Good afternoon. Thanks everyone for joining us. It's a pleasure to be here this afternoon to be able to share this symposium with the audience. And so my name is Ron Reeves. I'm a rehabilitation physician at Mayo Clinic. Today as well I have colleagues, Michael Stubblefield, Kira McNair and Britt Snyder as well, all from Kessler Institute Select Medical. We're looking forward to sharing some thoughts about cancer rehabilitation over the next 90 minutes or so. First I'll make a few introductory comments, setting the stage for the next talks. Dr. Snyder will talk about epidemiology. I'll spend a few minutes talking about cancer treatments that do have a lot of impact on the way we think about rehabilitation programs. And then Michael and Kira will finish up the session talking about prognosis and complications and very practical considerations for rehabilitation. They have an extraordinary program that they're leading, both in West Orange and across the country. I'm looking forward to hearing what everyone has to share. So the objectives today, as I mentioned, talk about epidemiology, clinical features and outcomes related to cancer and spinal cord injury. Talk about treatment options, both the traditional ones and the more novel treatments that have become available recently. Describe the rehabilitation challenges and describe details of orchestrating a program and achieving excellent outcomes. Fortunately we are quite a ways farther along than things were in Egypt several thousand years ago when a spinal cord injury was an ailment not to be treated. Cancer is an important part of our rehabilitation practice and it affects a huge number of people worldwide. On average it's about 160 deaths per 100,000 people. About 40% of us will eventually be treated for cancer. Breast, prostate, lung, colorectal and melanoma are the most common with lung cancer being the largest cause of cancer related death with almost 132,000 deaths per year in the U.S. For non-traumatic spinal cord injury cancer accounts for about 25 to 30% of admissions to inpatient rehabilitation and this is data from a worldwide survey we published several years ago. Fortunately over the last decades we've made considerable progress and survival for both breast cancer and lung cancer has been gradually improving and certainly other cancers are similarly experiencing improvements in survival as well, creating more needs for rehabilitation service providers, both inpatient and outpatient. We know that outcome of inpatient rehabilitation is an important predictor of survival following inpatient rehabilitation and this is data that we published a number of years ago looking at FIMS scores, demonstrating those people with the highest FIMS scores had better overall survival than those with the lowest FIMS scores. Unfortunately for cancer related myelopathy there still is a large subset of people who do not do very well but nonetheless benefit from rehabilitation services and so we see here for those people with metastatic cancer, very few survive past even two years and less than 10% surviving out to five years. Now fortunately Dr. Snyder is going to lead us through epidemiology, clinical features, and outcomes and then I'll speak about some details of cancer treatment. All right, good afternoon. I'm Britt Snyder, I'm one of the Spinal Cord Injury Specialists at Kessler Institute for Rehab. So I think one of the takeaways from today is looking at tumor location and the different types. And so we'll start by reviewing this. These tumors are classified based on anatomic location. Extradural tumors are the most common and these are located outside the dura and result in compression and then can cause myelopathy. The vast majority of these are metastatic tumors and the most common primary types of cancer include breast, lung, prostate, kidney, some lymphoma and melanoma as well. More rare are the extradural primary tumors and these are usually the plasma cell tumors, so multiple myeloma and plasma cytoma. Intradural extramedullary tumors arise within the dura but external, so outside the substance of the cord. These include the peripheral nerve sheath tumors, so the schwannomas and the neurofibromas. We also see leptomeningeal disease, that's extramedullary and also meningiomas. So then even more rare are the intradural intramedullary tumors and so these are often the primary tumors, most often gliomas and just as a reminder, they're four glial cell types and so they're astrocytes, ependymal cells, the oligodendrocytes and the microglia and the most common gliomas that we see are the astrocytomas and the ependymomas. And so these are within the substance of the cord, so within the parenchyma. We'll review a few of the most common types and so astrocytoma is the most common intramedullary tumor in children and so it does have a peak incidence in the first three decades of life. They tend to be found in the cervicothoracic or the thoracic region. The majority of them are low grade but we do see grades four, well up to four, which is in a glioblastoma and this photo here is a patient of ours who unfortunately had a glioblastoma of the cervical spine. They tend to be slowly progressive. The most common presenting symptom is pain. We also see sensory motor deficits. MRI is a preferred diagnostic modality and these tend to be iso or hypo intense on T1. They're hyper intense on T2 and they do enhance. Treatment is with resection. We'll do radiotherapy for subtotal resection and chemotherapy of malignant. Ependymomas are the most common intramedullary tumor in adults and these have a peak incidence within the second and fourth decades. They tend to be found in the cervical or the cervicothoracic region and that's with the exception of the myxopapillary ependymomas which are typically found at the conus or the cauda quina. They have a similar presentation to the astrocytomas so they're slowly progressive. They present with pain, sensory motor deficits. It can be difficult to differentiate them on MRI from the astrocytomas but one of the key features is that they tend to be centrally located whereas the astrocytomas are more eccentrically located. And these also are often associated with the syrinx and so if you look at this image here, the sagittal MRI, it's post gadolinium enhancement and you can see this peripheral ring of contrast enhancement around the syrinx, so the central cavity. Grade two is the most common that we see and because these tend to be very well delineated, we can often achieve complete surgical resection and the prognosis then is greatly related to the extent of the surgical resection and so when we can achieve the complete resection, the five year survival is 85% but they could recur locally. Peripheral nerve sheath tumors include the schwannomas and the neurofibromas and these are often associated with some syndromes such as neurofibromatosis types one and two and also schwannomatosis. They tend to be seen most often in the cervical and the lumbar spine. They can present with pain again and sensory motor deficits. The majority are benign but some can transform into the malignant peripheral nerve sheath tumors, so less than 1%. Complete surgical resection is curative and for those that are malignant, then they require radiation and chemotherapy. Approximately 12% of all meningiomas are found in the spine. These tend to have a bimodal peak incident, so within the fifth and the seventh decades. The thoracic spine is the most common location. Risk factors include a diagnosis of NF2, also if they've had a history of ionizing radiation. They're most often found in females and so there's some belief that there might be some hormonal influence. They can present with motor deficits. The large majority are benign and they can be followed potentially over time, but if they are symptomatic, then it's treated with resection. And then we have the extradural metastases and so this is variable and depends on the primary tumor type and the location. The highest incidence is within the fourth to sixth decades. The thoracic spine is the most common location and that's related to the volume of the spine there. They can present with pain. I know that Dr. Stubblefield will be talking more about this in ensuing sections, but pain can be worse at night, worse with activity. They can have sensory motor deficits, bladder bowel dysfunction. Treatment, again, depends on the type of the cancer, but often includes steroids, radiotherapy, surgical resection, and chemotherapy and immunotherapy. And the prognosis does vary, but on average three to 30 months and we'll be talking about this more as well. So now transitioning a bit to inpatient rehab. So up to 14% of SCI-related rehab admissions are patients with cancer-related myelopathy and up to 45% when we're just looking at the non-traumatic SCI admissions, up to 40% are due to cancer-related SCI. And this does vary based, well within the literature and based on the institution and is subject to referral bias. Some key clinical features of this population include a more prolonged symptom onset. Tend to see this in more men than women. However, when we're comparing it to the proportion of males versus females in traumatic SCI, it's more evenly distributed in this population. Paraplegia is more common than tetraplegia and these tend to result in incomplete injuries. And so this was a study of which Dr. Reeves is one of the authors and it is looking at non-traumatic SCI outcomes across nine rehab centers across the globe and this just highlights and in red what I said in the previous slide, but I wanna draw your attention