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Too Fragile for Rehab? Prehabilitation and Rehabil ...
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So thank you all for coming to our session today. Before we get started, there's some announcements that I have to read, and I'll try to go through them as quickly as possible. And I tend to talk fast anyway. So welcome to our presentation today. Please remember to silence your cell phones. This is being live audio recorded. We want to minimize as many distractions as possible. There's evaluation forms to complete for each individual session as a help with future planning. Session evaluations are located in the mobile app, online platform, and online learning portal. And please remember to visit the PM&R Pavilion. There's lots of interactive resources, education, fun. There's lots of hands-on education, educational theaters, anatomy and learning lab, career center sessions, and it's free. So please take advantage. Okay. And can we advance? Perfect, thank you. Okay. Okay. So thank you for coming, as I had mentioned before. So today we're gonna talk about five different programs spread across the country that have really involved the hematologic cancer population for those who are undergoing BMT, bone marrow transplant. And here I've listed the faculty, myself included, but we have a whole host of different faculty up here from different institutions, which will hopefully inspire you to take this knowledge home, bring it to your home institutions, and start work on collaboration. So overall session learning objectives, we're going to describe prehabilitation interventions for these patients that are done at different U.S. institutions. We are going to review the potential for comprehensive prehab to improve outcomes, and also identify different pearls and pitfalls that we've learned throughout the experience for this unique patient population. So to start with, I'm from UNC, and while there I'm the Director of Cancer Rehab, I have no disclosures, and here are my objectives. So I'm briefly going to go over some demographics of this patient population who do undergo bone marrow transplant. I am gonna review some prior literature about prehab interventions that have been done in this population, and I'm gonna review the initiative that I worked on with lots of different people at UNC, and how it got started, and some preliminary outcomes that are hot off the press from my statistician earlier this week. So why focus on this population? Well, you're all here, obviously you've drank the Kool-Aid of cancer rehab. We are a growing specialty, and as a result of the work of our colleagues, we have increasing patients to take care of. So even if you do not subspecialize in cancer rehab, whether you're in sports or pain, at some point, statistically, you're gonna come across and treat a handful of cancer patients. And in the United States, there's approximately 22,000 bone marrow transplants, or stem cell transplants, that are done each year. But even prior to undergoing bone marrow transplant, many patients have low levels of fitness and functional status. When they go through their conditioning chemotherapy process, a lot of agents that they are given can reduce cardiopulmonary function, patients don't feel good, they don't wanna eat, they become sarcopenic, they're not exercising, and then you're introducing a transplant into them, which makes them feel even worse. And deconditioning, not surprisingly, before the transplant is even done, is associated with a poor prognosis, it's associated with increased mortality, worsening symptoms, and worsening quality of life. And as rehab physicians, these are paramount and close to our hearts, I would hope, and ways that we can really help intervene. So why prehab for bone marrow transplant? There's been some studies, hopefully more in the coming years in this particular patient population, when to address and engage patients in getting stronger before they undergo transplant. Should it be done before conditioning? Should it be done in the interim, during conditioning, before transplant, at the time of transplant, and even after? And not surprisingly, as in other cancer populations as well, exercising before, during, and after transplant improves survival, which for oncology colleagues is sort of an elevator pitch as to why we should be engaged in this patient population from the very beginning. There have also been other studies that have demonstrated multimodal supportive care, so not just rehab, but getting nutrition involved, getting mental health support involved, et cetera, is feasible, and it helps improve patient outcomes. And so, as I mentioned here, physical activity during admission for bone marrow transplant, and some of these patients are admitted, and the next day after their conditioning, after admission, they get their bone marrow transplant. Sometimes they have to be in the hospital a week before they're ready and undergo transplant. Definitely improves fitness and reduces deconditioning. This has been studied using the six-minute walk test sort of as the gold standard, so to speak, but other strengthening tests as well. So what about prehab? So as I mentioned before, induction chemotherapy and bone marrow transplant together without any intervention causes reduced functional status. Post-transplant patients don't feel good. They don't wanna get out of bed. They're tired. Maybe they had steroids as part of their regimen, so there may be an element of steroid myopathy in there, and they overall have reduced fitness despite how strong they were beforehand, and deconditioning, as I mentioned before, and I want to repeat, is associated with poor prognosis. I've listed here some of the major studies that have been done for your reference if you wanna go and read and see the methodology that colleagues in rehab, but also in the hematologic world have done in this particular domain. So what about prehab? So hopefully some of you have a general understanding if you don't already do prehab in your practice, but sort of my elevator pitch to the oncologists that I work with, you know, it's always good to have an elevator pitch because you work with them in clinic, you see them, et cetera, but why should we be involved? Why should we see these patients before they start chemo, before they have a transplant, instead of being called in, you know, the fourth quarter? It's important to obtain a baseline functional status, know what their premorbid conditions are, you know, if they have a certain type of chemotherapy that causes reduced heart function, reduced lung function, it's important to know that. Beforehand, if they have a history of hypertension, if they have a history of COPD, et cetera, you wanna get them as strong as they can before they start treatment. Ideally, doing so, getting them stronger, getting them in a better overall health status will reduce morbidity and mortality and potentially increase treatment options for patients. Now, our oncology colleagues tend to use the ECOG and KPS to gauge whether patients are eligible for certain treatments. So if we come in early on and we say, hey, you know, I can get your patients stronger where they have better scores and potentially open up treatment options or keep them on treatment longer without dose reductions, then the oncology side of things tend to say, okay, well, that's great, I'm gonna send all my patients to you. And the goal from a rehab perspective is obviously to get them back to their highest level of function as soon as possible. So when I chat with patients and also my oncology colleagues about prehab, I tend to go through a SNAP acronym, if you will. So one is getting them to stop smoking, which in North Carolina, a lot of people do still smoke, talk to them about nutrition, specifically protein, and health literacy about what protein is and how to incorporate it in your diet without eating cheeseburgers every single day is sometimes a good introduction and sometimes people don't wanna go see a nutritionist. So I have to give them really big bullet points to try to stick to and engage every day. Reducing alcohol intake and then also reducing potato or sedentary behaviors as well. And like I said, I don't wanna address any competing medical factors at this prehab visit. So is someone on too many drugs? Are there other preexisting cognitive, physical impairments, et cetera? Are they frail? Which I know prior lectures during this conference have addressed frailty as well, but this is a good point to screen them too. So here is a pictorial that I like to use in almost all of my lectures on prehab. It was done by Frank O'Carly a number of years ago, who's a colorectal surgeon who has published extensively on the benefits of prehab. And what you can see here in the bold line is the bold line is the general trajectory of patients who undergo any stressor. In this case, they're gonna be undergoing surgery, but you can replicate this in the transplant population as well. Where they come in, baseline functional status because they're sick, they may have had other comorbidities, et cetera. We know they're gonna undergo a functional decline, which using temporary numbers, you can say, oh, maybe it's 10%, maybe it's 25%, et cetera. And it's gonna take a while to get back to that original functional state. The dotted line is the idea of prehab, where you say, okay, here they come in at a functional state, we have X amount of time before they undergo the stressor, in this case, transplant. Let's get them as strong as we can. Maybe it's an improvement of 5%, 10%, et cetera, knowing they're still gonna undergo that decline