Well, welcome everyone. So this is our monthly pediatric rehab medicine community AAPMNR lecture. This today is something of a combined approach because we also have a pediatric cancer rehab community. And so this is one of their first lecture series. I'm really excited to be getting more cancer education. I think it is very needed for pediatric cancer rehab. So we're very excited to have Dr. Chaviano today. So Dr. Chaviano is a Peds Rehab Medicine physician. She is currently at University of Alabama in Birmingham. She's board certified in PMNR, brain injury medicine and pediatric rehab medicine. She graduated residency from Michigan State University and fellowship from University of Texas Southwestern. She is the co-secretary of the AAPMNR Cancer Rehab Medicine Consortium and an active member of its subcommittee, Pediatric Cancer Rehab. She is the past chair of the education committee in the American Academy of CP and Developmental Medicine. She's a brain injury board exam content creator for the American Board of PMNR. She's the creator of I Can Rehab or Integrative Cancer Rehabilitation. I love that name. Program at both University of Texas Southwestern and University of Alabama at Birmingham. Her other clinical interests include osteopathic manipulative medicine, brain injury, mindfulness, education and graphic medicine. So we are really excited to hear her talk about cancer rehab today. Awesome. Thank you so much. I'm sorry. I didn't mean to give my own less exciting introduction. All right. Now the view that you see, do you see the correct view or do you see like the kind of weird presenter view? No, looks good. It looks good. Okay, great. Solid. All right, let's go ahead and get started. So cancer rehabilitation, integrating a rehabilitative approach across the continuum of oncological care. All right. My disclosure is we just recently got a KPRI grant and we'll go over a little bit of that in the future. So the big picture things, right, is we're going to define cancer rehabilitation, apply the Dietz model of cancer rehab care and kind of, again, learn how to build our own cancer rehab program. And mainly let's focus on cancer rehab. So what is it? So the way that I'm going to break this up is we'll talk about general concepts and then we'll go through the phases of cancer rehabilitation. So there's diagnosis, treatment, survivorship and end of life. So, you know, we're all peds rehab here. So we know that it's basically involving us a lot more into that oncological care continuum. And ICF model is one of my favorite things to always include because it gives us a really good approach and a really good model in how to fully integrate us and function into the oncological care. We know that we don't have enough research. We need more. There's some things that tell us that cancer rehab can be good and we just need more of it, right? And here's a couple of different studies that show those different things. So we also know that, you know, our oncological colleagues are getting much better at allowing our children to survive a lot more. And with that survivorship comes more impaired needs that we as rehab are actually set up great to do from a holistic standpoint. So what the really good news is is that really a lot of major cancer networks and committees and so on are starting to recognize the really the utility of cancer rehabilitation which I think is crucial in order to get our foot in the door. For those of you that aren't familiar, really one of the biggest founders for cancer rehabilitation is Dr. Dietz. And he thought of this approach of four phases for rehabilitation. We have preventative rehab, restorative rehab, supportive rehab, palliative rehab. We're familiar with this. So preventative meaning like we're preventing the, we're doing interventions to prevent the effect of disability or from treatment. More restorative, so we have a disrupted baseline and we're trying to restore to that baseline. Supportive is when we have a new functional baseline and we're supporting ongoing needs or, you know, obtaining those goals when we need to in those times. And then palliative rehabilitation. So one of my favorite, one of the, I think one of my favorite approaches and thoughts is the, this actually came out some time ago where a lot of oncologists were recognizing that we need to do a better job in that survivorship and end of life care mode when it comes to care planning and support and rehabilitation. And so my favorite, if we take away a few favorite things from this lecture today, this is probably one of my favorite slides and pictures. This comes from the Cancer Rehabilitation Textbook and it basically puts everything together including the DEETS model and then that model here in terms of the cancer care continuum and the way to think about it when you approach a patient. Review on functional metrics. I think this is important. I know we're all familiar with FIMS and WeFIMS but I think it's important to know that we, you know, this requires training. It requires direct