to the lengthy onset. So 50% of these individuals had an onset that was greater than one month and 81% had paraplegia compared to tetraplegia. So many of the goals that we have for inpatient rehab are the same for other clinical populations. We wanna manage their symptoms, improve their functional independence, their mobility, decrease pain, and reduce the risk of further complications. And then also key aspects are addressing the equipment needs and caregiver and patient education related to the SCI as well as the cancer. Studies have looked at outcomes in this population and we find that they tend to have a shorter rehab length of stay. They do have a greater likelihood of an interrupted stay and while the majority of patients do discharge to home, the percentage of home discharges is less than that of other etiologies. And this slide, I'll kind of skip it, says essentially the same thing, supports those findings. All right, and these patients, even those who potentially have a poor prognosis, do improve functionally and we'll be talking more about this but studies have shown that there are significant gains in functional independence. They do tend to have higher functional scores on admission compared to traumatic SCI and maybe some of the other non-traumatic SCI etiologies and there's less functional improvement. But they still improve. And this is an older study from 1996 but it is just showing that across most of the functional domains that patients achieved significant improvement in function, this is using the FIM from admission to discharge. And then the follow-up surveys did show that this improvement in function did extend at least three months past rehab discharge. Other benefits, potential benefits of inpatient rehab include improved survival, reduction in pain, fewer deaths from SCI-related complications, lower rates of depression and higher satisfaction with life scores. And then I just wanted to end on this case. So this is a gentleman that Dr. Stivelfield and I have had the pleasure of caring for in the most recent months. So this is a 69-year-old man. He has a history of oligometastatic prostate cancer so he had METs to the cervical and the lumbar spine. He's status post decompression and he was also treated with radiotherapy. He's receiving androgen deprivation therapy and has had an excellent response. So we saw him in our outpatient clinic with a three-year history of progressive functional and neurological decline. So he has incomplete spastic tetraplegia. He was suffering from neuropathic pain that wasn't controlled. He had autonomic dysfunction including orthostatic hypotension and he had neurogenic bowel and bladder dysfunction. Whoops. So the MRI that we got showed post-radiation changes centered around the C5 level and we did diagnose him with a delayed radiation myelopathy and we also suspected that he had a lumbosacral radiculoplexopathy as well. He was admitted to Kessler. So we talked as a team and we acknowledged the potential benefit of inpatient rehab and we were fortunately able to get him admitted to Kessler for inpatient rehab. And on admission he required moderate assistance for functional mobility and all of the self-cares. He had a length of stay of 20 days and during this time they were able to implement a bowel program and we actually were able to perform botulinum toxin injections for him because he had disabling spasticity. His neuropathic pain control was optimized and so he was discharged to home at a modified independent level. We recently saw him in clinic and repeated the botulinum toxin injections and he's just doing great. So this is a very positive example of how patients may benefit. All right. Thank you. Thanks. That was a fantastic talk, Britt. Now, I get the joy of the kind of nuts and bolts of the cancer treatment part of the talk for a few minutes here to set the stage for my colleagues. So, first of all, I don't have any disclosures, although I do have that are relevant to this talk, although I do have some research funding from Mitsubishi for a different aim. And, really, what I'm going to cover are things related to pharmacologic and radiation-based cancer treatment to set the stage for the next couple of talks. So, I'll make a few comments about economic considerations, cytotoxic therapy, which I think is something that it can be a little bit intimidating for physiatrists, orient everyone to immunotherapy, radiation therapy, and then just a couple of pragmatic considerations before I hand it over to Dr. McNair and Dr. Stubblefield. So, certainly one of the challenges with cancer-related inpatient rehabilitation care is managing the economics of the situation. So, inpatient rehabilitation margins can be quite narrow at times, and immune checkpoint inhibitor therapy adds about $70,000 to the cost of care for that individual, and that's just a recent innovation. CAR T-cell therapy, another fantastic innovation, adds hundreds of thousands of dollars to the cost of care for those individuals. Just stretcher transportation back and forth for radiation therapy can accumulate over time for inpatient rehabilitation as well. And, of course, there's fatigue side effects that all affect inpatient rehabilitation efficiency, and so it's important to have well-designed programs. So, chemotherapy, so traditional chemotherapy is cytotoxic therapy. There are different types of cytotoxic agents. They all fundamentally work through the same mechanism, which is disrupting DNA replication, which interrupts the cell cycle. Now, of course, tumor cells do become resistant to some agents, and that allows different, or requires agents to be changed over time. Separate from cytotoxic chemotherapy, however, is also hormone-based therapy. So, these therapies deny tumors that are driven by hormonal signals that are endogenous to us from the trigger or the mechanism by which that facilitates growth. The side effects, so hormone deprivation therapy is driven by what we're depriving. So, in men with prostate cancer, of course, there may be sexual side effects for agents that disrupt cell cycles, alopecia, GI side effects. Now, recent development, which has been ground-changing in cancer treatment, is the recognition that cancer cells have a mechanism by which they evade the immune system, and this is through relationship between T-cell-bound proteins that are blocked by the cancer cells. And as a result of this blockade of this relationship, the T-cells are relatively ineffective. So immune checkpoint inhibitors block this relationship from occurring or block the blockade, thereby allowing the T-cells to be more effective in their ability for our own immune system to fight the cancer. There are now seven different monoclonal antibodies available that treat a wide variety of cancers. And these show tremendous promise overall in their impact, at least in terms of decreasing morbidity and improving disease-free progression time or lack of disease progression. CAR-T cell therapy is another immunotherapy which uses a cell-based intervention. So the person with cancer gives their own T-cells which are genetically modified with a receptor on the T-cell that then recognizes a specific disease-related epitope on the tumor. And so, for example, in myeloma or in lymphoma, specific epitopes are known to exist on those cells and the CAR-T cells that are modified are infused back into the person with the cancer and thereby harness the power of the immune system to fight the cancer. Unfortunately, these therapies are extremely expensive. Now, there are a number of clinical trials, of course, running and they are also commercially available but they add hundreds of thousands of dollars to the cost of care. They're also associated with unique side effects. And so one of the key things for CAR-T cell therapy is immune effector cell-associated neurotoxicity. And so this is essentially a CNS syndrome of seizures and encephalopathy that can occur acutely with CAR-T cell therapy and can be quite devastating. As for the immunotherapies that are antibody-based, anything that could be a itis, so a myelitis, a dermatitis, a colitis, a pneumonitis are all potential side effects. And these are different from the side effects of traditional chemotherapy. And so it is important for us as physiatrists to recognize the unique side effects associated with different agents that the patients may be receiving so that during treatment, during therapy, we can also potentially become attuned to a side effect that may be developing. Radiation therapy traditionally is a wave of energy that's delivered to a defined tumor space. That wave of energy passes through normal tissues and that, unfortunately, is associated with the side effects. So skin irritation, problems with salivation, problems with GI, esophagitis, et cetera. Novel proton therapy or radiation that's a charged particle allows a much more discrete delivery of radiation at a higher dose to a very narrowly defined target, thereby limiting side effects to other tissues. Unfortunately, proton therapy facilities are extremely expensive, hundreds of millions of dollars to build. There's quite a controversy about is there actually cost-effectiveness for these therapies relative to traditional radiation therapy. And on a per individual basis, proton therapy is two to four times as expensive as traditional photon or energy-based wavelength treatment. So in summary, there are a number of treatment options for cancer that show tremendous progress in the realm of immunotherapy, both cell-based immunotherapy with CAR-T cells as well as immunotherapy with