All right, welcome, everybody, to the session titled Fighting Cancer with Fitness, a Sports Medicine Approach to Cancer Rehabilitation. My name is Raul Rosario Concepcion. I'm a provider of physical medicine rehabilitation at Sports Medicine at Mayo Clinic Florida. And I think that today we have a very interesting session that we're going to try to apply the sports medicine and musculoskeletal knowledge to try to help cancer patients improve their quality of life and functionality. So we decided to divide the session into three different presentations. First I'm going to talk a little bit about the most common musculoskeletal complaint and the importance of cancer rehabilitation in this population. Then Dr. Gerardo Miranda is going to talk about the benefits of exercising these cancer patients and why it's very important to implement this as part of the cancer treatment. And at the end, Dr. Fernando Sepulveda is going to talk about the different applications we can use the musculoskeletal ultrasound to try to help cancer patients improve their quality of life. So in terms of my presentation, I have no financial disclosure. I'm going to focus my presentation about and talk a little bit more about the importance of cancer rehabilitation and why we need more PM&R providers and maybe sports medicine provider to try to start seeing more cancer patients in their service in order to try to help them. And we're going to go through different and the most common musculoskeletal problems in this population. So first of all, why is cancer rehabilitation necessary? So we know that with the advancement of technology and medicine, cancer patients are living longer and surviving more. By surviving more, they can develop different impairments and disability that can decrease the quality of life and their functionality. And we use rehabilitation to try to help them improve this quality of life, enhance their function, and increase their level of physical activity and lifestyle. To put this into perspective, at this moment, we have even more than 17 million cancer survivors in the United States, and that number is supposed to increase in the next couple of years. In the 1950s, cancer patients survived more than five years, only 35%. Now more than 70% of the cancer patients survive more than five years, and they start developing this impairment that we can help with some rehabilitation. In order to compare, we know that half a million people suffer a spinal cord injury, according to the World Health Organization. And when we think about spinal cord injury, we think of rehabilitation and how this is extremely important part of their treatment. However, when we think about cancer patients, most people don't think about how their rehabilitation is a key component of their treatment plan. And we see that more than 50%, and some studies says even larger than this, of the cancer survivors can develop some type of impairment or difficulty that are amenable to rehabilitation. And that's where we can help the oncologist improve the care of the patient by providing a good rehabilitation care. However, we're seeing, even though we know that cancer patient would benefit from rehabilitation, we're seeing that these cancer patients are underserved. In this specific study by Cheville, she took 163 metastatic breast cancer patients and found that 92% of those patients had at least one physical impairment that was amenable to rehabilitation evaluation or treatment. She was able to identify 530 different impairments. And she noticed that of those 92% of the patients, only 30% received this inpatient care and evaluation of a rehabilitation provider or any type of physical therapy or occupational therapy. And even in the outpatient setting, 88% that require physical therapy or occupational therapy in outpatient, only 2% received this care. So in summary, we know that this population is being underserved in terms of rehabilitation. We know that a lot of them have impairment. We know that most of them do not receive the care. And this is even more evident in the outpatient setting. So as a sports medicine fan and a sports medicine provider, I like to bring this quote very quickly. This is Stuart Scott. He was an anchor in ESPN and he unfortunately died in 2015 from cancer. And in his last speech, he mentioned that you beat cancer by how you live, why you live, and in the manner in which you live. So it's not just surviving the cancer. It's also how you survive that cancer and how you live after you survive that cancer, which is extremely important. And that's how a PM&R provider can help this patient return to improve their quality of life. Another big question is, do we need additional training to start seeing cancer patient in our practice? First of all, we know that at least according to the fellowship program directory, there are eight Cancer Rehabilitation Fellowship Program currently as part of PM&R residency. And this fellowship at this moment is not yet recognized by the ABPM&R or the ABMS as an accredited specialty in physiatry. So technically, you don't need a fellowship to start seeing this patient. We know that more training is definitely better. So having that training is definitely very important as part of seeing this patient. But unfortunately, oncology patient cannot wait for enough physiatrists to be trained in cancer rehabilitation. Because as I said before, there's a lot of cancer patients out there. So we need more physiatrists that needs to step up and establish care and help these cancer patients. And this session basically is trying to find that knowledge from general PM&R or sports medicine to try to help these patients. So as you can see here, Cancer Rehabilitation Professionals offer the expertise of improve endurance, strength, mobility, increase ADLs, return to work and exercise better, decrease the fatigue, which are common things that a PM&R provider can provide in different conditions. And cancer patients can develop a lot of different impairments. And this was described in 1978 by Lehman. So this is not something new, even though in the last couple of years is where we started seeing more interest in cancer rehabilitation. It has been known for a while now. And these complications can be separated in different sections. It can be neurological, neuromuscular complication, pain complication, medical complication from the heart, kidneys, complication from the treatment that include chemotherapy and radiation, and musculoskeletal complication, which will be the target of today's presentation. So in order to talk about musculoskeletal complications, the first thing that we need to know is that this complication can be secondary to the cancer itself on the tumor, can be secondary to the treatment from cancer that we know it can be a little bit toxic, or it can be just a benign degenerative problem like any other patient without cancer. So the important point that I want to make right now is you have to be sure, and sometimes difficult to be sure if the pain is coming actually from the cancer. And I will bring this example, maybe hard to see on this x-ray, but this is a patient that came to my clinic for cancer rehabilitation evaluation after breast cancer, and she was complaining of this post-mastectomy pain syndrome. But at some point in the visit, I noticed that she was complaining of hip pain. And I asked a little bit more about that, and she said that two months ago, she started developing hip pain without any trauma. That's always concerning in a patient with