observation which is a little different from some of these other functional measures and metrics that are used in oncological spaces. So they use a lot of ECOG, Karnofsky and Lansky. And so Lansky is essentially the child's version of Karnofsky and it's done for kids zero to 16 years old. And, you know, it's good. It's a good measure but there's a lot of rater bias in it. And the ECOG is a little vague, right? So it's zero to five, five being dead, kind of vague but I use this graph pretty much weekly whenever I'm doing my cancer rehab rounds and seeing kids outpatient. So that way we have a good dialogue between our oncological teams in terms of function, right? So let's see here. For example, let's look at ECOG three and Lansky 40. And why I bring that up is I've noticed that a lot. And again, this is purely something that I've noted in just my clinical experiences. When we have kiddos that are living around a Lansky 40, ECOG three, I start to think about inpatient rehab especially if they're in that kind of space for about 10 days or more if they're an appropriate candidate, right? So that to me tells me a little bit more about just prognosis. And again, this is no evidence-based. This is just something that I've noticed in my clinical experience. So here are some barriers when it comes to cancer rehabilitation. I think the biggest is the complexity of these cases and where is the patient? Where are they gonna get their therapies? Where do they live? How far away are they from a rehabilitation center or where they can get their rehab? And so trying to get the roadmap and you'll hear me say that a bunch today is really key and having a good dialogue with your oncology team in terms of what is the roadmap and then where are they getting the treatments and how long will they be admitted or not admitted? Or are they gonna go downstairs and get their infusions or what days are those gonna be? Those different things. Like I said, cancer rehab is new, right? But I would say over the past five, 10 years, I've seen it explode and it's been super fun to see all kinds of different papers coming out regarding function and why it's good. And I just think we're in a really wonderful time right now to see a lot of research happening. And as you know, right, we're unicorns, right? There's like 350 of us-ish, right? And fewer of us have interest in cancer rehabilitation. So I do think it's important during fellowship and at least when you're in attending to have some awareness of cancer rehabilitation because you will get these patients. And we know that we are important in that team in terms of their rehab and their function. And we know also just lack of insurance coverage for different equipment, orthotics, therapy sessions, things like that. So we just went over general concepts. Now let's go through each one of these. The first will be diagnosis. And within diagnosis, I'm gonna talk about how I introduce myself in terms of education to the families or even to our oncology colleagues, rehabilitation medicine considerations to think about and then therapy considerations. So basically when I go and see and introduce myself to a family, I introduce who we are because not a lot of people know who we are. Plus I think you have to understand and which I understand too, they're seeing a bazillion different providers and doctors and they may need to be reminded a few times of who we are and how we can help. And that is okay, right? And I tell them that it is okay. I may introduce therapy intensities when I go in just to give a review of what's expected. If there is something specific that I need to address in terms of education, I may begin that dialogue. So if they're spinal cord injury, I may talk about neurogenic bowel and bladder, for example, because they may be having issues by the time I see them. Or if there's brain injury that I'm already discussing maybe neuro fatigue or I'm talking about tone or sensory changes or things like that. And then big thing I'm also talking about is the importance of therapy participation. I have kind of an elevator spiel where I say something like, therapy is really important. It's even when you feel sick, try to do as much as you can. You can even do therapy in bed if you need to. Things to think about for neuro-oncology. Again, we're assessing our common functional changes. So motor recovery, neurogenic bowel, bladder, cognitive mood changes, things like that. We kind of put on our TBI hat a lot of the time, our brain injury hat, and then it makes us feel a lot more comfortable when we're approaching these patients. Of course, we're always going to determine function at baseline versus current. And then of course, like I said, we're chatting with oncology. Okay, what's going on? We just finished our debulking. Okay, now what? Are we waiting for tumor board? Are we going to do chemo first? How many weeks do I have? Where are we at in terms of our therapy, like our baseline function, things like that. MSK tumors are another one, right? So trying to introduce prosthetics