of 10%, 25%, whatever the number is. But ultimately, you get them back to their prior level of function sooner with less complications, and then potentially increasing their overall health status as time goes on. So what about, what have I done at my institution? So I've been at UNC now over two years. And when I got there and started the cancer rehab program there, I said, okay, from a research standpoint, quality improvement standpoint, what are some low-hanging fruit? And the BMT clinicians that are there are very engaged and want their patients to improve as much as possible. So they welcome me with open arms. And chatting with the therapists on the inpatient side, they said, you know, one of our main struggles is when we start our cancer rehab meetings is we get called so late in these patients' trajectories, and then it's like, okay, we want them to get better in like three days. And they've been hospitalized, they had a transplant, maybe they had pneumonia, UTI, et cetera, you know, multiple hits to the system. And then therapy gets called in, and they're like, okay, wave your magic wand, do whatever you want, and let's get them home or let's get them to rehab. And so after lots of discussion between the therapists, myself, the he-monks, we said, what's an easy way that we can get early PT, OT engaged for all of these patients? And so in the fall of 2022, PT and OT consults got added to the admission order set in Epic for all patients who were admitted for a bone marrow transplant. And so my research question from this was, one, I wanted to prove, and I wanted to investigate for myself, is this helpful, is this not helpful? Does it reduce length of stay, which obviously from the administrator C-suite level, you know, that's money, and, you know, improve patient outcomes, et cetera. Does it reduce readmissions? And does it reduce 90-day mortality? So as mentioned before, these are the next slide. Please do not disseminate as I have to go back to my statistician and go through this more. But here's some early results that we have had. So from the 2021 to 2022, we used that as the control where, because these patients generally did not have PT and OT admission orders, so that was our control. And then the intervention we looked at and said, you know, from the time of PT and OT consults being added, did they have differences in these areas? So overall for the three-year time span, the average age was in the mid-50s. There were slightly more males than females. Overall totals in terms of both auto and allo transplants, I've listed here. So they were pretty much standard between 134 to 150 through the different years. You can see that there were a lot more auto versus allo transplants. And the top three diagnoses I've listed here, multiple myeloma, AML, and Hodgkin's lymphoma. So breaking this down, you know, I categorize them as those who received a consult and those who did not receive a consult. And you can see there was a pretty even split. And length of stay, surprisingly, did not really differ. Neither did readmissions, neither did 90-day readmissions, 30-day, 90-day, or mortality rate. So I was a little bit surprised at this, I'm gonna be totally honest, when I was going through the data that my statistician sent me earlier this week, and I chatted with her, and she said, you know what, why don't we look at this a little bit more? So my plan with this data set that I have of 400 plus patients is to now go back, I have to submit an IRB amendment, of course, but I'm gonna go back and say, okay, I know that there was a good, decent amount of patients in the 2022 cohort, what about the 2021 cohort? Did anyone, you know, get any additional PTOT consults that were just not part of the standardization? Does that change the numbers any differently? Additionally, we have the complications, but we didn't have time to analyze that data yet. So we're gonna look and see, does the consult itself matter in terms of predicting complications as well? And I think it's important, negative studies are always important in my mind, but it's important to say, okay, maybe, you know, my institution, this wasn't the best study, but it was a project that people bought into and are interested in, and it's important to continue to look for ways to support this at-risk population. Additionally, engaging in pre-hab interventions and research is important to figure out what works, and it's important to collaborate clinically with your colleagues across the table to help improve patient care overall. So with that, I'm gonna transition to our second of five speakers, and we'll take questions at the end. Thank you. Thank you, Sasha. Good morning. These lights are very bright. Could we turn them down a bit, please? Is it possible? Oh, okay. All right. Good morning. Welcome, everyone. I'm Anne Ngohong. I am one of our cancer rehab physicians at MD Anderson Cancer Center in Houston, Texas. And so my topic this morning is building a prehabilitation program for older adults undergoing cellular therapy, older adult cellular therapy recipients. And I have no conflicts to, no financial conflicts to disclose. So in 13 minutes, I'm going to quickly talk about reviewing the trends of stem cell transplant, why we developed our program, talk about our multidisciplinary enhanced recovery stem cell transplant program, and review some of our program metrics and outcomes. And so background data, why we started this program. We had actually started a surgical prehab program many years ago. Our transplant doctors, who weren't really our greatest referral in terms of in clinic, became suddenly interested because of some of this background data here. So showing the growth in terms of older adults receiving allogeneic transplant. And finally, we had data showing that our transplant patients in terms of 65 and older were also growing. And these patients are very vulnerable in terms of for complications. And then they broke down the patients based on age. Age matters. And 65 and older matters in terms of worse outcomes, worse survival, worse non-relapsed mortality, and worse relapse in terms of 65 and older. So we chose this age group. So our transplant doctors came to us. And what makes these patients more vulnerable? So what Dr. Knowlton mentioned, sarcopenia or older patients are at risk for muscle loss, worse muscle quality as they age. They're at risk for frailty in terms of the syndrome of weakness, fatigue, low nutritional status, sedentary. And all these concepts overlap. And these patients develop physical function impairment, which is what we can specialize in in terms of helping these patients. And so we got together with our transplant docs. And over it took probably a year of meetings with all the different disciplines deciding what was essential to help patients get through prehab. And so similar graph here in terms of we want to be able to optimize patient's physical function. And we've seen this. So some of our patients coming through prehab will increase and improve their functional status. They'll experience that decline that we come to expect. But when they recover, it's a lot, hopefully, easier. And some of our patients recover to even a greater functional level than when they started out. And so our transplant doctors came to us and they said, this is the process. This is the complicated process. And what can we do to optimize this process, make it streamlined so we can help improve patient outcomes? And so we started early. We asked our transplant doctors, please send patients early, at least three weeks in advance. And so they created order sets from outpatients. So this is all outpatient in terms of referrals to PM&R, PT, OT, dietician, clinical pharmacists, geriatricians to get patients seen earlier. And then the routine in terms of order set includes PT, OT, nutrition for all of our patients admitted. And then we see them again post-transplant. And I'll go over this in a little bit more detail. But these are the committed parties that are involved in our Enhanced Recovery Stem Cell Transplant Program in terms of PT, OT, PM&R. Our geriatricians have played a very active role in this. And then nutritional optimization, we presented a poster about this two days ago in terms of the importance of nutrition optimization for this patient population. So our dieticians have been seeing patients earlier. When we started this program, we eliminated the no fresh fruits and vegetable diet. And also they're seeing patients inpatient more regularly, optimizing nutrition, starting tube feeds if needed if they develop mycositis, GVHD during their hospitalization. And then the clinical pharmacy part is also very essential. So I sit in this multidisciplinary clinic every other Friday. And our pharmacists are essential in terms of trying to minimize opiate use, trying to decrease use of benzodiazepines in our patients. And then our nurses play a real important supportive role in the hospital in terms of screening for delirium. We are documenting fall risks, of course, interventions to minimize falls. And then on some of the floors, they're using the six-click AMPAC and looking at the change in the scores to trigger having PT, OT come in sooner. And so when we developed the program early on, we decided what are we going to measure. So some of these are the measures that we're looking at in terms of quality of life, physical function, survival metrics, which I'll go over in a few minutes here, and then in terms of length of stay. And these are really important metrics to look at and decide up front, like what do we want to improve and optimize in our intervention here. And so this looks a little complicated, but this is