antibodies. There's novel proton beam therapy as well. And these things are going to continue to shape the future of our rehabilitation care. I wanna thank you for your attention for that and I look forward to the presentation and it looks like Dr. Stubblefield was gonna take the next part here. So thank you. Oh my God, there are people there. I thought he was just talking to us. So good morning or afternoon. I'm in a particularly good mood today because I got to go birding this morning. We had 43 species, including a really, really nice-looking bald eagle. So it's very exciting. Oh, and a pileated woodpecker, which Brittany found. So if you guys did not get to go bird watching this morning, there's always tomorrow. All right. So I'm gonna skip that because we already talked about it. I get to talk a little bit about the complications. Obviously, I won't talk about all, but I'm gonna talk about some that I think are particularly important to understand. Right, obviously, the big dreaded issue that we see most often is cord compression, right? And it's kind of like being pregnant when you're looking at the images. You either are or you aren't. There's not a whole lot of in-between. So these images just kind of show this bone, which is eaten up. You can see the cauda equina here with cancer. Here's a bone also eaten up with cancer, all of these on MRI. There's the spinal cord. You see a little white CSF around it. So that's not cord compression, at least at that slice of the MRI. That is impingement, but it's not being compressed. Here, you start seeing this tenting of the posterior longitudinal ligament. You still see some CSF around the cord. Now here, that's fully pregnant. That's very gravid right there. So that's the cord right there, and you see all the tumor and it's smushed over. So I don't need to say a lot about the weakness associated with cancer affecting the spinal cord. You know that. Let's talk about some of the other issues. So one of the first things that comes up is, how do we know? Like, how can we predict? And this is a big thing for me, because I do mostly outpatient cancer rehabilitation, so I'm constantly in the position of trying to decide if somebody's cancer's actually starting to affect their spinal cord. And, you know, you would think a known history of cancer's useful, and it is, but it really kind of depends on where you are. So if you're in a very rural area, you're gonna have a lot of lung cancer showing up already deep into the throes of metastatic disease with cord compression not knowing they have it. Now, if you're in Manhattan, it is very hard for you to develop a cancer without knowing it, because there's a hospital on every corner, and usually a fairly good one. So in those situations, it's most of the patients showing up for the emergency will already know that they have a cancer. So the history of cancer doesn't always necessarily help you knowing the full history of cancer certainly can. The first signs and symptoms of cord compression, try to, it's pain, right? Far and away, that's what people show up with. Well, that's a problem because everybody's herniating a disc, everybody gets spinal compression fracture, stuff happens. So you really need to temper that with some other things that we're gonna talk about. And the problem is, once you start getting that back pain, if you start getting weakness, these patients progress to permanent weakness very, very quickly. So you're really wanting to find those patients who have cancer, the time course of pain. Also not as helpful as you might think, right? So we all, how many of you actually do cancer rehab or see some patients with cancer? Yeah, a good half of the audience, right? The truth is you all should raise it because if you're seeing patients, you're seeing cancer patients. So this really applies to all of you. But the people who do this full time are gonna tell the stories of breast cancer survivors who've had it for 20 years and then they develop metastatic disease because we've all seen patients like that if you see enough of them. So the time course doesn't necessarily help you. Some of the slower growing cancers, even untreated, can go for years. But patients who have like lymphoma, I've seen lymphoma, like you do an MRI on a Friday and you do an MRI on Monday and it's like this exponential explosive growth in these patients. So some of these can grow very quickly. And why is it important to find these patients early on? Well, this was a very old study really just looking at a surgical procedure and I've used this as kind of good evidence. So if patients come in to this surgery fully with normal strength, almost all of them leave with normal strength. But if they come in weak, they stay weak or at least half of them stay weak. So that's why having this high level of suspicion and knowing that a lot of the things we kind of take for granted, like how long and do you have a history of cancer aren't necessarily that helpful. So the punchline here is the only way to really know if somebody has spinal cord cancer is to image them. Right, which means you have to fight with the insurance company. Characteristics of local pain. This is another very interesting one. So when you herniate a disc, does that tend to hurt worse during the day or at night? Night. Night, yeah, I heard a little feeble night. But you guys know this, right? This is standard. Why does it hurt at night? Anybody ever think about that? Well, that's part of it. Well, you're laying down, the disc is decompressing and swelling. But two other things. One, this Vatson's plexus, which are these valveless veins kind of engorge when you're laying down and can swell the disc. The other one is your cortisol level drops at night. So guess what? Same effect on cancer. Cancer tends to hurt worse at night for exactly those same reasons. So this doesn't help you that much either. I'm kind of back to you need the image. But this is also, we were talking about this in the car, where metastatic disease goes in cancer patients. And it tends to go to where there's the most spine. So there's more thoracic spine than lumbar spine than cervical spine. So they tend to go in that order. With some exceptions, like pelvic cancers, particularly prostate cancer, tends to go to the lumbar spine because of these Vatson's plexus. It just has a clear highway to get there. Ridicular pain. This is another one that I put up when we're talking about pain because people forget about it. I'll talk about the nature of sort of bony versus instability pain. But a lot of these patients, that nerve root is being compressed and irritated. You know, you can see here, I think this is a laser pointer. So you see these nice little nerve roots here surrounded by fat and that one is not. So this patient may not, that bone's not compressed or anything. This patient, if they don't have a lot of biologic pain, they might just have ridicular pain as they're presenting symptom of cancer. And then if you remember one thing, I'm guessing you guys know everything I already told you. So there's no information here. I try to be useful occasionally. This is the one thing you should remember from my talk. You guys ready? Because this will come up and you will look so super smart. It's really, really impressive to your residents. Funicular pain. We all know about radicular pain. That's pain that you get from compressing a nerve root, tends to go in a dermatomal pattern. If you have weakness, it's in a myelotomal pattern. This is damage to the ascending spinal thalamic tracts like you would get in multiple sclerosis. This is a central nervous system type pain. It doesn't localize terribly well. I had a patient like this the other day and they just hurt on like a whole side of their body or both sides of their body and it's very nondescript. And I think I'm showing a horrendous MRI here. I can't see what I'm showing, but look at all that. Like look at that cord like expanded and whatever, right? And you can see the radiation changes here in this bone, right, how those have been leached. So this patient's had a resection and radiation for whatever that tumor was, I forget at this point. And now those spinal thalamic tracts are displeased and, excuse me, causing a lot of pain. So remember funicular pain. Weakness we've already talked about, right? That's kind of our normal thing. Sensory loss, not much here, except it tends to come sort of later. And once you start getting sensory loss, you're generally kind of in trouble with this because that really denotes that you're not getting back. But I'm gonna tell you one other thing that if you're halfway awake, you can remember, because this is really cool. Anybody want to remember for me what the posterior columns do? Awesome, you guys are so smart. I love this. So look at this tumor, right? So can you imagine that taking out those paired posterior spinal arteries? And if it does, this patient is gonna be strong. They're gonna have relatively normal sensation and not be able to walk even as well as a drunken sailor. And this is a tough one when you see it. The Asia classification does not take this into account. These patients are extremely impaired. And you see this, I think, I don't know that there's good data, and I've seen a dozen of these maybe in my career. There's not a lot of data on it, but they're impossible to rehabilitate. There's just literally nothing you can do about it. And it's really perplexing to people. I see nodding. So you guys have seen this? Okay, good. Who's seen this? All right, about a quarter of you. Okay, cool, good. But for the rest of