cancer, so I started with by doing like a basic x-ray. And you can see actually here in the femoral shaft, a bone lesion. And in the acetabular wall, you can see all this haziness over here that was concerning for metastatic disease. So we order more advanced studies like a bone scan, and you can see how it lights up around the pelvis and in the spine with an MRI also confirming our suspicion of metastatic disease in this patient. And you can see all this involvement in the acetabular wall and in the femoral shaft and even in the spine if you scroll the MRI. So by just trying to help the patient, we were able to identify a metastatic problem that then we refer to radiation oncology, orthopedics, and the primary oncologist, of course. So that's how can also we can help this patient. In terms of my cancer rehabilitation practice, the most common thing that I see are the common thing that we see in any MSK or sports medicine practice. We see rotator cuff dysfunction. We see adhesive capsulitis, frozen shoulder. We see tendon apathies, burst apathy, myofascial pain, which we already know how to help these patients because we already have that knowledge. So I'm going to focus the presentations on the things that are more specific to cancer patient that we have to understand in order to try to help the patient. So we're going to start first with shoulder dysfunction. So you can see this a lot with breast cancer patients, head and neck patients that suffer like nerve injury or surgical scar that can alter the biomechanics of the shoulder. And in this picture, you can see that they can develop tightness of the pectoralis and sternocleidomastoid muscles and weakness of the rhomboid and lower trapezius muscle. And this can create a shoulder dysfunction that presuppose the patient of having like scapular dyskinesia, rotator cuff impingement syndrome, and even bursitis or bursopathy of the subacromial space. The treatment for this, usually the same thing that we do for any other impingement syndrome, exercise and rehabilitation, focusing on increasing the strength of the scapular muscles and stretching the pectoralis muscle. We can also use some pain control modalities like medications or even corticosteroid injections to try to help the patient tolerate the rehabilitation a little bit better. The next condition I want to talk about is axillary web syndrome or cording. We see this more in breast cancer that suffer axillary lymph node dissection or they underwent that procedure. This patient developed this kind of palpable cord-like subcutaneous tissue extending from the axilla that actually can go through the elbow and even sometimes to the hand. Usually you can feel it and it's unclear the etiology of why this happened, but we think it's a damage and sclerosis of the lymphatic and the venous system that create this problem. This can be very painful, sometimes not painful, and the range of motion is the main complication that the patient develops. We start always with a good rehabilitation program to increase the range of motion and increase the strength of the shoulder. The physical therapy also can do some manual mobilization of the cording and sometimes even pop the cord out and the patient feel a significant relief after that happened. So this is a very decently common thing that we see after breast cancer surgery. One of the most common thing that I see in my clinic also is the post-mastectomy pain syndrome which is basically pain in the surgical region and the axilla that we suspect is secondary to this nerve injury of this very small cutaneous nerve that we have here in the chest wall and even in the intercostal brachial nerve right here that can develop this chronic pain that lingers more than the usual recovery from the surgery. This is usually present post-mastectomy but also can be seen post-lumpectomy treatment. So this is the way that I approach this problem in patients that are struggling a lot. We always start with a good rehabilitation program, increase the stretching of those tendons, increase the strength of those muscles. We can implement some desensitization techniques, having a good rehabilitation definitely key and most of my patients, they improve significantly just by doing a good rehabilitation program. If that doesn't work, we can also add some pain medication and the medication that we use are the one that usually stabilize the nerve a little bit, the neurostabilizer medication. We can start with gabapentin, pregabalin. We can also consider duloxetine as a good option. Sometimes using topical agents can be beneficial in trying to control the pain and I have a few patients that have responded very well to gabapentin. If the patient is not progressing and is still having significant problems and we know that it's not related to the cancer, right, which is very important, we can offer some intervention techniques that Dr. Sepulveda is going to talk a little bit more about that. We can offer intercostal nerve blocks, serratus plane blocks, and other trigger point injections that can help the patient's symptoms. Some people may say that Botox even helps in those muscles that are being activated like the pecs. I haven't tried that in my practice. Another common problem that we see is the aromatase inhibitor associated musculoskeletal syndrome. Basically, aromatase inhibitors are important agents in the treatment of usually breast cancer. After they finish surgery, chemotherapy, and radiation, some patients are started in this hormone receptor positive, in this endocrine therapy. But some of them can cause arthralgia, joint stiffness, bone pain. They present very similar to kind of a fibromyalgia type of problem. Some patients have to even discontinue the medication because the symptoms are so severe. We see that these symptoms are usually symmetrical and it's very associated to carpal tunnel syndrome and trigger fingers, which is something that we can definitely help in this patient. The treatment is exercise and having good results by getting the patient more active. Motion is lotion. So trying to get them more active definitely helps. Try to control the pain with some medication. Physical therapy and rehabilitation very important. In some occasion, we consider a steroid injection to try to help with the pain. Just trying to find that balance so they can receive the benefits from the medication. Lymphedema, very common problems that we see after breast cancer and other type of cancer like head and neck. Basically, what is happening is a disruption of the lymphatic system that leads to accumulation of fluid in the interstitial space that is eventually manifest as swelling. And it's very important that we control this because number one, the patient don't like the aesthetic of how it looks. Number two, if we let this become uncontrolled, we don't control it very well, the patient is at risk of developing infections and other type of skin complication from this. This is very common. We see it in 6-30% of the breast cancer surgeries and even more in some cases. Usually it's present initially in the first six months, but we can see it after. The diagnosis is clinically. When there's doubt, there's some studies that we can order, but usually it's very, very classic the presentation. The treatment, education to the patient so they understand what's going on is very important. They need to understand that we need to avoid skin infections and injuries. Compression therapies, they go to treatment. We like to put compression banding, compression garments. So