what we as a group, I think, should try to see in terms of resources, what we have at our institutions, and what we could potentially put together in terms of a comprehensive prehab program. So our program, so I put cellular therapy on here because we are seeing patients receiving CAR T-cell therapy also, in addition to our allogeneic transplant patients. And so they get referred directly to PM&R. Sometimes they're seen in our clinic, or sometimes we're seen in this multidisciplinary enhanced recovery clinic. We're very fortunate to have physical therapists working alongside with us in the clinic. But when they see the physiatrist, they receive the comprehensive PM&R consultation. Sometimes, if the counts are okay, we might do trigger point injections. If they're having pain, if they have knee pain, they're unable to ambulate and get physically ready for their transplant. We have bio impedance scale in the clinic also, or measuring in terms of optimizing body composition, whether a patient's overweight or underweight. And we work, of course, alongside with our other colleagues in OT, PT, dietician, and in our transplant docs. So I think being in the multidisciplinary clinic is important, and it's actually been really good to be able to bounce off ideas with the transplant clinicians as we go. And so pretty much, we'd see them outpatient, and then they're seen inpatient. They receive PT, OT again, and then we see them outpatient. And so when they're seen in our clinic, we pretty much follow the older ACSM guidelines in terms of moderate intensity aerobic exercise, 30 minutes, five days a week, because we really want to try to push our patients if we can. And also, the two times a week resistance training. We give them resistance tubes, resistance bands, if they're able to do it, if their counts aren't too low in terms of platelet counts. So here are some outcomes. So we took a step back after the first couple years, and we wanted to look at what were the outcomes. So in this particular study that we published, we looked at a cohort of patients who had received our ERCT program, so 67 patients who underwent the ERCT program in the first year of our program, and then historical controls that we, who had not received this comprehensive prehab program. And so again, these are, back to the original slides, these are older adults. We are trying to see patients who are the most vulnerable, the most medically complex, 65 and older, receiving allogeneic stem cell transplants. And so we found improved outcomes, improved nonrelapsed mortality, and improved overall survival by 21%. So this was shocking to us, that we were able to improve these metrics. We went back because we asked, were there any changes during this period when we started the ERCT program? And there were. The oncologist did change the conditioning regimen, and they did change some of the GVHD treatments. So we thought, well, maybe it was that. But when the statistician went through and controlled for these other variables in our multivariate analysis, we still had improved outcomes in terms of patients who received in this enhanced recovery stem cell transplant program had improved overall survival and nonrelapsed mortality. So this is really exciting. And so this next part, and this is still, we're still reviewing this. I actually have a set of data that we sent. This is the first analysis, and I have a second analysis with the statistician right now. So we went back and we said, okay, well, let's look at the patients with their baseline physical function. Our physiotherapists measure a whole cohort of, a whole set of functional tests there. And we wanted to know in this, in this research question, does someone's baseline physical function impact their oncology metrics in terms of their overall survival, nonrelapsed mortality, grade three to five transplant toxicities, length of stay, ICU stay. So that's the research question we're studying right now. And so we conduct, we've been conducting a retrospective analysis of 331 patients who presented to us for prehab. 39% of these patients were female, median age. Again, these are our older adults, highly vulnerable, potentially very, potentially frail patients. 69-year-old patients, 69 is the median age. These patients in terms of medical complexity scores, and these are, these are measured by our transplant doctors in terms of score three or greater, 58%, which is a moderate level of medical complexity. And then their DRAI, which is their disease-related index, which again looks at their complexity of the, in terms of their oncology diagnosis, was high or very high in 25% of these patients. So we split them up into patients who had transplant and no transplant. And so there was a clear difference, as expected, in terms of the patients who underwent transplant had lower physical function measures across the board, and it was all significant. The reason that these patients, the ones who didn't have transplant, so we, we would ask like, were they too weak, were they frail, were, and, and it's a mix. Some of them, their, their leukemia was refractory, they just couldn't get enough patients ready enough in terms of optimized with their chemotherapy to be ready for transplant. Some of them, some of them did have poor performance. They were not prehabable, not rehabable. There was very low level functionally, so we weren't able to improve them significantly enough in that window of time before transplant to get them ready for transplant. But, but our patients who did have transplant, I mean, their baseline scores were very good. The six-minute walk test, 456, in a patient who's on average 69 years old, that's, that's, that's very good for someone who's undergone already induction chemotherapy, maybe a couple rounds of chemotherapy. So again, a sit-to-stand score is very good, their gait speed is decent, hand grip strength is pretty good too. So our next research questions, this is what's sitting in the statistician's hopefully inbox, is looking again at the impact of these, all those baseline functional measures on those oncology measures. The first round, we haven't found any, any significant associations with the oncology outcomes in terms of the functional scores, but we're conducting multivariate analysis right now. So, so please stay tuned. Hopefully we have something published soon on this. So I have one minute to close up on my talk here. All right. So we've, we've, I think we've made a huge impact in terms of what we've done at our institution. When I started 12 years ago, we did not receive very many referrals from stem cell transplant, occasional like rehab consult for, for, for this patient's been in the hospital many months now after transplant. Can you help rehab this patient? But there's been this huge culture change. There was a time actually we started rounding with our consult, as the consult docs were rounding with the transplant team to try to actually demonstrate what we're able to, how we're able to help actually. So we were rounding on inpatient with, with the stem cell transplant team for a couple of years there. And then the whole prehab movement, and that's what really like helped. They came to us and they said, we, we've heard about this, you're doing this for surgical patients. Can you help us with our very, very vulnerable stem cell transplant patients? So that's been like a huge, huge factor in terms of the motivation and the heat and the motivation to send the patients to us. We've had transplant doctors who are like the non-believers and we say, please, please don't enroll my patients into ERCT. And pretty much I think, I think now all of the transplant docs send patients to ERCT, especially the 65 and older. This is a huge opportunity for research. I mean, we, we're all here in terms of we have people who have huge buy-in for what we're doing and they, our oncologists want to do research and they want us to partner with them. So the current things that we're working on are screening tools, we're working with, I've been nudging Dr. Smith in the audience there in terms of can we use the PROMIS 3D profile or other potential measures out there. And then it's an opportunity to cross-collaborate between different disciplines too. So I'm currently working with PT and OT on some publications, Dr. Ng here is working with the CAR-T team on some of our prehab for the lymphoma, myeloma patients. And so I think it's a really exciting time for us to be involved and to really help put our field on the map. And I will take questions at the end. Thank you. Hi, everyone. My name's Obato Bassey. I'm a cancer rehab doctor over in Chicago at Rush University Medical Center. So no financial disclosures. Not really going to go through the learning objectives. What I'm really going to talk about today is more kind of like what I've been trying to build at Rush and kind of the logistics behind that. Because I know often we see the data. We want to implement this at our institution, but we don't necessarily know how to get started. So just a little bit about me. So I did my residency at Rush. I did my fellowship at MD Anderson. So I'm kind of biased towards their prehab model. And then I returned to Rush, who's now partnered with MD Anderson. So I'm outpatient-based 100%. And I'm our first cancer physiatrist, which can really play a role in how you're developing your program, whether you're consult-based, inpatient-based, or outpatient-based. So this is an article, and I'm not going to go through this in detail, but I put the link up there as well for folks. So just talking about the rehab implications for cellular therapy, especially CAR T-cell therapy, as it's becoming