you, this is the second thing you can remember if you're still awake. So benign versus malignant back pain. This is always one that comes up. And again, the rule here is image. So benign pain, I have a bad back. I cleaned out the garage. I made my back worse. It's getting better, right? That's kind of the thing. Malignant pain, my back's really just starting to hurt. It hurts worse at night. Oh, and I'm coughing up blood. You think I should get that checked? Right, so it tends to come with more neurologic symptoms and other systemic issues, right? Types of pain we talk about in cancer is biologic versus instability pain. So biologic pain I call evil humor-mediated pain. So what are evil humors? Cytokine, substance P, bradykinin, all this inflammatory, oops, soup that's floating around. This is the sort of pain you get. See, I'm making, right, it's conversational, right? So I'm making my, they're laughing at me. I'm hoping with me, either way. So this is what you get from you irritate the periosteum, the lining of the bone and the other structures around. Remember, bone doesn't really have any nerve endings. In the bone, it's a periosteum and everything around it. You treat that, you give it steroids. It actually, it's potent anti-inflammatory, makes that better. That is different from instability pain. And those of you who've learned the three-column model of instability and trauma can forget all of that. That doesn't really apply here. This is the sort of pain you get when the bone is rocking back and forth and unable to do what it's supposed to do. It doesn't respond to steroids. The only way you can take care of that pain is to surgically fix that pain. So the surgeons have kind of a, this is the SINs. Believe it or not, there was an original SINs, and then there's this SINs. I know, somebody got that. So this is the modified SINs. I probably would prefer original SINs, whatever. But it looks at kind of, and you don't need to run around with pockets, but it looks at location, right? And kind of gives a score to it. But the basic concepts are if it's junctional, like cervical occipital, cervical thoracic, that gives you a higher score. That's more likely to be unstable versus if it's in your sacrum. Like we don't go in and surgically fix sacrums. We just shrug our shoulders, radiate it, and move along. Pain, absolutely, gives you a big three. Type of bone, if it's lytic, like a multiple myeloma, versus blastic, like a prostate cancer, alignment, right? So if your spine should look like this, but now looks like that, might be unstable, right? The vertebral body, if it's collapsed. And then the only real throwback to the three-column model is if both of the posterior elements are involved by tumor, you're more likely unstable. So is this patient's cancer causing pain? No, and this is just to remind you, just because you have mets to the bone doesn't mean you have spinal cord compression, doesn't necessarily mean you're gonna get spinal cord compression, and doesn't actually even mean you're gonna have pain, you know, if it's just confined to the marrow. All right, so switching gears quickly to prognosis. Prognosis sucks in spinal cord patients who have metastatic disease to the spine. Any questions or commentary on that? It sucks worse depending on the type of cancer and we at Kessler have been spending, and I really wanna hear Kira talking about myself, although I am entertaining myself thoroughly because I watched Birds this morning. But we spend a lot of time trying to figure out who's going to do well with us or not. And a lot of the old stuff, like, you know, comparing survival in patients, like, oh, GI cancers, look, they're more likely to die quickly, is true, but all of this paradigm has gotten changed by these checkpoint inhibitors and these other biologic agents. We're now taking cancers that used to be rapidly fatal and turning them into effectively chronic diseases. So all of this data is kind of out. So one of the terms that I like to think about when we're assessing a cancer patient for inpatient is do they have meaningful treatment options? I guess is the third big thing. If there's no more treatment options and they're circling the drain, you're not really, you probably shouldn't be bringing them in unless it's for a very short circumscribed course to get them home with hospice, right? You're not going to make this patient so much better so they can get more chemo that's going to kill them. Kira's going to talk about this. I have really nothing to say about that. I have nothing to say about that. I have a lot to say about this. Okay. So one of the big things, I was in a hotel like this trying to work on best practices for Kessler. This is really, I was probably in my underwear, but you don't need to know that. And I was trying to work on this graph to figure out where a demarcation would be to put patients on a supportive pathway versus a restorative pathway, which I think Kira is going to talk more about. And I was having real trouble. And it sort of dawned on me that all of my very smart palliative care colleagues had been using performance stats for like 100 years, which correlates very tightly with when the patient is going to die. So patients with advanced cancer and a KPS or Kronosky performance status of like 50 have like a 60-day mortality, right, median mortality. So that allowed me to kind of start thinking about if we could use the Kronosky or any performance status scale to help us predict who's going to be a good inpatient. So, and I'm going to go to here and then I'm going to go back. So this is the original Kronosky performance scale. and then Kira here had made a brilliant translation into rehab speak with the KPS, so that we actually have been using it functionally and are actually studying it. I'm gonna go back just a minute. So when we're thinking about who's gonna be a good candidate for us on the inpatient, we're thinking of treatment intent, right? So not just curative and palliative, but do they have meaningful treatment options? Let that resonate in your head when you're making it. What is their performance status? If it's 50 and below with advanced cancer, that's bad, right? I mean, that patient is not a patient likely to be alive in weeks to months based on the palliative care data. And then, you know, really their disease status. So if you come in and you have inactive disease, but your KPS is 40 from your recent UTI and sepsis, that would change our paradigm. Anyway, I'm going to stop talking. I'm going to turn this over to Kira, and I'm gonna get off the stage. So I'm an occupational therapist, so I'll just start there. So a big piece of what we were trying to do at Kessler with our program is that we were finding that a lot of the other factors that we use in inpatient rehab to determine prognosis and functional progress with patients wasn't quite working with our cancer rehab patients. So we tried to kind of go back to the drawing board to see which things would allow us to identify a little bit better of who would do better with us, and then who would be better candidates for inpatient rehab. So we started to actually use the original KPS scale, and then realized that it was a little bit challenging to figure out which language was gonna work, and our reliability wasn't consistent. So then we, a team of therapists at Kessler, we put together this final column here, and added a little bit more language in kind of typical inpatient rehab speak, you know, GG scores, care item set. And now what we did is, like a KPS score of a 40 correlates with patients who are at a max assist to total assist level. A KPS of a 50 is about generally a mod assist. KPS of a 60 is a general min assist. So what we started to do with all of our patients back in 2020 is every one of our patients who came in with an ICD-10 code of a cancer code in general, we started tracking their pre-morbid, so three months prior to acute care admission, and then admission to inpatient rehab, and discharge KPS scores. So we started to look at that for all of our patients at Kessler, and we ran a kind of quick inter-regular reliability study, which we did publish, and then found that across the therapists that were doing the scoring, that it was pretty reliable. So we started to use it more frequently, and we had about 430 patients in the study. And what we found was that the biggest predictor of transfer to the acute care hospital was a KPS score of a 40 on admission. So these were patients that they may have had a KPS score of 100, they may have been fully functioning prior to the acute care hospitalization, but if they came in with a KPS of a 40, they were eight times more likely to go out to the acute care hospital compared to those who came in at a KPS of a 60. So that would be like a min assist versus a max to total assist. And I'm sure you've seen that type of patient where you go into the room and you can just tell right away, this is someone who doesn't look healthy, this is someone who has a high burden of care. But this is now giving us a way to quantify that a little bit more, and then put that aside with other factors and see who might do better than others and how we might best support them during inpatient rehab and within the continuum of care. What we also found was about half of the patients who had an acute care transfer passed away in under three months. So it was a big eye opener to us to see were we selecting the right candidates in the first place, and then were there other places that we can kind of go back and see how better we can educate our staff who's sending