at first we try to be on the offense and try to decrease that swelling in the extremity. After that swelling is decreased, we can do more defense and control that swelling with some garments and probably pneumatic compression. And the physical and lymphedema therapies is extremely important. They're going to help you treat this patient a lot. They can even implement some manual lymphatic drainage, complete decongestive therapy that definitely a patient respond very well to those. In some cases, we need to refer to plastic surgery for some type of procedure that you can offer the patient to try to help control this a little bit better. Spinal accessory nerve palsy. We see this very commonly in head and neck and spine cancers. As you can see the nerve groans right there when usually they do the surgery. This can be damaged secondary to the surgery because sometimes it's hard to find during the surgery or indirectly if they put pressure and tension to that nerve, it can cause some type of injury or the radiation can cause problem. And this can create atrophy in the trapezius and the shorter gourd or dysfunction that can cause pain. The EMG or electrodiagnostic study can be helpful in terms of confirming our suspicion. It can also determine the severity of the problem to try to evaluate the outcome. Tension is extremely important to try to compensate for the muscle that are not being affected and sometimes we need orthosis to try to help the patient a little bit more. Peripheral neuropathy. I'm not going to get too much into this, but we know that it can happen after chemotherapy and chemotherapy can affect every single part of the nerve. It can be more of a poloneuropathy. It can then be more of a mononeuropathy or even small fibers. So we have to try to find that balance that the patient will receive the best benefit from the chemotherapy and have the less side effect because these agents are dose dependent. So sometimes we decrease the dose of the chemo or they decrease the dose of the chemotherapy, the oncologist, but then we don't have the optimal dose that is required to treat the cancer. So we can help these providers control these symptoms a little bit better so the patient can have an optimal dose. And this is just a quick list of different types of chemotherapy that can cause neuropathy or some kind of chemotherapy induced neuropathy. Radiation fibrosis syndrome is another complication that can happen after radiation, of course. It's a manifestation of progressive fibrotic sclerosis by providing a normal accumulation of thrombin in the intra and extravascular compartments that can affect actually the skin, the muscle, the ligaments, basically everything where it's radiated. This is secondary to the radiation field. So before my understanding that this was seen more because the radiation field was bigger and now where the treatment has become that the field is smaller and more specific to the tumor. So this complication is less seen. Definitely physical therapy, occupational therapy is very important to try to help. But this can be very challenging if it gets to the clinic pretty late. Cancer related fatigue, extremely common in my practice. It's basically a feeling of tiredness and exhaustion without any physical activity. So you feel tired all the time. And even sometimes if you sleep, you still feel tired when you wake up. And this can be very limiting and almost some paper says that 90% of cancer patient can develop this. And in my practice, almost all of them have some type of fatigue. So first of all, when I got a patient with cancer related fatigue, I want to make sure we're not missing other possible reason of fatigue like anemia. So that's why I order CBC to evaluate for electrolyte disturbances, BMP, hypothyroidism, vitamin deficiency, sometimes testosterone levels. And I always check the medication because maybe it's a side effect of a medication that is giving this sensation of exhaustion. Number one in terms of treatment is educating the patient. They need to understand what's going on. But exercise is very key in treating this. Usually almost every patient respond and they need to understand because sometimes it doesn't make sense that if I'm tired, I need to exercise because I'm going to be more tired. But actually the exercise after a few weeks to start feeling, giving you good results. And also we can use some medication, but usually this is not needed. Don't forget to evaluate the cognitive function, the psychological problems that this patient may have because the mind and the body are united. So at the end of the day, most of the things that we can see, we already know how to treat. We just need to increase the knowledge on those specific diagnosis that are related to a specific type of cancer. So it would be like a learning process to try to continue to learn and try to help this patient. And hopefully we can provide some type of care to this patient to improve the quality of life. So we need physiatry and physical therapy and occupational therapy to be involved on that care of the cancer patient in addition to all the other specialties that are involved in the care in order to try to make the patient better and increase their functionality. So what is the optimal goal? So once the patient has cancer or is diagnosed with cancer, getting an initial evaluation sometimes is helpful to help prepare the patient for the treatment that is coming and we call this prehabilitation. And we do this a lot in the sports medicine practice. When some patients that have an ACL tear, we prehabilitate and get them stronger and ready for the surgery. So sometimes we can offer patients that service of prehabilitation. After or during they are currently having treatment, we can help identify impairments that the patient may have and try to help them tolerate the treatment a little bit better by using rehabilitation or other modalities as part of the care. And at the end of the day, we always want the patient to increase their physical activity, increase their exercise routine and their wellness. And Dr. Miranda is going to talk a little bit more about the exercise in that area. So I want to conclude my presentation with this quote from Jimmy Balvano as a sports fan. Again, he was a college basketball coach and was one of his most important or memorable speeches. He said that cancer can take away all my physical abilities. It cannot touch my mind. It cannot touch my heart and it cannot touch my soul. So I invite you to consider start seeing more cancer patient in your practice, understanding that it will be a learning process, but definitely you can make a big difference in your practice. So this is my email, just in case that you have any question. I right now, I will finish my presentation and turn it to Dr. Gerardo Miranda, who is going to be talking about exercise in cancer patient and how it can benefit this patient. Dr. Gerardo Miranda did PM&R and Sports Medicine Fellowship in the University of Puerto Rico and currently serve as a assistant professor in the Mount Sinai Hospital in New York. So without further ado, I leave you Dr. Miranda. All right. Thank you, Dr. Rosario. So my part of the session is to talk about physical activity and exercise in cancer, the benefits before, during and after treatment. So currently serve as assistant professor in the Department of Rehabilitation and Human Performance at the Icahn School of Medicine at Mount Sinai. I'm also starting my practice in Puerto Rico as well. So it's a little complicated, but