanced cancer. In some studies, they have found that up to 75% of autopsy is done on advanced cancer patients show bony metastasis. So if you look at the breakdown, obviously multiple myeloma has bone involvement, but things like breast, prostate, lung cancer, thyroid cancer, these have very high prevalence in bone metastasis. If we just think about breast cancer alone and the fact that one out of eight women has breast cancer, and you try to extrapolate that to amounts of patients that live with advanced cancer, we're talking about huge numbers of patients. So when we look to see where bone metastasis is most prevalent it's most common in the axial skeleton, then the femur, the humerus, the skull, the ribs and the pelvis. Most of my patients that I see with bone metastasis are in the spine and in the femur. And we'll have a slide on this a little later, but when we are talking about bony metastasis, we wanna know what are the complications for bone metastasis? And the complications are, and the complications are things called skeletal related events, SREs. And when we're doing studies of bony metastasis, we're actually measuring how frequently do SREs occur. So SREs include pain, hypercalcemia, spinal cord compression and fractures. Specifically in rehab, the things that affect us are obviously pain, spinal cord compressions and fractures. Specifically when it comes to fractures, we want to know how do we prevent them? How do we not cause patients to have fractures based on our rehab interventions? So traditionally it was thought that most bony metastasis were either osteoblastic or osteolytic. And traditionally it was thought that the prostate cancer was osteoblastic, the multiple myeloma was osteolytic, and it was very well compartmentalized. But it turns out that the picture of bony metastasis is much more complicated. And that most bony lesions start out with a breakdown of bone, which is osteolytic, and then laying of new fragile bone, which is osteoblastic. And this process can continue and lead to weakened bone. And so we have to be careful not to assume that just because we don't see osteolytic lesions on an X-ray, that we assume that there is no bony metastasis involved. How do we evaluate bony metastasis? I want to spend just a couple of minutes on this. We can look at a few modalities. So the things that are available to us are X-rays, CAT scans, MRIs, and bone scans. And none of them are perfect. So in an X-ray, 50% of bone mass will have to be destroyed before it's apparent on an X-ray. CT is a good test. It's a good initial test. It's much more sensitive than an X-ray in terms of how much of the cortex has to be destroyed, but it's not 100%. MRI is extremely sensitive at picking up bony metastasis and is the number one modality to use for spine mets. But the problem with MRI is that sometimes it doesn't pick up the difference between a tumor and a side effect of treatment. So for example, patients that have had radiation to the spine, it's sometimes tricky to see what is a new lesion or what is a side effect of the radiation. So there's a high false positive rate. And again, it's best suited for spinal metastasis. Bone scan is another modality that we can use. The problem with bone scan is that it will pick up everything. So if there's a stress fracture, if there was osteomyelitis, it'll pick it up. So if I had to pick two ways to do this, if you can get an MRI, MRI is probably the most sensitive, probably the best thing we can do. But if you're having difficulty obtaining prior auth for an MRI and insurance won't authorize it, an X-ray and a bone scan together will likely give you your answer because everything will show up on the bone scan and the X-ray is a lot more specific. So either X-ray and bone scan or MRI. We talked a little bit about skeletal related events and this duration of survival of 20 months is actually old. I have patients that I've had with bone metastasis for five, six years. So again, it goes to show you that these patients are living much longer. Talk a little bit about bone metastasis in the spine. It's the most frequent site. 70% of cancer deaths have spinal involvement. And this leads to more than 20,000 cases of spinal cord compression a year. And most of them are extradural. I think if I could leave you with one pearl, it's that any patient with a history of cancer presenting with back pain has to be evaluated. So if the patient is currently undergoing cancer treatment, I would get an MRI right away. And if a patient has a remote history of cancer, I think it is reasonable to try a short course of treatment unless there are any red flags. And if the patient doesn't improve, go straight for MRI. So I want to shift gears a little bit and talk about why we're having this conversation about safety. So the American College of Sports Medicine had a round table discussion and guidelines for Americans with cancer. And their guidelines for exercise were exactly the same as the guidelines for all Americans, which is 150 to 300 minutes of moderate intensity activity and 75 to 150 minutes of, or I'm sorry, or 75 to 150 minutes of vigorous