patients to us, but then also how better we can manage the patients once they come to us. So the biggest factors that contributed to acute care transfer, the top patient population that went out acutely were those with hematologic malignancies. And this is something that's been widely shown in the research as well. Obviously these are patients that are typically gonna have an infection and might have to go out for a decline in status or additional medical care and can't stay in the inpatient rehab. As we saw previously, however, a lot of hematologic malignancies have spinal cord metastases of varying extent. So a lot of our patients with lymphoma or multiple myeloma that had gone out also were those who had spinal cord compression. And then biggest thing was the KPS score of a 40. And another big patient population that we were seeing were those with solid cancers with multiple areas of metastases, often one of the metastatic areas being the spinal cord. And then other factors were someone who had a previous acute care transfer, if they had respiratory needs in the acute care hospital. And then the biggest point to me was that these people weren't going out within like two or three days in inpatient rehab. We had over a week to intervene and attempt to decrease their risk of acute care transfer. So this was a huge goal for us as a team and we put a lot of things in place, which I'll talk about in a minute. And then the biggest factors that related to early death were individuals who had an acute care transfer during their stay, even if they came back to rehab and then went home, it still was likely that the patients that were going to be dying within three months or so. Obviously patients who discharged to hospice had higher rates of death, but that was the discharge destination we would prefer for those patients. Whereas others, we were seeing similar rates of death in patients who went out to skilled nursing facilities, which I will talk about what the data has kind of shown and why that might be the case. And obviously those with the KPS on admission, that low performance status weighed heavily on mortality as the research has shown as well. A big thing here is just because someone has a poor prognosis and that they might die in three to six months doesn't always mean they're not a candidate for inpatient rehab. Many of these patients do need inpatient rehab because they're too medically unstable and have such low performance status that they can't go right home. So these were people that other than inpatient rehab might be sent to a nursing home where they're probably going to die immediately. So by coming ideally to an inpatient rehab hospital, we can facilitate a short length of stay with the right supports and get them home sooner rather than later. But there's a lot of factors that need to come into play prior to admission to make that useful. And if there is a disconnect between what the patient and family knows and what the plan is for the inpatient stay, we find that it can lead to some kind of ugly outcomes. But we're working on it and a lot of the things that we've been putting into practice I'll kind of show you today that even when there is a sticky situation where someone's coming in and they're not necessarily fully aligned with what our goals are and we understand their prognosis is poor, our team has gotten a lot better at navigating that challenge. So I can kind of share with you what that looks like. So some more practical considerations. I am the OT so I'll give you the kind of hands-on things that you can possibly take back to your own practice and see how that can kind of support what you're doing and support the cancer rehab world in general. So one of the biggest things is that when we see cancer and SCI rehab kind of at the same time, a lot of our physiatrists and therapists that I've spoken to say that they're very comfortable talking about the functional prognosis but they're not comfortable at all talking about the oncologic prognosis. When it comes to someone with cancer-related myelopathy, both things are created equally. So often we actually need to address the cancer and the oncologic prognosis even more than we need to discuss the spinal cord injury and the functional prognosis. So we had a talk with about 30 of our therapists, our spinal cord therapists a couple years ago and this is the thought bubble that came out of it and what I wanted to know was how they felt about approaching an individual with cancer and how they compared that to working with people with spinal cord injuries. And I had so many therapists say, I'm perfectly fine telling someone they're not gonna walk again. And I'm sure there are people in this room that say the same thing. I'm perfectly fine telling somebody what their age impairment score is and how that's gonna affect their functional prognosis but there's no way I'm gonna tell them that they might die soon. And really the research shows no one wants to tell them that but it's not necessarily someone else's job to do it. Yes, oncologists likely are the people who have the best tools to be able to have that conversation because they have the concrete data that they can tell the patient. However, they don't often do that. So when no one has that conversation, none of us can do a good job. So a lot of the patients that we typically see in inpatient rehab kind of fall between, in terms of the DS classifications, fall between a supportive and palliative track. So we've kind of created a track that we call at Kessler the transitional track. So that's someone who may have treatment options in the future but it's often dependent upon how they do moving forward. So dependent on performance status, dependent on medical stability. So we have our whole team always ready to kind of go back and forth between the restorative side of things and the supportive and palliative things. So we kind of marry the approaches and make sure that everyone's looking out for a decline in status and prepared for that. And we always prepare the patient and the family, especially dependent upon the prognosis that they may and in certain cases will decline. And that we prepare them for that so that when they do, they're not necessarily going back to the acute care hospital because it is an expectation or we have the right supports in place. So a big piece of our education just coming into inpatient rehab was that we needed to accurately code these patients. Because inpatient rehab doesn't currently have a rehab impairment code specific to cancer, a lot of the patients come in and they might be on various programs with various different coding. So by pulling out the ICD-10 codes that are cancer specific, it has allowed us to be able to track who our cancer rehab patients are. So the other thing that we were finding is we were often coding the area of metastases but we weren't always coding the primary site of the cancer. So a lot of that wasn't really supporting what we were doing. Another big piece is that we found that a lot of the cancer related comorbidities and cancer related treatment don't often weigh on case mix index or CMD and CMI. So we were going to these meetings and they were like, yeah, our CMI for our cancer patients just it's fairly similar to our other patient populations. And we're like, why? These patients are so sick. And then we kind of looked into it further and CMI itself is a very complex thing. But because cancer rehab isn't always a patient population that's seen in inpatient rehab, it hasn't been that someone who has a history of chemotherapy, that doesn't weigh on their CMI, which is huge. So we can't use those typical things that we use for other programs for our cancer patients. So what we found is that it was important that we had a unique program for individuals with non-traumatic STI due to cancer and we can kind of balance both the cancer and the spinal cord injury rehab. And we do this by this flexibility between tracks. So we have to understand the patient's prognosis first, both oncologic and functional, which I'll talk about. And then we try to put them on a kind of pathway, which we typically do in spinal cord injury rehab. In general, we really like pathways. So this was helpful for our team of, all right, they now have a spinal cord injury and they have metastatic cancer and depending upon their oncologic prognosis, we're gonna kind of have more of a restorative approach, a supportive approach, or a combination of the two. So we often use, when we're talking about prognosis in general, is we use the dumps. So this is something that's been kind of used a little bit in the literature to help support kind of putting the pieces together and being able to do an effective chart review for the patient. So when it comes to an individual with cancer-related myelopathy, what we're gonna look at first is the neurologic status. So that might be what their age of impairment scale is, how they're functioning. Most of the time, that is what their performance status is, is based on their neurologic status. And then oncologically, there's lots of details we wanna know about their oncologic status. And Dr. Subblefield said that before as well, of what's the cancer history, what treatment have they had, do they have treatment approaches that are available moving forward, and how have they responded to previous treatment? And then what's their medical status? Are there comorbidities related to the cancer itself, related to the treatment? Are there going to be in the future? And then do they have pain? And then what's their support look like? So a lot