this is where we're at. So I don't have any financial disclosures. We're gonna discuss very briefly what cancer survivorship is, which is something that I like to add to every time I talk about any interventions in cancer patients. Discuss physical activity and exercise and why the two terms go hand in hand and we should understand the effects of physical activity and exercise in health, mortality, cancer prevention and treatment, and then discuss the components of an exercise prescription in this population. So survivorship, according to the National Coalition of Cancer Survivors, a cancer survivor is defined as an individual with cancer from the point of diagnosis through the balance of life. And this definition expanded to include family, friends and caregivers. Why is this important? When we talk about anything that has to do with a cancer survivor, we need to include family, friends and caregivers. And that goes hand in hand with what I'm gonna talk about with exercise, which is one point that I wanna emphasize that we should include other people in increasing the activity level for this population. So, and this goes hand in hand with what Dr. Rosario mentioned about prehabilitation and where can we get involved. So we can get involved from before the diagnosis, through the diagnosis and through the balance of life. And that's one of the things I like about our specialties that we can pretty much get involved with every pathology, every injury, any type of disease from any point in the care. And that goes with cancer patients. So in terms of exercise specifically, so physical activity, physical activity is any body movement that requires any energy expenditure. So it can be an activity of daily living, it can be recreational. This is different from exercise itself because exercise is a type of physical activity that involves planning and a structural movement of the body that is performed in a systematic manner. It can be in terms of frequency, intensity, duration and it's designed to improve, to have certain outcomes or goals. So exercise is a more structured type of physical activity. It has measurable parameters like safety, quality of life, physical fitness. And physical fitness is one term that Dr. Rosario put to our talk, right? When he organized this, fighting cancer with fitness, which is something that I've talked about exercise, physical activity and cancer. And every time I talk about it, I always add something. And this time I'm talking a little bit more about the fitness component of it. Why? Because this population is not, we should not forget that we have more cancer survivors. We have younger patients that are being diagnosed earlier in their life. And we have active individuals that are not gonna be, they're not just gonna feel okay by just increasing their physical activity. Some people wanna be able to measure. Physical fitness is considered the body's ability to function efficiently and effectively in athletic work or leisure activities. There's some genetic factors that go into this, right? But nevertheless, physical fitness components can be health related like body composition. So free body fat percentage, cardiovascular fitness like the VO2 max, flexibility, muscle endurance like lactic threshold, muscle strength like a one repetition max. It can be skill related like agility, balance, coordination and power, speed, reaction time. We know that these terms, we rarely talk to them when we talk about cancer patients or people can be fairly sick because we forget that we should treat every patient like an athlete. We hear like we hear in the human performance field. So it's important to treat every patient like if they were the best athlete in their specific sports. When we talk about benefits of activity and exercise. So now we're gonna interchange the terms because there's really no clear distinction between physical activity and exercise, their benefits in cancer patients. So we know, this is, it's very strong physical fitness. It may reduce the risk of several types of cancer, specifically breast, colon, endometrial cancer, prostate cancer. The data is available, the data that is available is more robust in the breast cancer area, but we're learning more and more about other different types of cancers as well. So this is a infographic from the ACSM, it's fairly new. I think it summarizes my talk. If I leave this there, I can just go home and that's it. I should have left it to the end. But it's here, what I wanted to point out is that there's evidence that shows that the effects of exercise on health-related outcomes and there's strong evidence for cancer-related fatigue like Dr. Rosario mentioned, there's some studies that suggest that 90% of patients have some sort of cancer-related fatigue, health-related quality of life, physical function, anxiety, depression, lymphedema. There's moderate evidence for bone health and sleep. So all this, we know there are problems in this population that we wanna deal with and we wanna help these patients with. The mechanism as to which, how exercise can help preventing cancer has been shown that improves biomarkers profile, changes in inflammatory mediators, improves immune function. We know that certain types of exercise, especially vigorous exercise for more than 90 to 120 minutes so more than two hours can cause a transient immune dysfunction. But we also know that exercise has a cumulative effect to improving immune function. So in acute, very acute, it can delay, but with cancer, we're talking more about long-term effect. So exercise improves immune function, changes in estrogen, progesterone and androgen specifically in breast cancer patients, improves insulin sensitivity and reduces fat mass and BMI. And some of these mechanisms also help with general health as we know. So the cancer prognosis, survival and disease free interval, there's a clear association in breast cancer and colon cancer in terms of physical activity. Greatest benefit is when you do nine to almost 15 meds per hours per week of physical activity, which is this is equivalent to walking three to five hours per week, which is a little bit higher than the minimum recommendation. And we know there's a protective effect if there's physical activity at three med hours per week, which is walking one hour, almost one hour a week. And this is the association is stronger in some patients, for example, in women with hormone sensitive tumors in breast cancer, but nevertheless, this is one of those things that I try to mention why it's beneficial to exercise in terms of cancer. And we try to understand the mechanisms and the data, but the data is clear. There's nothing that's detrimental about doing physical activity and cancer prevention. Is it safe? Is it efficacious? So it is. So exercise during chemotherapy and or radiotherapy is safe. And it is effective in improving aerobic fitness, muscle strength, body composition, and quality of life. Exercise following treatment is also safe, associated with very minimal side effect, which you can pretty much erase by following certain recommendations, specific populations. It is effective in improving aerobic thickness, muscle strength, flexibility, body composition, fatigue, muscle function, anxiety, body image, and quality of life. So this is important to understand that it is safe to do it. Barriers to physical activity and exercise. There's some acute effects of treatment like immune compromise that can affect what you can do and how well you can do it. And there's some other