intensity activity, as well as muscle strength, strengthening two days a week. So this is what we should all be trying to do. And we know how much exercise, know how much exercise benefits cancer patients. There are studies showing that exercise is helpful from pre-ablutation, during cancer treatment, after surgery and into survivorship. So our job is how do we help cancer patients that have advanced illness, or how do we meet cancer patients that have had some complications meet these guidelines? So part of this round table, they do say that this exercise prescription has to be individual, that we should take into account the patient's cancer course and their treatment course and what they're able to do and how we can adapt their prescription to their individual needs. So for example, if someone has lymphedema or decreased range of motion of their shoulders, we need to adapt their exercise prescription, or if somebody is cytopenic, they may not be able to go to the gym, they may not be able to go to the pool. What can we do to alter their exercise prescription? One thing I always keep in mind when prescribing exercise to cancer patients, not just patients with bone metastasis, is their bone health. So bone health across the board is a big problem for cancer patients because of several factors. Many patients, when they're undergoing chemotherapy, get steroids along with their chemotherapy. And so patients may actually be taking steroids on and off for about a year and sometimes longer. For prostate patients, we know that androgen deprivation therapy can actually cause bone loss and osteoporosis, and that's something we should be screening for. In women who are treated with aromatase inhibitors, again, we are screening for bone loss and we have to consider how do we build bone? How do we improve bone health? And it's important to remember that some of these patients may be below the age where we may be screening for osteoporosis. So if you have a patient who's taking an aromatase inhibitor, we do wanna make sure that they've had a bone density test, and we do wanna make sure that we talk about how do we build bone? Again, in our female cancer patients, chemotherapy can actually cause ovarian failure that may be premature. So we may have a patient in their 30s or 40s who has an ovarian failure and is at very high risk for osteoporosis. So when we are prescribing rehabilitation and when we're prescribing exercise, we wanna make sure that we do no harm. We wanna make sure that we don't cause fractures of patients that have bony lesions. And how do we do that? So there've been a lot of people who have asked the question which bony lesions are going to go on to fracture and have impending fracture. So some of the things that people have looked at is size of the lesion, percentage of the cortex involved. So if more than 50% of the cortex is involved, that patient may be more likely to fracture whether bone is weight-bearing or non-weight-bearing. So there's a difference between the femur and the ulna bone. So this is the things that people have looked at. And what they have come up with is that none of these things on their own are predictive of impending fractures. The biggest guidelines that are used today is something called the Merrill scoring system. So this study was done by Dr. Merrill who took 38 patients who had 78 bony lesions. And he looked to see what factors were present in those patients that had fractures. So the 38 patients with 78 lesions went on to have 27 fractures. And the things that he looked at were the size of the lesion as a percentage of the cortex, the site, if it was in the arm, if it was in the leg, the type where there was osteoblastic and osteolytic, and whether the patients had something called functional pain. So functional pain is pain with movement. So if you have a femur lesion and you have pain going up and down the stairs, that's called functional pain. And that pain was actually found to be the thing that contributed most to fracture risk more than anything else. So patients that had functional pain were found to have fractures at a much higher rate than anything else. So Merrill's gave the scoring system, which basically assigns points to the site, the type of lesion and the pain. And if you score more than nine, you're recommended to have a prophylaxis fixation. So for example, if you have more than two thirds of your cortex involved, and if it's mixed osteolytic, if it's osteolytic and your pain limits function, then you score a nine, and then you should have your lesion prophylactically fixed. I will tell you that in my office, if I have patients with functional pain, where their lesion is, off they go to our orthopedic oncologist to prophylactically do a fixation. Here's another really good study. This was done by Dr. Bunting. And they look at 54 patients with bony metastasis with no evidence of impending fracture. And these patients underwent a course of inpatient rehabilitation. And they found that 16 fractures happened in 12 patients. Eight of the 16 fractures were silent and six occurred in bed. And only one occurred during