more available. And I think it's important to become familiar with it, because it's becoming more available for also other diagnoses like lung cancer now at our institution. So being familiar with things like the side effects specific to it. And we talked about a lot of these impairments and the deconditioning that occurs with treatment. So we know these patients are coming in oftentimes when they're seeing us for prehab, and they're already sarcopenic, frail, cachectic. So there's a lot of factors that play a role in that, and it's probably going to increase as they're starting to get chemotherapy and treatment. And we know sarcopenia is associated with poor prognosis in most of the cancers. So there's a lot of different factors that are going to play a role in that. So we typically address as much as we can in the prehab realm. So when you look at the literature, we know patients are coming in. They already have decreased function and strength, essentially, when we're looking at that. And then sarcopenia is very common in these patients prior to their stem cell transplants as well, and has been found to correlate with increased fatigue, decreased strength, worse function, longer hospitalization, and then worse mortality overall. So this is a specific study looking more at the CAR T cell realm. So what they found was patients that had a lower skeletal muscle mass at baseline were at a greater risk for neurotoxicity or ICANNs, and then longer length of hospitalization, as well as independently associated with a worse risk of disease progression and worse survival at a year. Then compared to the patients who had normal skeletal muscle mass. So in this paper, they're mentioning as well, we should start implementing prehab more often. So this is kind of like the model I've tried to implement at our institution, kind of thinking about it as like prospective rehab. So when I started, I would say the culture was just very foreign to something like prehab. So the buy-in wasn't necessarily just there yet. There was already a frailty clinic with geriatrics. So when you're trying to build something like that, it may turn into a little bit of a turf thing. But it's different at each institution. And then it's just important to work with these groups to make sure we're all on the same page because we're trying to treat the patients and make sure they have the best outcomes. So ideally, we'd like to see them ahead of time in the clinic for a prehab assessment. And then as I was building the program, obviously, I had time. So I reached out to Dr. Smith, Dr. Andrews. I talked to MD Anderson already because I was interested in making something like an inpatient mobile team to really increase rehabilitation while the patients were admitted because our doctors are much more focused on the inpatient aspect of it than the outpatient pre-aspect. So I think that's a very easy thing to do at your institution if you can get the support. And then ideally, we want to see these patients after discharge, which is often when I'm still seeing them is more in the rehab phase. So that was the buy-in opportunity was seeing them for rehab and now introducing these other concepts to them. So we all know this. It's a prehab talk. We've been to several of these. But essentially, we're just trying to optimize function and improve outcomes for these patients. So just a little bit of the logistics at our institution. So I'm a little bit unique because I'm part of the cancer center. And then we have a PM&R service line. So PM&R does the inpatient consult. So I'm not necessarily involved unless I'm asked to specifically. So I approach our department, talk to my colleagues. And they've been very good at helping out in terms of the mobile team, identifying patients. And then I'll often meet with the team, which I'll talk about in a little bit. But for us, I really wanted to get physical occupational therapy involved. However, several institutions are kind of moving this route. We have a partnership with Select Medical. So it's a little bit difficult to bring a therapist into our clinic. We kind of have to pay them hourly, things of that nature. So patients aren't coming on a specific half day or a full day. Providers really want flexibility, especially with visit burden. So they want to be seen when they're on campus. And somewhere like Chicago, patients are coming from all over. It can be quite a travel. And then even for inpatient rehab now, we have a standalone facility, which a lot of institutions are moving towards. So it's kind of complicated the picture to a degree. So really, the prehab program centered around our BMT team. So when I got there, we already had a supportive oncology department. So they were already familiar with the psychosocial oncology aspect, the social work, the dietician. That's already been happening. So now it's kind of become routine for all the allogeneic patients above 65, similar to MD Anderson, to be enrolled in our prehab program, as well as the CAR T cell patients. But we don't have a volume quite as high as something like MD Anderson. So like I said, the barriers for me at the time was the culture and the buy-in from the primary team, which I think that can happen. But you just kind of got to stick with it and show them data, things of that nature. So really, this is kind of in the outpatient setting what we've been doing with the prehab program. They actually see myself. We do body composition, as Dr. Nwong mentioned. And then we actually got an exercise physiologist, so it kind of makes life a little bit easier, and easier for patients, too, because we're not worried about the financial aspect of that. So she actually does a baseline functional measure with the patients. So some of the patients are in the ICU, and she does a baseline functional measure with the patients. So some of the data we've presented. And then she does one-on-one exercise teaching with them, which I think is very important, because I think through my time in training and then as an attending now, patients do need a little bit more guidance, depending on who they are. So sometimes it's not good enough to just see them once and say, go do this. Some patients do great with that. Others really need a lot more hand-holding at times. It's great, because she has the flexibility to decide, does she want to see them weekly, every two weeks? So if it is a patient that is on top of everything, they can be seen less often. And then our role, if a patient doesn't have any impairments, I'm really doing the exercise counseling, especially with thrombocytopenia going on, nutrition counseling, exercise precautions, and safety. And then if they do have functional impairments, we can address that as physiatrists. And then when patients do need something like therapy, we still send them to outpatient physical therapy. But for us, it is a little bit harder, because it's not necessarily in our cancer center. So it is out of the way for patients after they're getting treatment. So this is our exercise physiologist, Ashley Sison. So she's great. So when we're getting patients to buy, and we often tell them, it's like training for a marathon. You don't just show up. Or like boot camp for the military. So now it's cool, because she was in the military. So she really puts them through boot camp. And she has the credit to do that. And this is just a little I'm not going to go to in depth, because it's beyond the scope of this talk. But why I think it's important to use objective data, like bioimpedance analysis, regardless of what kind of machine you have, to look at fat mass, muscle mass, especially in sarcopenic obese patients, and trending that throughout their time. And I think with patients, when they see those numbers, they buy in a little bit more, because they get excited to see where they're trending. So really on the mobile team side, the opportunities, it's different in the literature. There's people that talk about individual-based things, group-based. At our institution, I think the group-based idea was a little bit more difficult in terms of the time of the inpatient therapist, and then who was going to monitor some of these things. We do have a walking program, if patients are independent, that they can participate in. And then we've actually moved to having more in-room exercise equipment as well. So we do have a small gym, but again, we couldn't leave patients there unattended. And we don't have someone that can just stay in the room with them. So we're bringing the cycle ergometers or a recumbent bike to them, so they're not having falls getting on or off, things of that nature. So literature on this is very limited. Dr. Andrews will talk a little bit about his experience, too, at Michigan. But Mayo Clinic has a paper that I think people are familiar with when they look into this, talking about the cancer adaptive team, which is the first of its kind. So it was developed in 1980, and it developed of a physiatrist, a nurse, PTOT, social work, and chaplain. And they found improved Kornowski and Barthel index scores. MD Anderson has had a mobile team previously, and now University of Michigan has their MCOR team. So I didn't want to reinvent the wheel and just try to do things and then hit road bumps a million times. So I reached out to people who have been there and have these teams well-developed to learn from them and how we could implement it at Rush now. So when I was meeting with physical therapy, I had to get their buy-in to say, can I get the time of your therapist, essentially? So this is all the stuff I reached out to them. And Dr. Smith and the audience really helped me with. He went to Michigan previously