orthotics, trying to figure out if an amputation has occurred, if there's limb sparing that's going to occur, talking about orthotics, about trajectory of weight bearing status, timing for prosthesis, type of prosthesis, right? Like sometimes we can do a preliminary bypass prosthesis. Again, talking about our roadmap, always important. And then also making sure we do as thorough as a physical exam when we first see them because there will be changes, right? And we want to make sure we're ahead during those times that they have a change from their baseline. So therapy considerations, right? So we're in that preventative, maybe restorative rehabilitation phase in terms of the DEETS model. You know, and prehabilitation is a really hot topic and I am a huge proponent of it when we can get it. I've noticed in my experience that it's really challenging to do prehab by the time I come around. And even, I know when I spent time in the adult setting, sometimes it had a little bit more time. Like if we had patients undergoing like, you know, possible diagnosis for breast cancer or something like that, sometimes we could do some prehab beforehand as they were waiting for a specific plan. But sometimes what I'm noticing is when I get consulted, they're already on their way to getting the treatment and intervention and things like that. So sometimes that barrier is that timing of diagnosis and me being able to do more in terms of prehab for them. Again, getting a roadmap is crucial and then also determining therapy best plan of care, right? So sometimes they're so acute and you're undergoing so many things that really a lower frequency is most appropriate. And then when they're ready, we can do a higher frequency and then look at things like other, you know, different programs that your hospital may offer, right? So in terms of programs or inpatient rehab. And then of course, participation may be low. So always looking at the possibility for more conservative treatments like child life or pet therapy or music, things like that. So we've talked about cancer diagnosis. Next phase is we're gonna talk about cancer treatment. We're gonna talk about rehab medicine considerations and therapy considerations. So I could give whole talks on almost each one of these specifically, but this is where we shine, right? So we think about what is it that they're going through in this journey that can impair their function, right? So I think a classic one is chemotherapy induced peripheral neuropathy, right? So we're always looking at what I'm doing is I'm looking through, you know, the MAR and I'm like, okay, what drugs are they using right now? What is their chemotherapy based thing right now? So, oh, this can cause this, this can cause that. Okay, so I need to talk about blank or I need to look for blank, right? So my favorite table, this is adapted from, there's both the Cancer Rehab Book and the Peds Cancer Rehab Book. I love this graph, like this is just like solid. I'm not gonna read every single one of these to you. Let's just focus on vincristine, for example. So basically this has been, I sort of modified this. So it's divided based on ICF, which is how it was kind of originally done. So we have impairment activities, limitations of participation restrictions as well as different things to just think about. So vincristine, venblastine, we know it can cause polyneuropathy, it can cause some autonomic issues, rectal emptying, paresthesias, distal weakness, right? We know then if it causes those body impairments that when we translate that to limitations, right? Like mobility, ADLs transfers, we can see gait abnormality or we can be, maybe we have impaired ADLs because of distal weakness or we can have maybe some impaired toileting, right? Things to also think about is venblastine isn't so bad that you can have, but it's fairly minimal, still things to look at. And then of course, what you notice is you can see improvements of symptoms with decreased dose or at the end of therapy. And it goes on, but I love these kinds of tables. It's really helpful and I think about this when I'm seeing patients and when I'm looking at what medicines they're getting. Again, a lot of the classic things that we have to think about, right? In terms of rehab. So namely, posterior fossa syndrome is something we always need to look at and think about trying to determine what their new deficits are in terms of weakness, spasticity, dystonia, dysesthesias and resource accessibility. Limb sparing, a lot of the similar things, right? So just early mobilization when we can, gait training. And for amputation rotational plasties, we have a higher risk for phantom limb pain, right? So we're talking about different medications, desensitization exercises. We're talking about reducing hip flexion contractures by doing range of motion, hip strengthening and then positioning education, right, so doing tummy time, things like that. Possibility for pre-prosthetic therapies, right? And focusing on glutamine max for hip strengthening and then