issues with acute effects of treatment, like learning to cope with side effects like nausea, vomiting, fatigue, skin rashes, peripheral neuropathy, hair loss, pain, anxiety, depression, changes in self-esteem and body image. So those we need to take into consideration. And that's why another thing to really focus on is that exercise is like any other treatment that we do in our field. It's a team approach. And this includes, for example, psychology treatment as well. Long-term effects of treatment that can affect and can be a barrier to physical activity and exercise include lymphedema, fatigue, peripheral neuropathy, infertility, premature menopause, and changes in body composition, and cardiopulmonary changes like pulmonary emphysema, heart failure, among others. And late effects of treatment, cardiovascular disease can be an issue in this patient, especially those treated with cardiotoxic chemotherapy and osteoporosis, especially those treated with hormones that can lead to osteoporosis and other increased risk of fractures. So when we talk about exercise prescription itself, I really like this diagram here because it includes almost everything that we need to take into consideration. So if we go to individualization of the treatment, we talk about our prescription that should be very unique from patient to patient, take it into consideration based on cardiorespiratory fitness and muscle strength. And one aspect that I personally, usually you don't get to think about it too much. And one of the reasons is that, that I wanted to make a parenthesis here is that the way our health system is set up, we typically should have more people involved when we talk about exercise in this population. For example, we should have an exercise physiologist with us that can help assess that cardiorespiratory fitness and muscle strength in order to do this progressive overload. And that part is skipped unless you're doing a specific research where you're actually paying for an exercise physiologist. Very rarely do we see an exercise physiologist in our staff that is not doing research, that is a clinical individual that can help us with this progressive overload because the progressive overload, like if we talk about exercise and fitness in general, as much is needed, right? And then we talk about recovery. So appropriate rest, recovery session, there should be implemented in an exercise prescription. So we need to actually tell our patients in our prescription about recovery and then specificity. So specificity, if we are looking to improve our cardiorespiratory fitness, then we know we're gonna do more aerobic exercise. If we wanna improve muscle strength, then we will be doing more muscle strength resistance training. So the goals, like everything else that we do in our field, we should do an exercise prescription based on goals. One goal is to regain and improve physical function, aerobic capacity, strength, and flexibility, improve body image, composition, and quality of life, potentially reduce or delay recurrence of a primary or secondary cancer, and to improve the physiologic and psychological ability to withstand any current or future cancer treatments, right? So this is the prehabilitation component of it. The general medical assessment that needs to be performed includes assessing for peripheral neuropathy, assessing for any musculoskeletal issues that Dr. Rosario explained, Dr. Sepulveda is gonna talk about a little bit, but things to consider, shoulder and arm morbidity before upper extremity exercise, lymphedema in the lower extremities in people with, in females with gyne cancers, fracture risk, people that had surgeries, a lot of post-op healing, and cardiac evaluations with those that have been treated with cardiotoxicity, cardiotoxic medications. When we talk about exercise prescription that we've been talking about for a little bit now, we talk about exercise testing, right? So the ACSM guidelines for moderate to vigorous intensity exercise call for an exercise test before starting it, and especially to be very specific. First, to have a baseline assessment, and two, to watch for any possible complications that can occur. It's important, very important to know that no testing is required before walking flexibility or resistance training at a mild to moderate intensity. So you don't wait for exercise testing to tell somebody to start walking. And we know that for anybody who's been in the hospital rotated through a ward, very few, very few interventions that are done in the hospital require 100% bed rest. So walking is safe. One thing to take into consideration is that now we know that one repetition mask, one repetition max testing is safe in patients at risk or with lymphedema. Typically, it is recommended to maybe do this with a upper extremity compression garment. Cardiorespiratory capacity, like VO2 max, requires maximum effort. So it's important to know that if somebody has any cardiac issues, then you should avoid this at the moment. These are the recommendations for testing before an exercise program. These are the general recommendations. This is taken from the ACSM. It's just for us to know a little bit, and this involves mostly the cardiac conditions. And this is what's the guideline for stress testing as well. So when we talk, the exercise prescription itself. So we always mention the FIT principle, frequency, intensity, time, and type. So the FIT principle, when we talk about aerobic exercise, it's very, it all falls into the same, the FIT itself, it all goes into a frequency, time, or volume. We talk about aerobic exercise, that we should do moderate intensity exercise for 150 minutes to 300 minutes per week. 150 minutes is the minimum required for health benefits. When we talk about vigorous intensity, we talk about 75 minutes per week. The now interval training has been shown to be very, very popular, especially high intensity interval training. When this reference came out in 2011, the recommendation was to people to do at least bouts of 10 minutes of continual exercise in order to get benefits. Now in 2018, the newer physical activity guidelines recommend that any minute that you spend moving counts towards that weekly total. So it's important to know that if you have patients that do not tolerate 10 minutes of continued exercise, then they should do a little less, but they can definitely do exercise. Then high intensity interval training, high intensity, we know that you could use physiologic parameters, which I'm gonna talk about in a minute, but you can also use subjective parameters. So that this can be done in highly trained individuals or not so highly trained individuals. Or you can go into another option if you don't have the time to do the exercise or in order to quantify a little better, you can go to step counting, which we know that for general population, adult population, 7,000 to 10,000 steps a day can lead to health benefits. These are some examples of what moderate intensity, vigorous intensity, exercise, physical activity, home activities, or workplace activities look like. And I just wanted to have this slide there so that we can have it as a reference. And the aerobic exercise intensity can be measured with physiologic parameters like heart rate, maximum heart rate or heart rate reserve or VO2 max, but it can also be measured subjectively with perceived exertion, with a Borg scale, which is something that if you teach patients, individuals, clients, that they can learn and they can actually, it's actually a reliable