of these patients will have treatment moving forward or the plan for treatment moving forward, but the support makes a big difference on whether they'll be able to get to that treatment. And we know that if they can't get to that treatment, their prognosis is obviously gonna diminish pretty significantly. So the history really matters. So the next slide, I have a patient case, and it was a patient who came in, and that all I saw from the history and physical was that this was a patient with metastatic renal cell carcinoma with METS to bone, and that he had a T2, or I think it's T7, T8 tumor resection and decompression and fusion. But metastatic renal cell carcinoma with METS to the bone, when I first look at it, I think, oh, this is someone who probably has a ton of treatment options if this is a newer diagnosis, and if all he has is METS to the bone, he should do pretty well. Not the case. So, and this is why it's important. So then when I look at the timeline and actually kind of dive deeper and get our staff to be able to know what to look for in someone's chart, especially if we have it available, this was an individual who was diagnosed in 2010. He had a partial nephrectomy, and then he had progression of disease three years later, so he did well for three years, then had progression of disease. They started high-dose IL-2, so kind of a biologic therapy, and he had stable disease, and then progression of disease two years later. They started a monoclonal antibody, progression of disease. They started a different monoclonal antibody with a clinical trial, progression of disease. They started immunotherapy, continued to have progression of disease, and started to have some kind of medical issues going on related to the prolonged treatment. And then the patient himself was requesting a decrease in the treatment because he was reporting quality of life issues and essentially failure to thrive while on the available treatment for him. Then he had continued weakness leading up to this recent appointment that the oncologist sent him to the ER to get this emergent resection of the tumor. So knowing that history allowed us to be able to go in and kind of gauge what the patient's plan of care was gonna be. So some of the questions that we asked during the eval then kind of allowed us to facilitate what the length of stay was gonna look like, and it weighs heavily on what their discharge plan is. So the plan is that the patient needs to get additional radiation to the thoracic spine, but it's obviously palliative in nature. And he was actually unsure whether or not it was, you know, what the goal was of the radiation. So I put this into kind of the NOMPS framework, and this is something that we work with our staff to be able to do of kind of pulling out that valuable data. And then what we found was that he said one of his goals was to walk. He did have T4 Asian Pyramid Scale D paraplegia. So he would, in theory, have a decent functional prognosis and had a modest overall KPS score of a 50 on admission. However, he had significant failure to thrive. So he wasn't someone who was very strong. He wasn't getting any stronger. He was no longer really a candidate for any of the treatments and had a lot of medical comorbidities due to the prolonged use of these various treatments. So what we were able to ask him during the eval was what's important to you? Are you still taking the immunotherapy? Is there a plan to go back on that medication? Kind of how did that make you feel? And then what was the typical day like for you the last few months? This is often something that I'd like to ask my patients with cancer because a lot of times it shows what the quality of life has been, especially someone who's been on treatment for so long. And then the biggest question was what are the goals for the radiation? And kind of what's your plan with that? This is a different case I'm gonna kind of fly through, but a similar patient with metastatic renal cell carcinoma, but kind of showed that he had additional metastases and both brain and spine met simultaneously. So another case that's typical in our inpatient rehab program. So when the patients come to us, one of the biggest things that we're trying to do with our patients is decrease the risk of acute care transfers. We wanna get all the information on the front end. We wanna make sure we have good communication with the oncologist, ideally, before they even come to us so that we know what a decline in status looks like and we're prepared for that. And when it happens, we can treat it instead of sending them back to the oncologist to treat it. We also wanna find out which patients will do better than others. So the KPS is definitely helping us get there. And then if they're someone who maybe is medically unstable and maybe not quite a candidate for inpatient rehab, but we get them anyway, there's a lot of ways around that. So we try to adopt a 15-7 schedule where they might have three 45-minute sessions a day instead of having three hours of therapy a day. We also have done a lot of education with our therapy staff and all of our staff on how you can still have kind of quality billable treatment with the patient without requiring them to do a ton physically and get the family involved in treatment, education, mindfulness, a lot of these strategies. We also have an amazing palliative care nurse practitioner that comes in and does consults at the bedside. That's been huge for us as well. So this is something we put together based on our data from 2020. So this is our high-risk pathway that we use for our cancer patients. So any of our patients who come in with a KPS score of a 40 or a KPS of a 50 with these kind of additional comorbidities, we put them on what's called the high-risk pathway. So this kind of flags to the team that this patient is at high risk for acute care transfer. And some of the big parts of the pathway is to initiate the conversation with the oncologist if it hasn't been initiated yet, and then discuss some different options for whether or not that patient is someone who has treatment moving forward and how we can kind of address their oncologic care moving forward. And then we have an order set that we put in of just kind of more frequent blood draw, rounding. We're just keeping a closer eye on those patients. And then a big piece of this is putting in a palliative consult and having some conversations about end of life with the patients that we think are actually closer to end of life. This is also a sheet that we put together to give to our physiatry team that if you are gonna have that, I don't think I did that, right? They're shutting me down. That if they're having a conversation with the oncologist, what are the valuable questions to ask? So this was a really, really important thing that we use because what we were finding is you can't just call an oncologist and say, what's this patient's prognosis? They'll dance around in circles and not give you the concrete information. So you need to say things like, do you think this patient has valuable treatment options? Would you be surprised, this is Dr. Subbifield's favorite thing, is would you be surprised if this patient was dead in three months? And then they have to answer that question, right? So, I mean, they don't wanna be the grim reaper either. And I like to tell that to everyone, of like, it's not always their job either. Let's kind of have a collaboration with them and how we can all have that conversation. So one of the biggest pieces is understanding the patient's prognosis by really effective chart review. One thing that we've done at Kessler is we're not waiting for someone else to tell us the prognosis. We've gotten really good at being able to kind of pull that out ourselves. And we have a platform where kind of monthly we go through patient cases and try to make sure that we're all on the same page with understanding prognosis. That's been huge for our team. Another big piece is understanding what the patient and the family know. A lot of times the patient might have a good understanding, but the family has no idea, or the other way around. And that's a big piece that facilitates discharge planning. So when no one's on the same page, it's really hard for us to plan kind of what the next steps are. So that might be that patient who they might want to send them to a skilled nursing facility so that they can get additional radiation, knowing well that that patient's not gonna be a candidate for radiation if they're at that performance status level. So a lot of the tools that we use, we use the functional assessment of cancer therapy general to kind of gauge the patient's understanding of their prognosis and their quality of life. We also use a question prompt list. I think I have it here. So this is something that we put together as a team that we give to our patients, all of our patients who have cancer. And it allows them to go back to their oncology team with clear questions to kind of guide what their next steps are. So this is a lot of times our patients who haven't, you know, don't have great clarity on what their actual oncologic prognosis are. We'll talk with them and we'll try to guide them in the right direction, but if we don't want to tell them overtly what it is, we can kind of highlight which questions on this would be important for them or their families to take back to the team. And they use this all the time. I mean, we have staff members that use this now. And it's been something that's been widely used in the field of oncology to support shared decision making and