transitioning to post-prosthesis therapies. When we're thinking about therapies, more in the preventative restorative model in this phase to Dietz model, again, like I said before, we are expecting impaired participation. So little tips and tricks for medication for pre-therapy. Sometimes we need that if we find that conservative management isn't helpful. I found that olanzapine is actually something I really like that everyone kind of tends to do the Ativan, it depends culturally on which hospital, but they do that a lot for anxiety and nausea. But I've liked olanzapine, it doesn't make them sleepy. And there are some centers that are kind of starting to use this a little bit more, but I try to encourage that when we can and everything kind of what we talked about before. Therapy precautions, right, some of this, again, it also depends on the oncological team that you're working with in hospital and kind of what they prefer. But like, I think the big one that I wanted to hone in on is with thrombocytopenia is that recent studies have found minimal association between bleeding events and intensity of therapies, because we have previously suggested accommodations that make them kind of reduced activity, but really we just modify it to their intensity that they need, but not because there's a risk for bleeding necessarily. So I found that to be fairly important. So we talked about active cancer treatment, now we're in survivorship phase. So like I've said, we've gotten really much better in terms of survivorship over time and children can tolerate acute effects of treatment better than adults, but they are at risk for late effects. So COG is a fantastic guide for follow-up care. I have it, it is like, I think it's like 200 pages or more. And what I'll do is, I mean, we have a wonderful and every center usually has some sort of follow-up cancer clinic, but if I'm seeing those or happen to see a kid that they haven't quite followed up there or they're waiting to go, then I'll go through, I'll kind of type in for the PDF and look up different things that I need to consider. And that way I know what I'm talking, I'm prepared when I talk to them about what their risks are. There's been some debate where should we be included in these survivorship clinics or should we be removed from these clinics? And I guess the thought is patients may have this thought where they don't want to be involved in the cancer clinics anymore and they want to just kind of move on and be just in the PM&R clinics. And I can see that, but I think just in terms of like having a better multidisciplinary approach, having better, basically show up rate also to these cancer clinics, I think it would be also something to think about, involving us in that multidisciplinary survivorship clinic, I think would be also a good model to consider and just depends on the culture of the hospital. You know, and this is where we shine, right? So then we kind of, we maintain our Peds Rehab Hats as we go through and we think about what their functional needs are following their acute treatment, right? And whether they need any equipment or orthotics, how their community participation is. You can also have, you know, for example, obesity risk. So for example, a chemotherapy induced cardiovascular compromise, right? So working on, you know, what strategies we need to improve on in terms of improving their endurance or things like that. Again, talking about, you know, what their perceived, like impaired, if we have impaired cosmesis or impaired quality of life or pain, or do we have, we're at higher risk for increased energy expenditure. We're also at higher risk if we have amputation of spiking, contractures, and then any prosthetics that are needed. GDHD is something that I follow up on. I, as a DO, I've noticed, I was reading in some of the cancer rehab books and I noticed that there's contract relax, contract techniques are something that can be utilized in this population to improve contractures, which in like DO world is basically muscle energy techniques. And so, and you kind of find that DO, like when you kind of look at DO world and like massage techniques and therapies, everyone is kind of using different terms but they're actually doing the same thing. And I noticed that contract relax, contract techniques are something that's been utilized in a more evidence-based way regarding graft versus host disease. So I've actually had a series of patients where I've improved their outcomes pre and post. They do something called, oncology teams use P-ROM scale a lot to determine the level of contracture that is within certain joints. And I've noticed, at least in my, again, clinical experience, I've had improvements pre and post. So I think that's something as DOs, that's an extra technique that you could utilize and incorporate in your clinic. And the K levels for those of you that want that reminder. Again, DEET's model in this point is very impairment driven in terms of the particular model that we use for rehabilitation. So really