and gave them the same ideas and said, this is how we can help the patients. And then we did get the buy-in from them. So we're really just helping, assessing patients' therapy tolerance, determining the appropriate level of post-acute rehab. And I think it's really good, even for my PM and R colleagues, because it's almost like a test for acute rehab at times. And it helps facilitate the discussion with the BMT teams at times when we say, this patient is not appropriate for acute rehab. Now we have objective data to say, you're not tolerating this many sessions while you're here right now. The patient's not going to be able to tolerate acute rehab. Beforehand, there'd always be that pushback of, we can't send them to another facility, or we want to really send them to acute rehab. And you take them, and you might be doing more harm than good by trying to put them through acute rehab at that point. So those are the very common situations that we're seeing these patients when they're not able to discharge to inpatient rehab due to some type of cancer treatment, and especially with the frequency. And now that we're at a standalone, we really are more strict with, if it's chemo every week or every two weeks, we can't keep going back and forth. So this has been a game changer for us, because patients aren't just sitting on the floor getting more deconditioned and getting less therapy, and also for those really medically complex patients. So part of our team is myself, PT, OT, speech as needed, the nurse, and then psychosocial oncology, which I think is very important, too. And then we try to keep the criteria loose. So it's on our hemonc floor. So 14 days, we have 32 beds there. So any patients with hematologic malignancies that have been admitted for more than two days and ideally have a disposition home and aren't just coming from a facility, and we're projecting that they're going back to a facility. If the patients are already on an independent level, we want to see the patients that are less functional. So they just need to be alert, willing, and medically safe to participate. So our intervention has been at least one PT and OT session a day. So patients are, on average, getting 10 sessions a week, and then the weekends are off just due to staffing. And then the max census for us is about five patients. So we just do weekly virtual meetings to review the patients, and then we have EPIC lists of current patients on it and candidates. So that way, we're not doing this in person and taking up more time because we're all busy. And then we just stay in touch through our EPIC group chat. So it's worked out really great, especially because the therapists aren't necessarily dedicated to this team to ideally go to different floors at our institution. So we're just trying it on one floor right now. And then we typically will just communicate. I'll talk to the PM and our team through our EPIC handouts as well, so we're on the same page when a consult comes in. So this is kind of the more difficult part is we've kind of re-evaluated at times what patients we were going to see because on the floor, this could change outcomes in terms of sometimes we have a patient that's just being readmitted versus a patient that's coming in for a stem cell transplant. So their length of stay is looking completely different at times. But we kind of settled on this is data that we're collecting now, and we built out EPIC flow sheets. They'll be easy to pull later, but functional measures. And we kind of mirrored that around what functional measures we're doing in the prehab clinic so that we can have the same data at outpatient prehab, inpatient admission, and then we repeat these scores when we see them again to kind of see are they having that decline as expected, how far is it, and can we improve these scores. We're doing MOCAs weekly, brief fatigue inventory, AMPAC, KPS, COMPAS, length of stay, their discharge destination. And then we use QI scores at our institution, but we're trying to figure out a way to use the FIM efficiency score, which is a little bit easier when you're looking at their admission FIM scores minus the discharge FIM scores, and then divide by the length of stay. So you're kind of taking that variable out of was this patient here for three weeks versus a week. And then considerations, I would say if you're saying I want to go to my institution, I want to do this, is what's your therapist availability? Is it going to be dedicated to one unit? Do you need to buy their time out? We got around that by just using the therapist on the hemog floor already, looking at what cancer population and location. So we've gotten questions from other teams, but it's just been difficult because, as I said, our surgical floor is a couple floors down, and we can't have the therapist just go down there and see them. And then physiatrist availability. So for myself, I've kind of had to change this around. When I was first working and building up my clinic, I would go and do these consults. But now, as I'm kind of like the primary cancer physiatrist there, we really have recruited general PM&R to take over those consults again, and then I'm kind of doing things from afar and come in when I need to. And I think that's important also to talk to your group about because there's different comfort levels and experience with cancer patients. So often, I'm getting called more when it's in the palliative realm, and maybe palliative care is consulted, but things haven't been discussed about what ideally is going to happen in the long term. And then talking about post-acute rehab recommendations can also vary by provider. So that's often come up is that comfort level comes into play. So you want to talk to your colleagues and say, hey, they're on the mobile team. Maybe don't make a hard recommendation at the start. Let's just see how they do. They're going to be here for a little bit of time. And I just want to mention our cancer rehab mobile team. They've been huge, and it's really, I would say, driven by the therapists. And they do a lot of the hard work, and then I'm just kind of giving my two cents sometimes. And then my colleague, Dr. Solibriu Sosa, who has been terrific and also helps out when I'm not available. So yeah, that's it. And then we'll take questions at the end. Thanks. All right, hi everybody, I'm Cody Andrews, I'm at the University of Michigan. Some of the headings are going to be cut off of my slides, so I apologize about that in advance. But I'm going to be talking a little bit about transitions of care for inpatient cancer teams. For bone marrow transplant patients, I don't have any conflicts of interest. So I want to talk about some barriers to inpatient rehabilitation for these patients, and then potential complications, just kind of a practical guide for how do you take care of these patients when they're under your care, and then spend a little bit of time describing our approach at the University of Michigan. So as we all know, these patients have a lifelong illness, and they have many complications along the way. Somebody who's undergone a bone marrow transplant, or even like CAR T cell therapy or something like that, are going to have complications that carry forward throughout their life. They're at high risk in institutionalized settings, they have weakened immune systems, and then you're exposing them to entire healthcare teams, and therapists, and nurses, and janitors, and custodial staff, and greeters, and everybody along the way. They often have a lot of chronic debility that's built up, and despite all of that, they can be very challenging to take care of, but they can be really rewarding to take care of too. These patients can make a lot of meaningful progress whenever they work with us and with our therapy teams, as long as we know how to keep them safe while they're doing that. So yeah, let's say that you want to admit a patient to your inpatient rehab unit. You have a bone marrow transplant patient, you see them on consults, you're like, this patient really needs us, how do we get them there? Even before you admit them to your unit, there's often a lot of roadblocks, barriers, and things like that that get in the way. These patients are highly medically complex, you have to make sure that your team is comfortable taking care of them. A lot of these patients do not meet a 60% rule qualifying diagnosis. A lot of them are just debility patients, and so they're high audit risk. Sometimes you can, a lot of them have steroid myopathy, critical illness neuropathy, and myopathy, things like that, but these are patients who, from just a payer perspective, are often challenging to get into your units. And then, you're also thinking about getting them there, and what about the other medical teams that are taking care of them? So does your inpatient rehab team, does the physician who's accepting them feel comfortable with these patients? Again, they're really complex, they have a lot of treatments going on. They tend to have high rates of transfer back to acute care, just because they are very sick and fragile. And sometimes hematology teams just aren't comfortable giving up control over their patients. They spend a lot of time taking care of them. The patients are very ill. They develop relationships with them, and they sometimes don't feel like the patients will be safe in other settings. Patients can also be a barrier to admission. Sometimes patients are fearful. They're like, you want me to go to a therapy gym? There's going to be 10 other patients working around me. They told me that I have a weakened immune system. I had a patient a couple months ago, somebody I followed