Let's start. Thanks everybody for joining us in this session that we titled, You Can Do It, Tips for Incorporating Cancer Rehabilitation into Your Existing PM&R Practice. So the idea of this session basically is try to give you like the tools for you to feel a little bit more comfortable to see patients with cancer in your clinic. We have, I think, an excellent faculty. I decided to introduce all of them at the beginning for the sense of time, and then we can definitely go ahead with the presentation. So first of all, we have Sarah Park is an assistant professor in the Department of Physical Medicine and Rehabilitation at Mayo Clinic Arizona. She currently serves as chair of the APM&R Cancer Rehabilitation Physician Consortium Research Subgroup. She has a clinical expertise in the evaluation and treatment of musculoskeletal and functional disorder resulting from cancer and cancer therapy. Dr. Park received her medical degree from University of Colorado and served as chief resident in physical medicine and rehabilitation at the University of Washington. Dr. Park is board certified in physical medicine and rehabilitation and completed a fellowship training in cancer rehabilitation at the University of Texas MD Anderson Cancer Center. Then the second speaker would be me. So I completed my medical education residency in the University of Puerto Rico, where I served as chief resident, and then I did a sports medicine fellowship in Mayo Clinic Florida, where I currently work, and I have a clinic basically with a mixture of MSK ultrasound and a little bit of breast cancer. I have a special interest in musculoskeletal problems, tendinopathy, musculoskeletal ultrasound, and also try to help breast cancer with exercise prescription and some rehabilitation. I serve as part of the medical staff of the U.S. Basketball Junior National Teams, and I've been traveling with them for the last couple of years with tournaments. And the last speaker will be Dr. Sean Smith that worked in the University of Michigan Royal Cancer Center Cancer Rehabilitation Program with a clinical emphasize on restoring function and reducing symptoms burden in patients with history of cancer. He served on the editorial board of the Archive of Rehabilitation Research and Clinical Translation and previously the Journal of Clinical Oncology and Supportive Care in Cancer. He currently co-shares the APMNR Cancer Rehabilitation BOLD Initiative and previously the ASCO Education Committee for Symptoms and Survivorship. His research emphasis is the assessment of function in cancer patients. So without further ado, let's start with the session. So I invite Dr. Park to come over here. Thank you. All right. Thank you so much for that excellent introduction, Dr. Rosario. So I'll start out with our first objective, which is to describe the current and future need for cancer rehabilitation professionals. So we all know that cancer is common. I was surprised to learn, though, that about one in two men and one in two women in this country will be diagnosed with cancer at some point in their lifetime. This means that about half to a third of our patients at some point will be cancer patients. So whether or not you want to be practicing cancer rehabilitation, you are. Although these statistics are quite sobering, good news is that death rates are also decreasing. We've seen the trend in five-year overall survival improve from 1975 to 2017, from 49% to 68%. As we have death rates decreasing, we have more survivors. For the purposes of this talk, we'll be defining cancer survivor by the American Cancer Society guideline as any person with a history of cancer from the time of diagnosis through the remainder of their life, meaning you're a survivor from the day you're diagnosed. And you'll see this actually on the halls of MD Anderson, and it's something that I use in my clinical practice on a daily basis. So now that we're on the same page about what a survivor is, we can talk about the prevalence of survivorship. So we know that this year we'll have about 18 million cancer survivors in this country. By 2030, this will increase to 22 million. And the most common cancer types in men and women respectively, prostate and breast, are also the most common types of survivors that we have. And their numbers alone will amount to almost 8 million people. These guys have really high cancer rehabilitation needs, as Dr. Rosario will get to in a little bit. And compared to some of our other populations in rehabilitation, like SEI has about 220,000 a year, you can see this is a huge volume. So what do we know about survivors other than their sex and their primary tumor type? We know that mostly they're older. Only about 10% are younger than age 50, and about two-thirds are firmly in the geriatric age group. And with age comes wisdom and comorbidities. So I like to think about this and the rehabilitation needs in terms of the accelerated aging model of functional decline. So our poor lifestyle behaviors, whether it's risky sexual activity, alcohol use, sedentary lifestyle, they catch up with us over time. And then you add an acute insult like a cancer diagnosis, and boom, you have a precipitous functional decline. We see this really bear out in the data. About two-thirds of cancer