patient-centered communication. We have not yet had an oncologist yell at us for using it. So I think that they prefer that. Like, you know, they prefer to actually have someone overtly ask them the question because then they don't have to kind of skirt around the topic. And that kind of leads me to the most important thing. A lot of these conversations are very difficult. When you are having the conversation, make sure that it's not just, how's your bowel and bladder function? Oh yeah, and you're dying. So a lot of times it has to be in a different setting. It might be in a family meeting and with family support there. And then discharge planning for these patients should be based on functional and oncologic prognosis. So you need to prepare for fluctuations in status and additional treatment. This is one little thing of just, patients who do go to skilled nursing facilities often have high rates of mortality, higher rates of mortality than what I was even already saying. So what we're trying to do is improve use of palliative care. The American Society of Clinical Oncology recommends a palliative care consult for anyone with advanced cancer within eight weeks of diagnosis. And this is significantly underutilized. Advanced cancer would be anyone with stage four solid cancer. So this is a lot of our patients are going a long time without getting palliative care. And palliative care shouldn't be something that's only used at the end of life. So this is kind of a summary of what multidisciplinary intervention looks like for these patients. If you are not familiar with NCCN, I encourage you to use NCCN to kind of guide some of that prognosis stuff. So depending on what treatment options are available, there is an NCCN guideline that tells you what their next treatment might be. So I definitely encourage you to use that. And then the National Hospice and Palliative Care Organization, they also have a great amount of information and webinars available for staff if people are not comfortable talking about palliative care and end of life. So prognosis for individuals with cancer-related myelopathy is multifactorial, as we kind of learned today. And a lot of the pieces of the program have to marry both the cancer side and the spinal cord injury side. So if you're not comfortable talking about one piece of it, I encourage you to get more comfortable talking about it or find someone who is more comfortable talking about it. And that's why I'm an OT here talking with you today because I'm often a little bit more comfortable talking about it with my patients than most of the physiatrists that I work with. So they'll just kind of push me into the conversation as well, and I'm happy to do that. And it's fine and it's completely understandable. So I do want to thank the American Spinal Injury Association. We are kind of part of the Asia's Education Committee. So that was kind of who helped facilitate putting this little group together today. So I want to thank the Asia Education Committee and Asia for supporting this. And I don't know if we have any time. I think we do. Yeah. So if people have questions. Thank you. Hello, is this on? Okay, hi, Phil Chang, Cedars-Sinai. That was amazing, thank you so much for that presentation. Just a couple of questions, the first is, I think I already kind of know the answer based off of all the tools you guys developed to kind of assess performance status, but you find that oncologists are often kind of overestimating performance status because I feel like they do that a lot just because, and I think this is right for them to do, but so they can qualify for clinical trials, but are you clearly seeing that discrepancy? My second question is just, when diagnosing funicular pain, is it just like cord compression and then kind of nondescript location, or is there more specific criteria? Because I feel like I have a greater predisposition to just call it like nosey plastic or like centrally sensitized, or does it not matter because you just kind of treat with SNRIs and TCAs and et cetera, thank you. Oncologists overestimate everything. Right, right, I mean, we're giving a talk at ACRM where we'll go into that in more detail, but it's pretty much a factor of five, right? So if an oncologist tells you you have six months to live, you really have about a month, and there's good data on that, and it's pretty terrifying, but yeah, and that's kind of our problem, and I get it. On the funicular pain, yeah, well, first of all, you have to have a spinal cord injury, right? So you have to have evidence of damage, and then it has to not fit into any other clear pain syndrome. It has to not be radicular in a peripheral nerve distribution and a plexus distribution, and then you can more reliably say that it's funicular pain. Does that help? Yeah. Okay, yeah, and it can be anywhere, but these are the ones when you're scratching your head going that doesn't make sense, consider funicular pain. Great question. And in terms of the performance status thing, seriously, everyone, what we were finding was that everyone was overestimating performance status, even our liaisons. We were having them score in the field, and they were sending us back, they were saying this patient was coming in at a KPS of a 70, and I'm like, they're not even appropriate for inpatient rehab if they're coming in already at a 70. So that was actually what was helpful about our inpatient rehab description of the KPS was actually identifying a little bit further true burden of care, and it helped us, but people still overestimate no matter what, especially if it weighs on treatment options. Hey dudes, you guys gave a great talk. If you ever wanna do a KPS but with Lansky, we should totally have a chat because that was a really cool study. So I think my question is a little different, but sort of patient-specific with one that I have right now, actually. How do you guys do autonomic dysreflexia training and or management in a person that has neutropenia and they don't want to do suppositories or anything like that? You know, there's a very delicate balance, of course, I would say that in our experience, for the most part, all typical spinal cord cares can be safely delivered other than the really, really, you know, virtually no measurable ANC. So at the very bottom of the ANC spectrum, then we do end up backing away from that using primarily oral laxatives and stimulants to avoid needing rectal stimulation because of the concerns about mucosal injury. But for the most part, other than the very, very lowest level ANCs and we don't have a cutoff. It's more of a just an overall qualitative decision about the individual's overall risk and their degree to which they're benefited and tolerating from while care in particular. But certainly at the very... Those people with almost immeasurable ANCs, we will step back from it just out of abundance of caution and in part playing nice with the oncologists, quite honestly. I don't know if... Yeah. Yeah, yeah. That comes up all the time. Yeah. I feel like that was asked one of the last times. Yeah. Oh, okay. Yeah. That's a great question. Awesome, thank you guys. Hello, I have a question regarding incorporating the KPS into, I guess if you suggest like into consults when we're looking at a patient that should be admitted and if so, or even when on day of admission to inpatient rehabilitation, is that something that is more, you know, the physiatrist does or the therapist on their initial evaluations? Both, I guess, yeah, some guidance on how to start incorporating that into the practice. The biggest piece was getting everyone comfortable with the language. So we had the liaisons, so any referral sources, the therapist and the physiatrist, kind of everyone. What we found was it started with a push from therapists because what we were doing is we were scoring them anyway on admission, we just were putting a number to it. So we already have to do all those scores and then we were taking that and throwing it into what the KPS score would be. But we were finding that it wasn't always consistently getting somewhere that the physicians were able to see that KPS score. So we've actually shifted more into a model where everyone's doing a kind of gross assessment of KPS on admission and that's been better in supporting the whole team, understanding how the KPS affects their goals moving forward. And if I'm hearing you right, I feel like you're asking a models of care question. So one model of care that we use at Kessler is we have clinical liaisons, used to be nurses, now it's nurses and therapists who are going out and assessing these patients as the first row. I've had three calls today from clinical liaisons asking questions about cases. So they run them by me, they run them by the other medical directors. If you're the physicians, we have physicians doing consults, making that determination, it's the same rules apply. You have to really double, triple, quadruple down on your understanding of the history because that's gonna give you 90% of what you need. Ask that question, do they have meaningful treatment options and then look at their performance status and then make your own read on if this patient's gonna live to get out of your facility or not or bounce back to acute care. Yeah, thank you. Thank you so much, that was a great talk. I'm a palliative care fellow, so I'm really impressed with how much your institution has sort of incorporated palliative care for these patients. My question is actually two parts. So one, I'm curious about what is sort of your trigger for when you're consulting palliative