source. This is an example of different MET levels in common activities, just to know which ones, how intense, if you're gonna look, if you're gonna measure it by METs. In cancer, you wanna walk close to 2.5 miles per hour. And that is a good measure in terms of goals in cancer patients. Resistance exercises. So a lot of people are afraid of resistance exercises when we talk about cancer patients. They're effective and safe during and after therapy. Depending on the level of the patient, it is recommended that maybe at the beginning, they do it on a supervised program. Important to watch for changes and symptoms around the arm and shoulder, especially patients that had kin ports and maybe using compression garments for those that are at risk or with diagnosed lymphedema. Watch for hernias in post-ostomy patients and watch for symptoms that are exacerbated by the exercise itself. The general recommendation is the same general recommendation as to the general population. The FIT principle, each measure muscle group two to three times per week. Intensity is gonna depend on the individual and the goal and time of duration. It's gonna depend on the goal as well and type. There's different types of resistance exercise. It could be body weight exercises using machines, using free weights, resistance bands. It depends on the level of the patient on the individual. Other exercise recommendation, flexibility training as per ACSM guidelines. It's important to watch for people that might be at risk of osteoporosis or have diagnosed osteoporosis because they have an elevated risk of fractures. Balance training. We know it's proven that it helps reduce risk of falls in the elderly, but it's not clear. There's limited data in cancer survivors. And then aquatic training. Aquatic training can be very helpful for people that have chronic pain and it can have a soothing effect and a decreased resistance type of effect to control edema, reduce weight bearing and provide energy during exercise. So it can be very useful in this population as well. Special considerations in yoga seems safe as long as you take into consideration any upper extremity arm or shoulder issues and sports participation. There's no clear evidence in cancer survivors. Lower extremity exercises, including running, cycling should be safe following treatment. There's some evidence about triathletes that improves triathlon training can improve fitness and quality of life. And caution should be taken with upper extremity activities such as tennis and swimming. Again, as long as you take into consideration any shoulder arm issues, it should be okay. And contact sporting people with ostomies, then that should be maybe taken into consideration, maybe avoid contact sport in this population. To maintain benefits of exercise, physiology changes can decrease after one or two weeks of not exercising. so you lose it very fast. It's hard to gain it and it's easy to lose it. But it's important to know that some of those gains that you obtain through exercise, especially those that have to do with neuromuscular and functional changes are maintained if you do a weekly session. So to end, exercise recommendations should have a team approach. So it's important to involve different players and those in the exercise world. I think exercise physiologists can be a very useful team member. Avoiding activity, may start moderate intensity exercise as soon as possible, as tolerated by the patient. Although there are evidence of safety and effectiveness in some of this population, right? We have a lot of data on colon cancer. We have a lot of data in breast cancer, not necessarily a lot of data in other types of cancers. It's still safe and we can extrapolate what we know from those more study cancers to other types. Exercise is safe and effective and it should be individualized, especially taking into consideration the person's physical limitations or vulnerabilities, but also their functional and fitness goals. And that's the end. I took a little bit more time than I should have, but if you have any questions, please email me or email Dr. Rosario with it. Now we're gonna go with Dr. Sepulveda. Hi, my name is Fernando Sepulveda. I'm an assistant professor at the University of Puerto Rico, PMR department. And I wanna thank Dr. Smiranda and Dr. Rosario for two great lectures and to setting up my presentation. I'll be talking about the application of MSK ultrasound in treating cancer patients. So I have no relevant financial disclosures or I won't be talking about off label usage of certain medications. So I feel like I'll be preaching to the choir a little bit, but I'll be reviewing some of the basics of MSK ultrasound. I'll discuss diagnostic and procedure applications in dealing with cancer patients. And I'll talk briefly about the safety of those procedures while we're dealing with cancer patients. So just some general basics of ultrasound. So as we've learned over the past few years, ultrasound is a great tool in our toolbox to deal with PMR issues. So there's a few reasons for that. First of all, it's relatively quick. If you have an MSK ultrasound machine in your clinic, you can set it up real quick and just scan the patient or use it for procedures compared to an MRI, which takes more of a legwork to get it going. It's convenient. There's really a lot of portable machines with increasing resolution, which makes our job easier. There's even some handheld devices that you can connect them to our tablets or phones. They can take them from clinic to clinic. So that's convenient, it's available. The prices have gone down dramatically. Some of the high-end machines still are a little bit pricey, but for most of the applications we use on our daily clinic, you can get a good machine for a fair price. And it's safe, right? So you can use ultrasound in most of our patients. The contraindications are pretty few, if any. So one of the tools or advantages of using MSK ultrasound is that you can do real-time visualization of any structure you're looking for, and it can help you compare one side to the other. If you think that what you're looking at is a little funky and you're not sure if it's normal or not, you can just go to the other side and just compare it and see what's normal for that person. And if what you're seeing is pathologic or it's not right, and you can do more advanced imaging or just take it from there if you've made an assessment. And that's fairly easy to do. Also, you get great soft tissue resolution that I would argue it's comparable to MRI, particularly when you're looking at superficial structures that don't have bone that get in the way and obscure the image. So again, it's a cheap alternative to look for some structures and help you make an assessment or do procedures as we'll discuss further along. Again, for procedure guidance, it's extremely useful. And this is an example of median nerve hydrodissection. So it can help you avoid intraneural injections, avoid vascular structures, and just improve your accuracy. One of the biggest drawbacks of MS-Gel is it's operator dependent, right? So you need to be skillful. I've been practicing this for, I don't know, maybe eight years or so, and I still have a lot to learn. I continue to learn every day. And the more I use it, the more comfortable I get evaluating certain diagnostics or just performing some procedures. So you gotta do the hours, the flight hours to get comfortable with it, take courses, read, practice. So you can maybe do some more advanced stuff or