outpatient for years. I tried to admit her, and she was like, absolutely not, no, thank you, I appreciate it. I do not want to come. I am at risk. And so we rehabbed her in her room there. A lot of patients don't have resources. Their home accessibility can be a big issue. And then their family and caregivers. Never forget about the family and caregivers. Before somebody undergoes a bone marrow transplant, they go through screening and making sure that they have caregiver support and things like that. But those caregivers are taking on a lot whenever they're caring for their loved ones with these diseases. And so there's a lot of burnout. There's a big knowledge gap with these patients and their families a lot of time. And then, you know, are their families available to like provide, you know, they get the kind of medical spiel from their hematologist. But then now the patient's been in the hospital with pneumonia for two months, and now they're really physically debilitated. Are they able to help them physically as well? But let's say you overcome all that, and now you're admitting your patient. Congratulations. You have a patient coming to your unit. So how do you keep them healthy through two to three weeks of rehab, and how do you make sure that that is a safe and meaningful and helpful experience for them? So there's a lot of potential complications that can come up for these patients. So to just kind of go through some of these briefly, thrombocytopenia is a big one. A lot of these patients are immunosuppressed, or all these patients are immunosuppressed. And there's a lot of medication side effects to be aware of. So talking about thrombocytopenia, like what's safe? Like what platelet level is safe to exercise somebody at? What platelet level is okay to get somebody out of bed with? The short answer is, is that there's not a whole lot of data about this. We go on institutional experience and levels where bad things have not happened frequently a lot of the time, but there's not a whole lot of data out there. Technically, thrombocytopenia is less, a platelet's less than 150,000. They can usually exercise at much lower levels than that. But these patients are high fall risk. They have neuropathy. They're really debilitated. So if they fall, they're at a really high risk for a bleeding complication. Venous embolism, prophylaxis is a problem. Usually most times, if the platelets are less than 50,000, that's held. A lot of these patients live right around 50 with their platelets. And so if they're at 70 when they come to you, and then they suddenly drop to 30 over a couple of days, not unusual at all. You have to know how to manage the ongoing needs with that. The activity modifications, typically at our institution, and these are, I think, pretty transferable to most places. If the platelets are over 10 and they don't have signs of active bleeding, we typically don't have any significant activity modifications. If it's 5 to 10, usually they're going to get a transfusion, but they can do bedside therapies. And then less than 5,000, we usually hold therapies altogether. And then they're immunocompromised as well. So a lot of these patients, no matter where they come after their transplant, are immunocompromised. If they're within the first 100 days after their transplant, they're not fully engrafted. And so they're considered to be very immunocompromised until then. And a lot of these patients have low neutrophil counts. So anybody who has an ANC of less than 500, you have to watch them very, very closely, especially in institutionalized settings. Fever is an absolute emergency in these patients. Send them to the ICU. They're about to crash if they do develop a fever. You want to avoid antipyretics. So pain control can be an issue for these patients. This isn't somebody that you want to just give NSAIDs and Tylenol without thinking about it. They can mask a fever if they're developing one. These patients often need to be on special isolation precautions just to protect them, especially in an institutionalized setting like an inpatient rehab unit. A lot of the medications that these patients are on can come with their own unique kind of host of side effects. So a few of the common ones that these patients are on. So tacrolimus is a really common medication these patients get. It causes a lot of electrolyte abnormalities. These patients can get hyperkalemic, so their potassium can go very high. Sometimes that does need temporizing. They can get very hypomagnesemic at the same time. That's very hard to fight against often. These patients often need magnesium infusions while they're institutionalized. It's just hard to keep up orally a lot of the time. Be aware that tacrolimus can cause Prez syndrome as well. It's a rare complication, but one that you definitely don't want to miss. Even on acute care, I will say, I want to empower you guys, and I want you to go home and empower your therapists. If you notice something off with patients, no matter what setting they're in, if their mental status seems off, you and your therapist might be the first ones to notice that. So always feel empowered to bring that up to hematology teams. Corticosteroids, obviously, rehab uses a lot of steroids in a lot of settings, but these patients are on there for immunosuppression. Long-term use can cause myopathy, peptic ulcer disease. Some of these patients need to be on peptic ulcer prophylaxis, which is a bit controversial. Long-term PPI use can cause a lot of issues with calcium absorption and things like that. These patients are at risk for GI complications from their transplants, and so a lot of times they do need to be on those. Anybody who's on more than 20 milligram equivalents of prednisone for more than a month needs to be on some kind of PJP prophylaxis. Usually it's back term three times a week. There's other regimens out there, but that's what we use at the University of Michigan. Tyrosine kinase inhibitors can also cause a lot of fatigue and issues like that. So these are patients that you're asking to exercise three to four hours a day, five days a week, and then they're on tyrosine kinase inhibitors and kind of feel like crud, so they don't want to do things all the time. And again, these patients are heavily immunosuppressed. So just to kind of reflect back on that, some of the things that we're doing at the University of Michigan. Like Dr. Obasi mentioned, we do have a mobile cancer team called the MCOR team, or Michigan Comprehensive Oncology Rehabilitation Team. Since 2016, we've had 261 distinct patients who have had therapy and physicians on their case. It's even more whenever you just count that they've seen therapy only. For instance, last year we had 32 unique patients come through, and then 14 of those actually ended up admitting to our inpatient rehab unit. We have a dedicated therapist group, and I can't speak highly enough of them. They are the ones that enable our program to work. Dr. Smith and I have worked hard to build that program, but the work we've done pales in comparison to what the really smart, talented therapists that we work with enable us to do. We do meetings twice a week with them usually. Sometimes we do email rounds. Basically discussing progress of patients. Are they ready to go home? Are they ready to come to rehab? How are they doing? How can we help? We lead those meetings with the therapist as well. Once they come to our inpatient rehab unit, we have weekly meetings with our BMT team. We went through a transition recently at the University of Michigan. We used to have an embedded rehab unit at our university hospital. We're now at an off-site location, a joint venture with Trinity Health. The bone marrow transplant team has also been fantastic. They have all gotten credentialed at Trinity to follow those patients while they're there and help us make sure their patients stay healthy while they're going through rehab. Getting buy-in from those physicians and their enthusiastic support for these programs has been really critical as well. We couldn't do it without them, of course. The fact that they're willing to jump through all those hoops to make sure they can still care for their patients while we're doing rehab with them has been really helpful and made sure that we have been able to continue this program for patients. Yeah, so we'll, again, take questions at the end, so I will pass it off. So, hi everybody. I'm Aaliyah Aber. I'm a cancer rehabilitation physician up in Seattle at Providence Swedish and so I'm just going to give you guys some ideas about how to have one of these programs potentially in like a private setting. So I'm in a non-academic private hospital setting in the community and we don't have to talk about objectives. So, I joined a practice that had an existing cancer rehabilitation physician. I was coming from fellowship with Dr. No, so I had all of this, these ideas about how wonderful prehab was and how important it was for many patient populations. So, I joined this practice and it was a very different practice style than where I was in training. So, I went to each tumor board and, you know, introduced myself, gave a small presentation on what I was interested in and really highlighted prehabilitation as something that could be applicable in many different settings. So, multiple stakeholders reached out and said, yes, we want a prehabilitation program. How can we do it? So, we ended up starting multiple prehabilitation programs, but we're going to talk about the one for cell therapies. At our institution, we, it's all outpatient based cell therapy programs. So, initially it was only a auto stem cell transplants that were outpatient