assessing goal, like they don't need to be in therapy forever, but right, just assessing like, hey, what do you need right now? What are your goals? And doing little bits of outpatient therapy when they need it. End of life. I love, love working with our palliative care teams. I think if I was like, wanted to do another fellowship, I was like, oh no, I gotta, I gotta go out and work. But I love palliative care. And I always work very closely with these teams and help and assist and kind of, we kind of tag team and address different skills and supportive efforts that we're doing together. I am one of those that are, I'm a huge proponent of having palliative care involved even much earlier than necessarily just end of life care, as you know, right? So again, we're very goal-driven. We share a lot of care conferences as well. And then we work together in terms of, if we are transitioning to hospice, what equipment is needed or not needed, or what, you know, what kinds of medicines are needed at this time, or what can I help out with? But again, just like having that communication with them and talking with families about goals are, is really just a, it's a really beautiful collaboration to have. Okay. So hopefully I've excited you about, hey, maybe I should build a cancer rehab program. So this next bit of the talk is to actually talk about, how can I build a cancer rehab program? So first I'm gonna talk about what's out there. So Sprint by our very own Dr. Elaine Zhao over at Seattle Children's is a fantastic program. That's a very two week intensity based program for cancer rehab patients, where it's about two to three hours a day. It's basically, you know, in our world, like a very pre-IPR, right? And they used the PD to evaluate improvements. So that's one fantastic program that exists. The next, which came out fairly recently from Dr. Tanner, which another person I absolutely love is CREATE, which is basically how they built an integrated therapy based programs. It's wonderful. I highly recommend looking at this paper. I loved all their different facets of how they incorporated different things and what they did specifically in their culture and in that hospital. And it was, it's a wonderful framework. And they talked about how they utilize the Stoplight Program specifically, and they're starting to use the Stoplight Program for other disciplines. So for those not familiar with the Stoplight Program, this is what it looks like. It's a busy slide, but let's look at the very top. And you look at activity level, performance scale. Aha, we know what performance scale is now, right? Cause we talked about land skis and that's how they utilize that. They determine where they are functionally, what they do with them and what that frequency looks like thereafter. So if you look all the way down, you see, oh, their land ski is like maybe equal to or less than 60. We need to see them a little bit more frequently all the way up to, you know, green light. Our land ski is a hundred. We are a-okay. Let's just do reassessments as we need to. There's a bone marrow transplant program over in Cincy. And then I was just told recently and learned about the SPARK Program over in Colorado, which is fantastic. It's a sprint-like program that I'm learning a little bit more about and that I've been learning a little bit more about. So Specialized Accelerated Rehabilitation in the Center for Cancer and Blood Disorders. So creating a program, right? So after you read that wonderful paper by Dr. Tanner, different thoughts that I've learned and then different frameworks that I've noted. And again, there's a really good chapter for this in the Cancer Rehab Textbook that I'm gonna go through now that helps you create that framework for creating the program. So first, we talk about defining a clinical landscape. So that means that, you know, we know that we're unicorns, right? And we're even more special rainbow unicorns because if you're really into cancer rehab and this is something that you want to do, right? So the big thing is try to figure out when you get there, do people know exactly what we do? How integrated are we already? What's the relationship between therapies and PM&R and oncology? How open is that system, you know, to change and incorporation of rehabilitation? And, you know, I say, what is the rehab roadmap, right? So like, where do these kids go right now? Like, where's that flow typically? Are there programs that exist already? Are there protocols? Are there guidelines? Or do they just get kind of funneled and we're not really sure where exactly they go? So a lot of us are gonna be at academic institutions and some of us are gonna be in community, right? So these are different stipulations to think about when you're looking at the greater picture, right? You're academic, it's a little bit larger, we're drawing from more, you know, from a lot more areas in the country versus a community may be smaller when maybe we're doing more of the community. Academic, we may have disease specific oncologists