feel comfortable incorporating it in your daily practice. There are some drawbacks in terms of what you can evaluate with MS-Gel ultrasound. For example, if you, there's a cancer patient, breast cancer, who has shoulder pain, and you believe that the etiology of the pain might be related to a labral tear, for example. That's not something you can evaluate with MS-Gel ultrasound. You can rule out other pathologies, such as rotator cuff tendinopathy or so, but you can't see the labrum inside the joint. Also, if you're thinking about spine pathology, there's also a limited amount of diagnostics you can perform on that area. So although it's really useful for some things, it does have its limits and you gotta know those limits to know how far you can take it and when to maybe order more advanced imaging to help your patient. So just some general concepts in terms of diagnostics and procedures. In terms of diagnostics, you can use it to evaluate neuropathies, including entrapment neuropathies. Dr. Rosario commented earlier that cancer patients, or particularly those who are in certain treatments, particularly aromatized inhibitors, might get an increased incidence of carpal tunnel syndrome. And that's something you can readily evaluate using MS-Gel ultrasound, along with other entrapment neuropathies. Also, patients who develop peripheral neuropathy related to chemotherapy, you can see some changes, both in the nerves and in the muscle. Here's a picture, the upper aspect, you can see the muscles of, this is the leg muscles, anterior tip of a patient who lost his echo texture in his anterior tip related to neuropathy. And below, you can see the normal echo texture or peripheral pattern you see on the muscles. So you can evaluate from myopathies as well. So this is an example of an evaluation of an entrapment neuropathy, particularly in median nerve, which is, I guess, the most commonly occurring entrapment neuropathy, not just in cancer patients, but overall. And so as you can see, you can evaluate the cross-sectional area of the median nerve, and that's one of the criteria used for diagnosis. Also, you can see the median nerve excursion, just have the patient move around his fingers and see how the nerve moves or glides within the tunnel. And below, you can see a notch that forms at the site of entrapment and the corresponding edema you get proximal to the nerve entrapment. And that's criteria you can use as well to diagnose carpal tunnel syndrome. And you can also correlate it to electrodiagnostic studies, which we're usually accustomed to performing. So this is an evaluation comparing a symptomatic side or pathologic side to a control. And you can see the doubling or more than doubling of the size of the nerve compared to the control to the affected side. So some people use more than 11 millimeters in the cross-sectional area as pathologic. Some people use 14. I usually like to use 14 just to get more specific diagnosis. And I usually correlate it with obviously symptoms and the electrodiagnostic studies. But it's certainly helpful to differentiate and narrow down your differential diagnosis. So I usually do more procedures than diagnostics. And again, ultrasound is very useful for interventions. It should be more accurate. If you're seeing the structure you want to inject, so it's logical to think that it's gonna be more accurate to perform those injections. And there's multiple studies that have been performed looking at the accuracy of ultrasound-guided injections compared to anatomically-guided injections, the need for less injectate. So when I was taught anatomically-guided injections, particularly for some nerve blocks like suprascapular nerve or so, I was taught to inject a lot of volume to make sure that the spread reached the nerve and you get the appropriate nerve block. But with ultrasound-guided, you can lower the injectate because you're seeing the needle reach the side of the nerve and you can get a good hydrodissection of the nerve and a good block with less injectate, possibly reducing the possible complications or toxicity from some of those injectates. Also, as we talked earlier, you can avoid injury to neurovascular structures. You can perform a dynamic evaluation right then and there while you're performing or before you're performing the procedure. So you have real-time imaging while you're injecting compared to using fluoroscopic guidance, for example, or you can use double ultrasound as well so you can see the vascular structures as opposed to fluoroscopic guidance. Obviously, it might have some drawbacks or more deep injections or some structures that the bone gets in the way, then fluoroscopic guidance might be more helpful. So as a general rule, you usually use a linear probe for superficial structures and a curvilinear probe for deeper structures. Remember to pre-scan. I saw a patient about two months ago with right shoulder pain that sounded, by history and part of the physical exam, as a shoulder impingement. But during the exam, I saw a small mass. I scanned it before thinking about injecting it, and it just didn't look right. It didn't look like a common lipoma that you might get around the shoulder in the clinic. So I sent it out for MRI. Again, with the MRI, you can get a clear diagnosis. So I recently sent him for a biopsy. And again, no real limits. We're not necessarily trained during residency and that this might change from residency to residency. And as we incorporate more of the use of the diagnostic ultrasound, this may change. But we don't typically see a lot of tumors or masses during our training. So know your limits. If you don't feel comfortable or it doesn't look right, just pull back, avoid the injection, and just send him for more advanced imaging and get a good characterization of your mass or whatever tissue you wanna make sure you're looking at. Also, be mindful of optimizing your image. Make sure the depth is appropriate, the frequency, the focus again. All that will help you optimize your image and get a better result from your procedure because you're seeing what you're injecting. So going into some of the common injections you might perform in patients with cancer or cancer-related illnesses or secondary pathologies related to their treatment. So one of the common things we see in the clinic is adhesive capsulitis or frozen shoulder. So depending on the study, you see from 30 to 80% of patients who've had mastectomy related to breast cancer might develop loss in racial motion and possibly adhesive capsulitis. So one of the procedures we can perform are glenomoral joint injections and or hydrodilation. So I usually do a posterior approach, have the patient lay on their side with the affected arm facing up in lateral liquidus position. I look for the spine of the scapula, go a little bit down and lateral and find the joint as you can see it in the picture and go from lateral to medial in my injection approach. And it's a pretty steep approach. So sometimes you might not see the needle as sharply as you might while injecting other structures. Be mindful of trying to avoid the labrums. You know, you don't cause an injury to it. You can also perform this injections anteriorly through the rotator cuff interval or just following the insertion of the long head of the biceps into the glenomoral joint. What we usually do is posteriorly. If you're doing a hydrodilation, which has pretty decent literature behind it to treat adhesive capsulitis, I sometimes perform or usually perform a suprascapular nerve block