and then they added CAR T cell therapies. I think in the history of our program, since like 2018 when we started the prehab, there's been over 500 stem cell transplants and over 150 CAR T patients, but that is expected to exponentially grow in the next few years and we'll talk a little bit about it. Some of the challenges are that we have patients that are coming both locally to Seattle, but also there's a much broader catchment. We're talking about patients from Oregon, Idaho, Montana, Wyoming. People fly in from Hawaii. There's a lot of reciprocal reciprocity with Alaska. So, people are flying in. They might be there for a day, two days, and then they go back to their community. So, all of us had to be very community based. So, initially we developed a pathway really in close coordination with the cell therapy nurse managers, right? So, we started having weekly multidisciplinary rounds to try and make sure everyone was on the same page. Our hematologists, oncologists were, they were bought in from the beginning. They were like, prehab is amazing, let's do it, but then the practicality of how do we actually get this patient in our office when they might only be here for a few days? How do we get this patient a consult with our physical therapists, or do they have to see a community physical therapist, or am I the only contact that they're gonna have for exercise counseling before their transplant? So, we tried to make it work, and we started out with a much more complicated referral pathway and all the points of contact that we wanted to have with patients, with the dieticians, with the social workers, with the psychiatrists, with every physical therapist and me, because I was coming from this amazing complicated program, and I wanted them to have all of those things, and it turns out it's really hard to coordinate all of that, so I had to own all of the prehab referrals. So, they all come to me, and then I can just, I can help that patient get all of the things that they need, because the transplant coordinators were swamped with all of their medical coordination for getting them ready for transplant and CAR T, so you really had, I really had to be a partner in it. Okay, so you've seen the intervention, very similar to everyone else's prehab intervention. They have a physiatry consult, deal with any other barriers that they might have to exercise, get buy-in from patients. I draw the prehab chart for patients in their prehab consult. I draw them the chart of, like, this is where everyone starts, and if you do prehab, you get better, and if you don't do anything, you kind of stay the same, and then after stem cell transplant, everyone goes down, and if you look at where you are, if you did prehab, look, you're kind of close to where you are now. Doesn't that sound like a better idea? And they're all like, yeah, let's do it. Okay, so then you give them all a counseling of, like, this is how you're gonna do your aerobic exercise, this is how you're gonna do your resistance exercise, and when you are on your transplant team, you drop your resistance. Everyone does body weight at that point, and I also give them a stress reduction kind of boot camp, so we practice relaxation breathing, we practice how they're going to... I tell them you're gonna let things wash off of you, because when you go through this, there's inevitably going to be someone who's not as kind as they could be, there's going to be someone that steals your parking spot, and you're gonna start to get frustrated, and if you sit there and stew over it, that's giving your energy away, and if you give your energy away, that's not our program, right? You need all your energy to rebuild all your cells and get everybody back on track, so I give them a little stress reduction talk, and then if there's some real issues, then they talk to the psychiatrist and the social workers. So the patients are referred to cell therapies by community oncologists, right? They've done all of their other treatments, they're at the point when they either need a CAR T treatment or they need a stem cell transplant, and that's not something that our community partners can do, so they're referred in, they have a consult with our team, and at that point, they're kind of put on track for a transplant, perhaps put on track for CAR T. They might still have maintenance therapy to do, they might still have scans to do, but they will come see me for prehab about that point, and ideally, I have about six, four to six weeks before they walk into a cell therapy regimen, so I have time to get some interventions. Sometimes I see them five days, but you know, you do your best. When the patients go on to their cell therapy team, they're basically, it's day one of their transplant infusion, their CAR T infusion, and then they're kind of in this bubble of, you know, it's outpatient, it's pretty much daily labs, they're coming back to the clinic, but we're trying to keep them out of the hospital. I step back, right? They have an amazing acute care team, that's when all of the nurses, PAs, and everyone is following them. They might go in the hospital for a fever workup, but the goal is to keep them out, right? Remember, we're in a, you know, we're in a for-profit system, and it's expensive when they go in the hospital, so the whole idea is to keep them out of the hospital, and then I see everybody three to six weeks after their discharge from that team, and that's where we kind of regroup, ideally repeat their functional measures, and then start their rehab, get them back to work if they're, if they're working, because we see a broad range of ages. So I also put some slides in here that I thought might be practically helpful to anybody who is out there trying to write these, write orders, write notes, get this justified by payers. So I write all of the, when I write our PT referrals, sometimes it's to PTs in the community, right? Someone lives down south, they hate traffic, they're not going to come up for one other appointment, so I have to partner with a community PT, and I'm so detailed in what I write in those PT referrals on what the patient's history is. I literally copy and paste my diagnosis and assessment for all of their comorbidities into the, like, the body of the PT referral so that that PT can see that, oh, this person has neuropathy and had bone mets, and these are some of the precautions that you need to think of. So as an example, this is just some documentation, as I see lots of people who I've talked to in the past said, well, I don't understand how to get this covered, right? If I'm gonna send somebody to prehab, how do we get this covered? So in this example, I, like I said, I will write down all of their bony lesions, I'll write down that they have fatigue, I'll write down their history of what their exercise history has been, perhaps, and maybe they're still exercising throughout their treatment leading up to transplant. Maybe they're not, right? Maybe they're not doing anything. I'll write their sensory exam, I document their joint, you know, joint range of motion, because people do come in with frozen shoulders, and you're like, was that, was that like that before? I can't really remember. And then other things that have been going on, I will also document their weight history, right? I don't know, sometimes I have a hard time finding a trajectory of someone's weight prior to me seeing them, and so I document their weight to see, you know, does this actually meet criteria for like cachexia? And most people will. I also leave crumbs in my note for other people, so like, that they might have a history or they might have a risk for osteoporosis, right? Stem cell transplant is in itself a risk for osteoporosis, those patients are higher risk for that in the future in their primary cares, their other practitioners might not realize that when they see them later. So I leave a little crumb, maybe if I never see them again or I don't get to finish the workup, I leave a crumb about you might want to recheck their vitamin D, they might need a dexa scan in the future. This is just another example for someone who I saw with primary CNS lymphoma, and again, kind of bulleting out all of the things that might be helpful for my colleagues, right? Other people who might be seeing them. And then, as an example, here's their ICD-10 codes, right? There's ICD-10 codes for pretty much all of these things, and if you're seeing a patient in rehab, they have an impairment, right? They have an impairment in their function, even if you might say well you're still walking or you're not walking with a cane, so is that really an impairment? If you ask them, those people go, yeah, I used to like run five miles every day and now I'm like just walking, so they'll consider it an impairment, the patient will. And if they're a candidate for stem cell transplant, put it in your documentation, right? That increases their medical complexity, and if you're building on medical complexity, you can justify it. So again, these are just examples of how I refer to the physical therapist. So we have some physical therapists in our Cancer Institute who I will try and get patients to see. I will, you know, try and get them to walk down and see them, if possible, because these patients will not come back for another visit, right? They don't want to drive another hour, two hours, and sit in traffic. And then, if it's an out-of-our-system PT, a local physical therapist, I'll outline, look, this patient's getting ready for stem cell transplant. This is what I want you to do. I think you can help them get a little bit more activity tolerance, and please call me. I put my phone number