an actual rehabilitation session. And some of the conclusions that Dr. Bunting came to is that if you have a lesion that's progressive and that's going to fracture, it's likely going to fracture because of the nature of the lesion and the disease and its progression, not because of anything we do. And the alternative to not doing exercise or not offering patients that have rehabilitation needs is bed rest, right? So we have to tell people to stay in bed. And if people stay in bed, you see all these complications that are, a lot of them are a lot worse than a fracture that can be fixed by an orthopedic surgeon. So we really want to think about when we're doing an exercise and physical therapy prescription, what are we looking for, right? In terms of flexibility, using modalities, using orthotics to offload extremities with bone and metastasis, doing posture retraining on patients that may have spinal metastasis, core strengthening, functional retraining. So these are all the things that we can kind of recommend to our patients. So when I do a specific exercise prescription for a patient that comes in with cancer or bone and metastasis, I really make it individualized. So I see what is the pain assessment? Can this patient tolerate exercise or physical therapy? What is the fracture risk? Are there any venous access devices? So does the patient have a port that we need to protect and come up with some precautions? Is there peripheral neuropathy from chemotherapy that we need to make sure we give specific precautions for? Is there immunosuppression? Is the patient's cytopenic? And we need to alter where the patient has therapy or what they're doing. So now I wanna go into a little bit more on the exercise front in patients that have bone and metastasis. So in this one study, looking at 50 patients with bone metastases, they tried to see how many of them were getting exercise. And they noted that 92% were interested in completing exercise programs, but only 29% were interested in doing physical therapy. And 39% were able to meet current exercise guidelines. And obviously that's a huge gap. And they found that those that were able to exercise obviously had higher physical functioning scores, higher general health scores, and higher measures of physical performance. That's gonna come as no surprise to us. So our job as rehabilitation professionals is how do we bridge that gap between the patients that need the exercise and the patients that get the exercise? And I think one of the first steps is convincing patients and oncologists that what we are prescribing to patients is safe. So when we are talking about bone health and what we can offer. So we know that our patients, hopefully are getting pharmacological therapy, but we need to think about what we can do to offer rehab interventions for education about preventing fractures. So education about heavy lifting, lifting techniques, high impact activities, bracing. This is all that's kind of in our wheelhouse. In a review study of 11 studies looking at exercise interventions for patients who have metastatic cancer with bone involvement, there was definitely an improved in exercise behavior, muscle strength, aerobic fitness, and walking speed, and no skeletal related events and no aggravation of fatigue or increased bone pain. So this is kind of where we have to start saying, we know exercise is good for you. We know that exercise is safe for cancer patients. Well, what am I going to say when I have a patient with an L2 bone mat who wants to ride a bike or who wants to row? Now we've got to really go down to the nitty gritty of what's safe. So I really love this study, the effective resistance training duration during radiotherapy on spinal bone metastasis in cancer patients. So in this study, they took 60 patients and they randomized them to a group of resistance training and passive PT. And I love this study because we know that resistive exercise can help build bone. So for patients that may have had androgen deprivation therapy, or patients that may have had chemotherapy on top of their bone metastasis, we know that we need to do something to build bone and resistive exercise can do it. What was interesting about this study is that they looked at bone density of the involved metastatic bone lesion. So if you had a lesion at L2, the aim of the study was to see if they can improve the bone density of that lesion. So they did not exclude the part of the body that had bone in metastasis from exercise. And this study went on for 12 weeks and they found that bone density was significantly increased in the intervention group. And there was no increase in bone density in the passive PT group and there were no fractures. And this basically shows that paravertebral strengthening and paravertebral resistive exercises are safe in patients that have bony lesions in their spine. And not only that, not only just safe, but that it can increase their bone density, their bone health. And in this other study, they took a little bit of a different approach. They said, we wanna do resistance exercise in prostate cancer patients with bone mets, but