where in the community we may have oncologists that are wearing multiple hats, for example, right? So next, I also recommend exploring clinical opportunities and the way to think about it, or at least I think about is, okay, outpatient, inpatient, tumor boards, what therapy services exist, what research opportunities exist, right? So in outpatient clinics, are they multidisciplinary? Is therapy there? Is PM&R already there? If not, are they cool with us going in there? Do we as division or department have the bandwidth for one of us to go there and see if that's something that we're open to? Or maybe inpatient, like, do we have the bandwidth or readiness to do an oncology specific rehab consult service, right? And then kind of determining inpatient rehab and how it is right now and where the oncologist kids go right now. Like, do they mostly go inpatient? Are they too complex? Is, you know, what floor do they stay on? Do they stay on the on floor? Are they co-managed? Understanding the culture that exists at your current institution. You can look at tumor boards, right? Is rehab there? Are we not there? Rehab services, right? So like I kind of talked about before, like, what do we have there? Like, do we have, what kind of equipment? Do we have any therapists that are specialized in anything particular undergoing cancer or neuro-onc or lymphedema or pain or things like that? And then what are the research opportunities that exist within oncology? Are they open to assessing, you know, outcomes or functional metrics or things like that? That's how to kind of look at and think about defining clinical landscape. Next is identifying champions and then networking opportunities. And so this is a list of potential champions that you can reach out to, tell them what you're thinking of, tell them a program that we're thinking of creating and then kind of assess their goals. Like, hey, I would like to incorporate more rehabilitation in their care. What are you looking for to make a service that's more integrated and multidisciplinary? So the way that I've learned this is, again, making sure that your leadership is fully aware and supportive of this endeavor, always letting people know what the outline of your program looks like. And also when we need to, like being open and then letting providers know, do you know exactly what we do? It's okay if you don't. Not a lot of people know what we do. And just being open to having that same elevator spiel ready for you, sharing your goals. And then, yeah, a lot of this stuff kind of makes sense. Like, spread your network, let your champions know, hey, is there anyone else that you would also recognize that would love to be a part of our team? And, oh, that's your goals? Well, I can add that to my program goal. That's great. And again, like I said, creating that goal setting and implementing the program. So I have found that probably the quickest way to kind of gather patients is acute consults and inpatient rehab follow-ups. And then they'll eventually trickle into your outpatient clinics. And then trying to figure out, what is your referral system going to look like? You can consider being present at some of the tumor boards a few times, or most of the time, or kind of whatever your bandwidth allows. Like I said, come up with that elevator spiel about who you are and how we can be helpful. Increasing FaceTime as much as possible, right? So going out to dinner or hanging out with the oncology teams or whatever. And then I also created a PM&R referral sheet, so that way they know, here's when to refer PM&R, for example. So it is going to happen where your patients will be lost to follow-up, right? And I love this paper. I love Dr. Chevelle. But here are some of the five things that she had found. So a lot of the themes that we're going to expect when we're program building and when we see a lot of these patients is the patients are too busy. Rehab is not necessary. They're waiting for some process to reach completion before they start rehab. That rehab is not beneficial and participation will be burdensome, right? So like having that awareness is key when building your program. I learned that I was trying to kind of simplify and categorize as much as possible, but I found I was being a little too rigid and I had to kind of be a little bit more flexible. Communication and coordination is key. And then there's so much opportunity for research that I highly recommend getting involved in, even if it's a, hey, you're doing this, are you doing this paper on outcomes for X tumor? Like, how about I add some WFIMs to that? Or how about I have, how about I help you with having a short paragraph on something with this paper to add a little bit more, right? So that's just, you know, being open to that multidisciplinary collaboration. You can determine or figure out like how helpful it is to have a rehab specific tumor boards, right? So that's something that I utilized at UT Southwestern and the therapists there, they enjoyed it. They appreciated to have, it was