in the referrals. Call me if you have any questions, if you're worried, especially if you see anything. Like, I think what Cody was saying, you know, I have a very warm relationship with all of the therapists I refer to, and I tell them, if you see something that makes you worried, tell me, because you're seeing this patient in a different way, and I'll escalate your worries. Because a lot of our physical therapists don't feel comfortable reaching out to the oncologists. They see them as, like, they're kind of on another team, basically, and they might not hear back from them or talk to them regularly, but they'll reach out to me, and then I can advocate for the patient or another workup. So, in developing this program, what was really important was coming back to the stakeholders, coming back with functional measures. These are the pre-six-minute walk tests for these patients. This is what they were right before transplant, and then look at where they are now. Look at how much better they got. The patients will demonstrate the value. We also ended up, you know, I ended up in negotiations for, like, bundled payments. You know, we had, we would have referrals from, like, HMO Kaiser, right? So Kaiser refused to pay initially for cancer rehab. They said, no, we have our own rehab doctors. They can do it here, and so we had to advocate and say, you know, if you're sending them to our institution for their stem cell transplant, for their CAR T therapy, our program includes rehab, and so here's our code for, you know, rehab visits, and here are three PT visits with our, with our team to help the patient get through this whole treatment, and once we talked to the payer, they were like, yeah. I mean, a CAR T therapy is, like, $500,000, right? And so if you go in and say, we're gonna have, like, a few visits with a cancer rehab physician and some physical therapy visit, but this patient's gonna come back and be better, they were all in. They just didn't realize what we were asking initially, so come back and round back with them. You can contact me if you have any questions. I was trying to be quick because I think we're out of time. Thank you. Okay, so thank you. I know we're running a tad bit late, but I want to definitely open up for any last-minute pressing questions, but you're welcome to talk to us after, too. Hi, thank you for your talk. My name is Erin Kelly. I'm at Jefferson, Philadelphia. My issue is for patients, for outpatient, and I think that is really important, getting them before they get to the hospital. If they can't afford it, if it is not convenient to them, is oncology kind of footing any bills with any grants, or are you helping with the copays for therapy in any way if patients can't go? I know you just mentioned bundled payments, but I wasn't sure more specifically. So I would just say what I've done for a lot of people, if there is a payment issue, I get the social work involved and we will do financial assistance. So we basically write off their physical therapy and then they don't have a copay, so I'll do that for like patients who are elderly and the copay is prohibitive. Sometimes that takes a little bit more time than we have getting them ready for like a transplant, perhaps, because it's paperwork, so it's harder. And so I basically got like a MedBridge account and I have prehab exercises, and I will do the exercise counseling in my visit with them and demonstrate their, like set them up with their home program. It's a very, I have three, it's very simple, you know. I can, I'll share it with you if you want. Great talk, thank you so much, and really sincerely thank you for all the work that you're doing. So in the experience of the panel, is there like a minimum number of weeks before like patients undergo transplant that you feel like is effective? And like is there a minimum like level or number of minutes for like aerobic and resistance training sessions that you feel like is beneficial? And what do you feel like is, like how important are all the other multimodal aspects of stress reduction, smoking sensation, and nutrition versus just exercise by itself? Thank you. Yeah, so I mean I think it's different for each patient because we know what the recommendations are for minutes of aerobic exercise and then strength training, but I think for our patients it's just starting to get them to buy in and then starting with some type of program. I usually start with a walking and sit-to-stand program at minimum, and then like PTR exercise physiologist takes care of that. What was the other part of your question? The duration. How early? For me, as early as possible at minimum, four weeks would be ideal, but sometimes we get them two weeks, yeah. So I ideally like them four weeks before to really see a change, but to be honest sometimes they do send them and they come like a day before their transplant and there's not much to do, but it's more education and working with the providers to try to get them in earlier. We usually recommend for them to be referred to us at least three to four weeks in advance. A lot of the CAR T-cell recipients, when they're receiving their apheresis and they're sending their cells off for processing, we probably, we have a slightly smaller window of time, three weeks or less usually, and so depending on the protocol they're on. So that's been a bit of a challenge because the CAR T-cell patients physically, functionally have been more impaired. So we would like more time, but it's not always feasible, so we do what we can and the oncologists are very, in terms of they work with us in terms of how we'll send them early and you just do what you can. Our transplant docs are a little bit more restrictive and like if you can't get them to improve, then we might not do the transplant. And I agree with what they said too, just to add on in terms of the nutrition aspect, a lot of times we'll use a CAR analogy with patients and say, you know, I'm asking you to drive 500 miles in this potential trip, which is the exercise component, you know, increase aerobic resistance, etc. But if you don't fill the tank with nutrition, essentially protein, even though I want you to go the 500 miles, you may only go 10, you may only go 100. So I feel like clinically in that sense, patients like, oh yeah, I do need to eat better, oh yeah, I do need to exercise and they can see the correlate that way. And then there was one question that came in online. Is there a role for anabolic steroid therapy to reverse or delay sarcopenia? And if so, what conditions or situations is it indicated and or contraindicated? I don't use anabolic steroids. From the literature I've seen, the risks outweigh the benefits and they've caused, you know, liver issues. So it's really, there's no role currently for testosterone replacement therapy unless you're talking about a different setting, like post-transplant down the line for its appropriate use. I agree with that. We can answer questions outside. Thank you all.
Video Summary
The session focused on establishing and developing prehabilitation (prehab) programs for patients undergoing treatments like bone marrow transplants (BMT) and CAR T-cell therapy. The presenters, including physicians from institutions like UNC and MD Anderson, discussed the growing necessity for prehab due to heightened vulnerability among older adults undergoing these therapies. Prehab aims to improve fitness levels before treatment, reducing post-treatment complications, length of stay, readmissions, and ultimately enhancing survival rates.<br /><br />The session encompassed several key themes:<br /><br />1. **Importance of Prehab**: Prehabilitation can improve outcomes by increasing patient strength and fitness levels before intensive treatments. It involves engaging patients in aerobic and resistance exercises, dietary improvements, stress management, and other supportive care measures to mitigate post-treatment declines and aid recovery.<br /><br />2. **Collaborative Efforts**: Cross-disciplinary collaboration among oncologists, physiatrists, physical therapists, occupational therapists, nutritionists, and social workers is crucial. Multidisciplinary teams work together to streamline the prehab process, providing comprehensive care focused on both physical and psychosocial needs.<br /><br />3. **Program Implementation**: Presenters shared experiences with forming prehab programs, emphasizing institutional buy-in, stakeholder engagement, and addressing logistical challenges. Programs were tailored to specific institutional contexts, patient demographics, and treatment types.<br /><br />4. **Outpatient and Inpatient Coordination**: Coordination between outpatient prehab initiatives and inpatient mobile rehab teams was highlighted. This included managing logistical challenges, like scheduling and financial concerns, and ensuring consistent follow-up and support post-treatment.<br /><br />5. **Measuring Outcomes**: Metrics like overall survival, non-relapsed mortality, quality of life, and physical function were emphasized for evaluating program efficacy. Institutions presented results showing improved patient outcomes tied to comprehensive prehab programs.<br /><br />The importance of customizing prehab initiatives according to available resources and patient needs was stressed, with ongoing assessments to refine approaches for optimized patient care.
Keywords
prehabilitation
bone marrow transplants
CAR T-cell therapy
fitness improvement
multidisciplinary collaboration
aerobic exercises
resistance exercises
program implementation
outpatient coordination
measuring outcomes
patient care optimization
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