since it's that covers part of the joint capsule and it makes the procedure less uncomfortable. The amount of volume varies a lot. Usually patients with adhesive capsulitis don't allow to the pressure, doesn't allow you to inject a large volume. So I've seen posts from some of my colleagues who've injected 20, 30, even 40 ccs. And I'm guessing the capsule might rupture a little bit, but sometimes people get great results from those injections. I usually inject from 15 to 20 ccs, might get to 20, but they usually do pretty well as well. So again, patients that have been treated with aromatase inhibitors might get medial nerve entrapment. And so corticosteroid injections for this element has been studied a lot in the past. And it helps decrease swelling in the tenosynovium. So it's the improvement in function and pain that has been documented. It may help determine if surgical release will succeed. Usually when you look at literature for carpal tunnel, it's better than for ulnar neuropathy at the elbow. So when you compare surgical release to injections, surgical release might be superior six to 12 months out, but it has a greater incidence of adverse events. So I usually discuss this with the patient and most of them prefer to go along first with the injection and if they get good results, then that's that. If they don't, then we can prefer them surgery and that's certainly an option. And most of them like the conservative approach first. Through the years I've been maybe increasing the amount of injectate I use with normal saline in the mix. And some people do use different mixes for this nerve blocks. I usually use a small amount of corticosteroid anesthetic. And if I'm doing a hydro dissection, I use normal saline. So I'm using a little bit more volume to perform the hydro dissection and get a better hydro dissection of the nerve from the surrounding structures. So again, using ultrasound guidance helps avoid injury to the adjacent areas. It helps you visualize as you're separating the soft tissue adhesions or obstructions of the nerve. So it allows you to perform these injections with efficacy and with safety. And this is the approach I usually use or what it's called an ulnar approach. So I line up the probe in short axis with the corresponding nerve. And then I put my needle in the in-plane view or long axis corresponding to the probe. And I usually first separate the nerve from the transverse carpal ligament squarely. And then from the different tendons below it. And the patient might get some paresthesias during or after the procedure. I usually tell them that's normal and that might happen for a few hours, but it should be back to normal within a few hours. Another useful procedure we might use for cancer patients, particularly those posts up or who have a posterior persistent lateral thoracic pain, it's a serratus plane block, which basically you identify the latissimus dorsi and go just below it to the serratus interior and inject it above and below the muscle to get a good nerve block. Usually you put the patient on a supine position and go into the mid axillary area, count to the fifth rib in the mid axillary line. And again, place the needle below the latissimus dorsi and above and below the serratus interior and put in there you're injecting and you usually get good lateral thoracic anesthesia. And that's particularly useful for post-op pain. And this is a example of the C or the third picture would show the approach for serratus interior injections. The other two are for pectoralis injections. Also another tool we might use are intercostal brachial nerve blocks. So Dr. Rosario talked about post-mostectomy pain syndrome. The prevalence of it might be fairly high. It might go up to 42% of patients who've been treated with surgical excision of axillary nodes. Those patients who do develop the symptoms might get those symptoms for a long time after the procedure. And the reason for that is that the nerve is the intercostal brachial nerve, it's in the surgical field when you're performing the axillary lymph node dissections. So it might be severed or injured or compressed during surgery. So injecting it might help relieve the symptoms. And usually patients have pain in the anterior thorax, the axilla and the upper arm. So this is the approach you might use to inject the nerve or around the nerve. So again, you put the patient in with the arm rotated externally and abducted 90 degrees and that you find, the easiest way I usually look for it is finding the axillary nerve and vein and just look for the particular honeycomb appearance you usually get with nerves and inject the nerve and its surrounding tissues to make sure you get a good hydrodissection of the nerve and good anesthesia around it. And finally, when talking about injections and there's more that we can discuss, but in the interest of time, I've focused on a few of them. Patients treated with aromatase inhibitors might get trigger fingers. And there's also a few approaches we can use to treat that. Again, this is in long axis view of the tendon, you can identify the A1 pulley and just enter the needle in an in-plane approach to inject in the sheath or just above the nerve and in the A1 pulley. You can also try short axis view of the tendon, but get an in-plane view of the needle to put in your injectate. Or also you can try a short axis view of the tendon and an off-plane view of the needle using a walk down technique and get your injectate in the sheath where you want it and within the A1 pulley to decrease the inflammation and or the pain and improve this patient's function. In terms of safety, there are a lot of studies looking at the safety of injections or procedures in patients previously treated for cancer. But there was a recently published study in the journal for ISPRM and where they looked at more than 500 injections performed on patients with either active or active cancer or previously treated for cancer. The most common injection or indication for injection was OA and most of the injections were performed on their ultrasound guidance. So the adverse effects were relatively low. Only four were procedure related. So they found that injections overall are fairly safe. One of the things that patients have been taught particularly when they get axillary and artery sections is to avoid anyone touching their arm because that might precipitate lymphedema. So when talking about with our colleagues in the cancer rehab field, they feel fairly comfortable in performing injections on those patients, particularly if they have a fairly long history of not developing lymphedema in that arm, good hygiene, et cetera. So you discuss this with the patient and if they feel comfortable, we proceed with the procedure. So finally, MSK ultrasound is another area in PMR where ultrasound is useful. I usually tell the residents that don't look at these procedures or fancy new tools as excluding the rehab we know, just a way to expand our practice and get better quality of life and get a better function for our patients. So you can use it both for diagnostics and for procedure guidance in a safe manner. And it's fairly easy to incorporate into our practices. So thank you for your time and hope you're enjoying this new version of APMR Annual Assembly.

Fighting Cancer with Fitness

Sports Medicine Approach

Cancer Rehabilitation

Quality of Life

Functionality

Musculoskeletal Problems

Physical Medicine and Rehabilitation

Exercise Benefits

Musculoskeletal Ultrasound

Ultrasound-guided Injections