we do not wanna do resistive exercises through the lesion that has the bone mets. So if somebody had a pelvic lesion they did exercises on the upper body and trunk, but they excluded the pelvis. And if somebody has, you know, a lumbar spine lesion, they did exercises on the upper body and lower body, but not the trunk. So this way they excluded the area of the body that had the metastatic lesion. Oops, sorry. And they found that this was, you know, safe and effective and that they were able to build a bone density overall. And again, in this study, there were no skeletal related events. Now I wanna switch a little bit of gears a little bit from bone metastasis to lymphedema. So lymphedema is extremely common in cancer patients, 3 to 5 million people in the US who have secondary lymphedema. And it's, you could see it in any cancer, but it's very prevalent in breast cancer, sarcoma, and gynecological cancers. And, you know, lymphedema is one of those things that if you don't look for it, you don't see it. Well, if you work with cancer patients, it's almost overwhelming how many patients have lymphedema, have had lymphedema for years and nobody's addressed it. So I wanna focus only on secondary lymphedema, which is lymphedema from cancer most likely. And I wanna just do a couple of slides just to catch you up on treatment, the treatment of lymphedema. And lymphedema could be a whole separate lecture by itself, so I'm not gonna go into all the details, but basically secondary lymphedema is caused by cancer, cancer treatment, obesity is a huge contributor, trauma, infections like cellulitis, venous insufficiency puts people at a higher risk for lymphedema, and sometimes surgery can cause lymphedema as well by damaging our lymphatic vessels. But the number one thing that we see is cancer treatment. So we said that cancer treatment is the number one risk factor, specifically lymphadenectomy, which is the removal of lymph nodes is a stronger predictor of lymphedema. So that has to do with how many lymph nodes were removed, where the lymph nodes were in terms of were they just in the breast, were they axillary or iliac, and cellulitis is a big risk factor for lymphedema. And the tricky thing with lymphedema is that it can be immediate or it can be delayed. So I've had patients that have had no lymphedema for five to 10 years, and then something happens and they develop lymphedema. The thing about lymphedema and exercise specifically is that there are a lot of resources for lymphedema patients on the internet, both in terms of the treatment of lymphedema and how to kind of live with it. And some of that information is not correct. So I think it's really important for really all physiatrists to kind of know the basics of how do we treat lymphedema and what precautions we should take. So really important, the earlier we can diagnose and treat the lymphedema, the better. And the gold standard is something called complete decongestive therapy. So that includes manual lymphatic drainage, which is a special type of massage, compression, bandaging during the treatment, and then the maintenance phase, which is a compression sleeve to kind of maintain whatever reduction of volume you have. And it's important to know that lymphedema is a chronic condition. So once you have lymphedema, you're likely going to have it for life in some form. And it becomes really important for us to advise our patients of how they can exercise with lymphedema. I apologize, someone's clearly trying to reach me. So if you go on the internet, and look up lymphedema, there's going to be a lot of facts, some of which are not correct. So I kind of wanted to go through the most common things that patients find and talk them through. So needle sticks, there's no evidence that needle sticks can cause lymphedema, but there is anecdotal evidence. And I've heard some of this anecdotal evidence myself from my patients. And so while we can say that so far, we don't have a study backing this up, there is anecdotal evidence. So I would say people should try to avoid needle sticks if they can. Same thing with compression. So this they actually have studied in that when they do carpal tunnel surgery, there is quite significant compression before they do the nerve release. And that compression is way more than a typical BP cuff. And they've done studies showing no increase in lymphedema exacerbations or lymphedema onset after carpal tunnel surgery. So from that, we can extrapolate that we don't have good evidence to show that BP measurements can exacerbate lymphedema. Avoid air travel, it's also anecdotal. Maintain normal body weight. There's very strong clinical evidence for that. So keeping your body weight down is one of the best ways to prevent lymphedema and to prevent exacerbation specifically of lymphedema. Avoid extreme temperatures is anecdotal and avoid vigorous exercise is wrong. And this is where this part of the misinformation is probably the most vocal. And it really hurts our patients because remember we said that our patients may have had chemotherapy and they may have had an aromatase inhibitor and their