care for these patients and when that consult is happening. Just based on what you've talked about, I think it could be really useful to involve them prior to the transfer to IRF. I don't know if that's happening, but I could see value in sort of navigating that transition of care. And then the second part of the question is, do you have any advice for getting buy-in from rehab professionals who may see words like palliative or like expected prognosis less than six months, stage four cancer, and getting buy-in on sort of the value of still providing rehab services to these patients? Yeah. It's definitely been a push, and we now use palliative for not even just our cancer patients. Now that we have our nurse practitioner who's available, we ideally would prefer if it is someone who is truly a palliative care candidate, we'd always prefer that they're followed by palliative before they come to us. And then we don't have someone new come in, right? But then we say, whenever you're going back for your oncology visit, I recommend that you also follow up with your palliative care team and see, you know, with these new changes how that can be supported. But we've been finding the same thing, that the literature is finding that these patients who are candidates aren't getting referrals. So then a lot of times we're starting that referral process way later than we would want to. Usually we try to facilitate a palliative care consultant inpatient within the first week. If it's somebody who we know has very poor prognosis, it's usually within the first two or three days. Because we know we want to get them out within seven days, and if we don't, then they're not gonna be able to get home quickly. Then for your second part of the question, one of my things is demystifying the mystical, right? A lot of rehab clinicians, but not people in this room, are terrified of cancer patients. They don't want to have conversations about death and dying. It is this big black box. And I think part of it is, we're trained to understand spinal cord Asia impairments, and if that's gonna translate into certain functional levels, there's great data on it. We have been notoriously bad about understanding oncology, which is this moving target. So our take, my take when I first got there, was I just have to educate everybody the best ways, team rounds. So even if you don't know a lick about cancer, if you get everybody together and talk about it, you can get an oncologist involved, or if you're the one leading it, it really focuses your mind. If you have the cases in advance, you're going and hanging on every word, looking it up, Googling it. I'm a shameless Googler. I'll Google in front of patients. I don't care. I do not know everything. And that will slowly start demystifying the mystical for your team so that they can have these conversations. I'll just say, and then kick it back to Kira, how empowered our team has been by these conversations. It went from never lifting your eyes to look at the patient when they were dying, to fully understanding your role in improving their function and quality of life, even up until the end. Yeah. I think we definitely still have physiatrists who actually use palliative care to come in and have the conversation they don't want. And that's fine too. At least someone's having the conversation. But I think that overall, in general, there isn't as much of an understanding of the role of palliative in physical medicine and rehab simultaneously. And I think that we've pushed the team to understand it more. But I still have meetings with our team where I'll reinforce that this patient isn't gonna do well. They need a palliative consult. And I'll have some kind of kickback. What has helped me at least is having the data. So I, for the longest time, I'd go into these meetings and I'd say, our patients are dying. But our patients are dying. And they would say, well, give me that information. And so I started Googling our patients. So I started tracking our patients and Googling. And then we'd come back to the team meeting and say, 40% of our patients from last quarter died. We only sent 1% of them home on hospice. And then they had to start listening to me. So at least, I think it definitely helps. And the more data that's out there, the better. And that skilled nursing facility data is an article that just came out within the last two years. And now I bring that to our teams to say a lot of our patients that are going to skilled nursing are gonna have higher rates of mortality. We need to tell them that when we're making that referral. Yeah. Great, that's great. Thank you so much. If they're not getting better on a weekend, you don't have any options. Very true, yes. They're not accessible, there's nobody to care for them, and this is your only option. So yes and no, right? So globally for the AMRPA, they've been looking at this because they are very interested in getting patients who will do better in rehab into rehab and not into sub-acutes or nursing facilities. And they have some data, I honestly don't know if they published it or not yet, saying that the mortality rate is actually higher even when you control for these factors. So you're right that the elephant in the room is it may be cyclical, as you're saying, but I don't know that we really know that. So, you know, the patients are being neglected in skilled nursing relative to coming to us and going home. So they're probably, my gut tells me there's a higher mortality there for these patients, or earlier mortality for these patients. And a big piece is the misconception that they will be able to get treatment at the facility. A lot of times we'll have patients that will go there because they don't have transportation from home with the assumption that they'll have coverage of transportation from the facility, and then they don't. Is there sometimes card outs for SNFs that don't apply to IRs? Yes, sometimes, but it has to be bundled in and it has to be planned prior to admission. And if that's not an agreement prior to admission to the SNF, they might think that, get there, and realize they're not gonna be able to go for that treatment. And then we're basically sending them there to die. Yeah, this is a great talk, and a lot of everything you said resonates really heavily with me because I've been trying to basically start a similar program to this at my institution. My first question I'm asked to is how, and it's hard to quantify, but how vital, in your opinion, is palliative involvement in this type of a program? Because one of the barriers I have is we have two hospitals and the main hospital takes care of all the patients. The other hospital, which has a rehab unit, does some orthosurgery, some neurosurgeon, has a small ICU, and that's it. And it's been really difficult to get support. I'm fortunate that I have a very awesome palliative department at my institution. The problem is their bandwidth is very, very low, and we haven't really been able, they basically told us we can't come to the rehab unit, particularly to have some of these types of conversations to help facilitate these kinds of rough patients. And I've been trying to navigate these waters. So how important is that involvement in your opinion? You're saying this is- I'm putting it back on you, yeah. The answer is critical. There's no doubt. It's hard, right? So if you want to take on that role, great, right? Or if you have a case manager or social worker who can really have these conversations and help with the planning, okay. But I think it's critical to have somebody at least in that role, if not with that title. And when it's not palliative care, it's just harder to have it be a consistent part of each patient who needs it actually getting that. So we have a great psychologist who will have end of life conversations. And we don't necessarily need palliative when that psychologist is consulting with these patients, but that's not always the case. So it is definitely a vital component of this advanced cancer rehab. Thank you for that. Yeah, because unfortunately I do outpatient. I'm in the consulting position. So I'm like, this is a great person. I have a really in-depth conversation about their functional prognosis about kind of where I think this is heading. But then once they get to the unit, then that's where I'm not there. And then that's where the comfortability level falls off a cliff. And I've done conversations. Basically my team told me, we're not really comfortable with this. We want palliative. And palliative said, we can't do it either. So that was an issue. Just one big concept. And then I see our next speaker standing patiently at the back of the room. So I hope you all... Is that the whole team should be empowered to be a part of this conversation. So we don't pull it off like the therapists, anybody can be a part of that conversation because it's a journey. It's not like you have one big conversation. It's like not a honey we need to talk sort of situation. You want to kind of prep them a little at a time for being a partner in their own death. Which sounds bad, but it's true if they're gonna have a good death and not one kicking and screaming in an ICU. It's slow, steady pressure is what Dr. Summerfield always tells me. It took us like six years to get here. So yeah, just keep pushing. Thank you guys. Thank you.

cancer rehabilitation

epidemiology

treatment options

complications

early detection

inpatient rehabilitation

multidisciplinary team approach

functional independence

acute care transfer

effective communication

patient-centered approach