weekly and then it became every two weeks where it was essentially therapists that were on their cancer rotation would check in and talk about, hey, this is something that's going on with this patient. Hey, can you help out from this standpoint or things like that? Kind of figuring out, you know, in terms of your consult service, is it separate from the one that you have? Is it gonna be just you? Is it gonna be kind of a shared thing? How often will you be on your cancer rehab service? And then of course, using your unique skill sets to define your program, right? So like I talked a little bit about OMN and I also do a lot of meditation, mindfulness, things like that. And just, you know, remaining flexible as the program continues to grow and build and you get more people excited to kind of join in and help build it. And of course, obviously you gotta, you know, have fun and be proud of all the hard work that you've put in. So I'll be very, very brief with this. I just wanted to let you know what I have and what I've been creating. I created it at UT Southwestern initially and I have it here at University of Alabama at Birmingham, just so you have an example of what something could look like, okay? So like I've said, mine is called I Can Rehab. It's an integrated cancer rehabilitation program. It's essentially what I've just talked about. It's that clinical infrastructure after I went through all this particular guidelines to try to incorporate cancer rehab and rehab services more into the oncological spaces, right? So these are examples of what we just went over in terms of what a clinical landscape looks like, at least at University of Alabama at Birmingham, right? It's going to be different for whatever hospital setting that you're at. So I'll show you or share a couple of things, right? So we are a major academic institution, right? We're one of the few in the Southeast, for example, that you can go to, right? We have an after cancer experience clinic, for example, actually for the clinic, we have, or for a survivorship, we have inpatient rehab located on site, right? So that's really helpful. So it's just these different things that you're like, okay, here's what we have, and that'll be something to be able to build for yourself as well. Here are our tumor boards that we have at UAB. Here's some of our rehabilitation services and equipment that we have that can be utilized for our cancer oncology patient services. And again, like understanding what research is available, right, and what you can be a part of. And so these are some of the examples that I'm doing right now. So I'm very lucky. I have, we are working with the Oculus and a lot of the BMT populations. So essentially when the patients are admitted to BMT, they're given an Oculus and an exercise regimen, and then we follow their course and until they discharge, and then we continue with coaching and we continue to increase their exercise and gaming experience, and we're trying to see if this helps improve outcomes. Here's examples again of identifying champions and networking, right? So here are the champions that I've recognized and they're part of the program, and here are other goals that we're looking into in terms of cancer rehab care. So for example, the therapists, like one big thing that we're working on right now, we're working on creating a Sprint-like, Spark-like program for our cancer rehab kits. So that's kind of like a big fun project that I'm excited to work on right now. So this is an example of what it looks like in terms of when to consult Peds Rehab Medicine. But I guess the big takeaways here is, you know, oncology is, I mean, it is one of my passions. It is something that's so complex and something that is so crucial that we are a part of this process to help improve functional outcomes and quality of care in this population. And it's a new emerging field, but I highly, like, join us! Like, you can create a cancer rehab program. It is fun. You get to have a lot more collaboration and dialogue, and you feel like you're making a big difference with this patient population. If y'all have any questions, if y'all are excited to start your own cancer rehab program, if you want copies of this PowerPoint, if you want the copy of my referral sheet, I'm happy to give that to you. You know, and please also join us in AAPMNR. We have a fun subcommittee of Peds Cancer Rehab folks where we all get together and just chat about, you know, case studies, or we talk about what's going on in their facility. We help each other out. Like, it's just this really fun, lovely collaborative group that I highly recommend that you guys join up with us. So, I'm gonna stop sharing. All right. Thank y'all again for coming. Please tell me questions that y'all have, or thoughts, or concerns, jokes. Thank you so much. That was great. It seemed like you got a lot of enthusiastic responses about olanzapine. I was wondering if you could just talk more about when you consider starting it, what you look for. Yes, that's a great question. So, when