bone health is not as good as it can be. And now we're telling them they should not exercise. So I wanna just look at a couple of studies showing the opposite. So this is a great study looking at 154 patients who were randomized to resistance exercise, weightlifting and usual care, which was a program that did not involve a resistive exercise, just aerobic activity. And these are the exercises that they did. And the primary outcome was lymphedema onset and an increase in arm swelling. What I really liked about this program is that they did not have a ceiling on how much you can lift in that if you had lifted before and you could do 20 pounds, you can start with 20 pounds. Or if you never weightlifted, you can start with five pounds, but there was no ceiling on how much the weightlifting was. So if you see at the outcome of the study, they looked at an exacerbation as an increase in arm swelling by more than 5%. So you can see that 11% in the weightlifting group had an exacerbation of more than 5% or equal and 17% in the control group. But this actually was a lot more interesting in the patients who we expect to have more severe lymphedema or higher risk for lymphedema. And these are patients that had more than five lymph nodes removed when they had their surgery. And there the numbers were 7% in the intervention group and 22% in the control group. So from this, we can say that not only is exercise safe and weightlifting is safe for patients that have lymphedema, but maybe there may be some kind of protection that happens with exercise. Maybe the vasodilation that happens with exercise is good. Maybe the muscles kind of pumping the lymphatic fluid acts like a pump. So I take this study to mean that not only is exercise safe in lymphedema, but it's also very effective in preventing exacerbations. So here's another study looking at 141 patients. And again, patients were put through a resistance training program versus an aerobic training program. And their outcomes were change in arm and hand swelling at one year. And their secondary outcomes were incidents of lymphedema exacerbations, number of severity of lymphedema symptoms and muscle strength. So when we look at the change in measurements, the people that had the 5% increase in swelling were about the same in the intervention and control group. But when we look at patient symptoms, the severity of symptoms were less in the intervention group. And the strength was obviously improved in the intervention group. And the incidence of exacerbations was decreased in the intervention group. So again, I think these two studies together, specifically because they have a large amount of patients, have led me to educate my patients on the importance of doing resistive exercises, even with lymphedema. I wanna shift gears a little bit more and talk about modalities. I'm sure a lot of you have had physical therapists come to you and say, well, could we use a modality in cancer patients? And this is where also, we have a study that was done, I think in the 70s or the 80s of using heat or using ultrasound in mice. And there was some concern that heat and ultrasounds can cause vasodilation, which may kind of like feed the tumor. And because of that, we've had this blanket statement of no heat, no ultrasound in cancer patients, which I think honestly doesn't make sense and is not really supported by science. I wanna talk a little bit about what I think are more sound practices. So one, I do think that we should never put heat or ultrasound over insensate areas. And that may be a site where the patient had surgery and over a scar and they can't feel and they can't say, it's too hot or I feeling discomfort. I would not put it directly over a tumor. And I would not put it over skin that was recently exposed to radiation. But I think other than this, anywhere else in the body, even in an active cancer patients, I would be okay. And when we look at some of the emerging treatments for cancer, we are using MRI focused thermal ablation for patients that have bone mass. So we are giving heat, really deep heat to tumor sites. So I think this whole concept of feeding the tumor is not 100%. In addition, for patients that have lymphedema, we do use ultrasound and we do use lasers to treat lymphedema. And we use both ultrasound and laser to treat something called axillary cording or upper extremity cording. And we haven't had any safety concerns doing that. So I think that patients that have needs for ultrasound, if you have neck pain or if you have back pain and you've had a history of breast cancer, I would have no reservations. I'm gonna talk a little bit about TENS. There's probably a lot of roles for TENS that have been described, not just in the treatment of pain, but treatment of nausea in active cancer patients. So I think we don't know a lot about TENS. And I think this is an area that needs to be studied more. I would say avoid TENS in patients with bone metastasis over bone lesions. Again, no TENS directly over active tumor. And it's probably best to wait till we know more about TENS units. And obviously okay to use in the palliative setting or advanced cancer setting. Spinal manipulation and massage. Specifically, I wanna talk about massage. So traditionally, we've been told to avoid massaging cancer patients for fear of causing metastasis. And one of the problems is that it's really contradictory to our current treatments of lymphedema, which is a type of massage. So I think more sensible precautions includes lighter pressure over areas that have bony lesions, bony metastasis, avoiding massage over skin that has radiation dermatitis or burns, avoid direct pressure over tumor sites, and avoid all spinal traction in patients with spinal bony metastatic disease or patients that have osteoporosis. Other than these, I think I would be comfortable with massage being used in cancer patients. And I actually prescribe it quite frequently. So that's all I have, but I look forward to your questions. And if anything I didn't cover in this lecture that you wanna know about, I'm happy to talk about. Thank you so much. I appreciate it. That was an interesting review of a lot of topics that I think are very relevant. As you mentioned, I don't think that any of us are gonna have any kind of practice in PM&R that we won't encounter some of this. So I appreciate it. And kind of debunking a lot of these myths and misunderstandings of the data. I don't, if there are any questions, please send them in. I haven't had any yet. I think this has been a very straightforward and digestible lecture. One question here, primary bone tumors, same guidelines as METs or different in terms of fracture risk and exercise? So primary bone tumors, I think would depend on the treatment, right? Because metastatic disease to the bone is a sign of advanced cancer that usually gets what kind of therapy? One is radiation therapy and two systemic therapy. So usually if you have say breast cancer and now you progress to metastatic cancer in the bone, usually your chemotherapy will get changed and you will get radiation say to the spine if your lesion is painful. Primary bone tumors usually may have a surgical treatment even before there is a fracture risk. So I think it would very much depend on was there any kind of surgery? Was there any kind of fixation? Or was there radiation? But if there was not, I would say yes, treat it the same. Okay, thank you. Again, another question here, can you comment on pediatric cancer patient populations with regard to bone METs, physical activity, guidelines, exercise prescriptions, study limitations and that sort of thing? So I'll be honest with you. I don't see pediatric patients. The only thing that I can think of that's different in pediatric patients is growth. So what happens when you have a bony MET through a growth plate? How does that affect? How does exercise affect that? So I think that's something that I would kind of have to think about. But I think other than that, I would treat it the same. I would say that if the patient is not having functional pain, so I'll just give you an example. Say you have a kid with a humeral lesion from a sarcoma and they wanna play baseball, but every time they pitch, they have pain. That is not someone that I would encourage exercise with weights in their upper extremity. That is somebody that I would send to a surgeon. But if I had someone who had a humeral lesion that was not causing them pain, and they asked me if it was okay for them to lift weights, I would probably say, okay, and start low and go slow and see how we do. Thank you. Okay, that makes sense. I think the growth plate question is a potentially interesting one, I think, for further research, if there's not already papers out there. Absolutely. And I wanna say that a lot of what we do does not have a lot of evidence to back us up. And some of this, we just have to sit and kind of logically think through this. We're very lucky that we've had a lot of.
Video Summary
The video transcript is a lecture on safety considerations in cancer rehabilitation. The speaker, Dr. Maltzer, discusses topics such as bone metastasis, lymphedema, and modalities in cancer rehabilitation. She emphasizes the importance of individualizing exercise prescriptions for cancer patients based on their specific needs, bone health, and fracture risk. Dr. Maltzer presents evidence that suggests exercise is safe and beneficial for cancer patients, including those with bone metastasis and lymphedema. She also challenges some common misconceptions about exercise and cancer, such as the belief that exercise should be avoided in cancer patients. Additionally, she addresses the use of modalities like heat, ultrasound, and massage in cancer rehabilitation, providing guidelines for their safe use. The lecture acknowledges the limitations of the current evidence base and calls for further research in the field. Overall, Dr. Maltzer provides valuable insights and practical recommendations for delivering safe and effective rehabilitation to cancer patients.
Keywords
cancer rehabilitation
bone metastasis
lymphedema
exercise prescriptions
individualizing
beneficial
common misconceptions
safe use
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