I see that we have a lot more Ativan than I like, if we're a little sleepier than I like, we're not tolerating therapies very well, we're anxious, we have a lot of emesis or nausea, and we're already undergoing a lot of issues from that standpoint, then I'll say, I'll go to the oncology team and I say, hey, is there any way you're open to reducing the Ativan and adding olanzapine instead? And we can do it pre-therapy in the morning. Sometimes what I do for these kids when they're super anxious is I ask our therapy teams and Child Life to come up with a nice schedule. We have it up in the room and we have that. So, something that they can depend on and reduces their anxiety. And we do like 30, 45 minutes pre, then I'll do a little small dose of olanzapine. And it does work. It is very helpful. Ooh, yes, Dr. Skolsky. Yes, radiation-induced nausea as well. It does. Thank you. Any other questions? That was awesome, Kelly. Thank you. Thank you, Raji. Yes, agree, Dr. Lynch. It is very useful in TBI. But yeah, I'm also open to learning. So, if you guys have any thing you wanna share or I'm always open to any other thoughts that people have, but please join us over in our subcommittee, really. It's a really fun group if you're interested. Okay, so some thank yous coming in. Just waiting to see if anybody else has any other questions. I think one thing is how different it can be when you have, I think in cancer rehab in particular really highlights where things can be different between having a standalone rehab and being able to do it in-house. I have the latter and it definitely can bring some challenges with, of course, if we're getting radiation or just when the treatment plan, we just don't know what it is. So, it's kind of interesting to hear how different places approach that. Sorry, I know I cut somebody else off too. I think Vera. Yeah. Oh, I started typing my question, but yeah, this is Yara Tatlana and I will be starting at Worcester Medical in just a week actually. And super excited to start there. And speaking of that, I was actually curious, how did you go initially at UT Southwestern? How did you go about kind of introducing the idea of the program to them? Did you say, hey, people do this, like people do things like this at Seattle and people do things like this at Harvard or like how did you let them choose or did you come up with something that you wanted and then you kind of pushed for that specific thing? Yeah, a little bit of all of that to be honest, right? So, I came to them, told them, here's the program I'm starting, here are my thoughts, here's some evidence behind that, what are you looking at? Here's my goals, what are your goals? So, that's kind of how I approached it. I hope that kind of answers your question. I think I just did all of the above. Yeah, it makes sense, yeah. Okay, and then you kind of came up with what would make everyone happy. Yes, yes, like at UT Southwestern, they were focused a little bit more on like world health reports and that scale. So, I was like, okay, and there's I guess some sort of rehab section in there. So, I said, okay, like I'm happy to help out with that. So, that's like one example. And I would say here for oncology, their big focus is just like my availability. Like, yay, you exist, we're gonna start sending you patients. That sounds great, that's lovely. So, I think just like communicating and being open. I'm really lucky here at UAB. I've got a lot of like really cool oncologists that I even hang out with them like after work and they're just like lovely people. I know one challenge can be in a lot of places, like at academic centers where there's a lot of silos and it's hard to break down that barrier. So, I think just showing up and going to touchdown spaces I found to be the most helpful. So, it's like, hey, like I'm here. And hey, how are you doing? And kind of having that small talk and kind of like getting their attention a little bit more. So, there's like, oh, right, the rehab doc just came by. Let's go ahead and talk to her about a thing. I don't even wanna say like, and I'll do this now. Like I'll go to the touchdown space, I give my recs and then we chat a little bit and I say, anyone else you need help with? And then they'll be like, actually, you know what? I've got two consults for you. You're like, thank you so much. Like, so, like that's the tricky part though, right? Is breaking down the barriers. So, give yourself some space and some self-love and recognize that it's hard, but just it will happen for you. It will happen. Thank you. This was wonderful. And thanks for the talk. Of course, yeah. Okay. Just more thank yous and how fantastic this was. Thank you all for all of your lovely positivity. I'm very grateful. All right, well, we can wrap up. Thank you so much, everybody. Have a great week. Awesome. Take care, dudes. Have a good one.

pediatric cancer rehabilitation

oncological care

DEETS model

prehabilitation

early intervention

rehab program development

palliative care

cancer rehab strategies