patients of all comers reported functional loss. This was from a paper in 2009 by Andrew Cheville. I'm really preaching to the choir here, but we know that reducing disability matters. So for cancer patients specifically, we find that functional decline can impact patients' ability to receive primary or subsequent lines of treatment. And in older adults, we find that these are strong predictors of all-cause mortality. Also we see the social implications of this. So as everyone in this room, I'm sure, can attest, if we are able to prevent functional decline in a patient, we also help their caregivers. And that increases productivity for families and communities. It follows then that this has tremendous impact on economics. So in 2018, the WHO stated that the total economic impact of cancer worldwide is about 1.5% of the world's gross domestic product. So we really cannot afford to neglect this problem any longer. I hope the next question you're considering is, how can I help? And this is really the crux of our discussion today. As a PMNR provider, you already have the skills that you need to help these patients live and live better. PMNR is full of the best and brightest. In 2020, it was one of the most in-demand medical specialties for the match. And we really see that, you know, despite our multitude of subspecializations in the field, we're all focused on one thing, which is function. Whether you're a general physiatrist or have fellowship training in any of these areas, your skills really set you up to be an essential member of the oncology team. So I hope you see yourself here. Despite the fact that PMNR providers can be hugely helpful to cancer patients, access to rehabilitation services remain low in this population. Some studies show only 1% to 2% of patients are getting the services that they need. And this is really for three reasons. First is that oncologists don't routinely screen for functional impairment. Second is that patients don't know to ask for this kind of care. And third, which I'll focus on for a moment here, is that we really have a limited availability of cancer rehabilitation professionals. When I tell my patients that I'm the only fellowship-trained cancer rehabilitation doctor in the state of Arizona, they're universally floored. They say to me, Doc, how is this possible? This has been such an important part of my care. How come everybody doesn't have access to this? And I give them the three reasons I just gave you. I also share some details, like when I trained in my fellowship just four years ago, we only had five fellowships and seven fellowship positions. Now we have 11 fellowships and 13 positions available. So that's an awesome degree of increase, and I'm delighted to share it, but cancer survivors can't wait for enough physiatrists to be trained in cancer rehabilitation. For fun, I just did a little back-of-the-envelope calculation to find out what our provider-patient ratio looks like, and I had to actually be a little creative in approaching this because we don't have an exact headcount of fellowship-trained cancer rehab docs. Instead, I used our membership in the CRPC subgroup, and as of two weeks ago, it was 493. I'm happy to report that after this conference, we're up to 502, so it's increasing in popularity as we speak, and hopefully a few more of you will join us. So, in summary, there are so many reasons to hone your knowledge with this population. Over the next two sections with Dr. Rosario and Dr. Smith, I hope that you'll develop some tangible skills that you can use to have a more formal cancer rehabilitation emphasis in your practice. These patients are already embedded in everything we do, and I want to thank you for taking the time to increase your knowledge with this population, to improve their safety, and also to enhance the reputation of our specialty in your broader medical community. We can do this. Thank you, Sara, that was great. So she delineated why it's important to try to help this population, and I'm going to give you, in my talk, some skills that you might see, because one of the big problems is that you might feel not prepared to see a patient with cancer. It might feel like they're too complicated and too difficult, but actually it's not, and that's one of the things that I want to point in my presentation. So we decided to title this presentation, Pearls and Precautions, Applying Physiatric Principles to Patients with Cancer. So I have nothing to disclose, and the objectives of my presentation is basically try to explain how a general physiatrist, they already have the skills to start seeing patients with cancer. What are the pearls and the precautions that you may need to learn to feel more comfortable seeing this population, and what skills, like electrodiagnostic skills or ultrasound skills, you can also apply to try to help these patients. So the first point that I want to make is, why do I see patients with cancer in my clinic? I'm a sports doctor, so when you see sports medicine, you don't think about cancer rehabilitation, right? So one of the things that I notice is that this population is being underserved, and I feel that with my skills, even though I have a very big interest in helping athletes and acute injuries, I'm being able to provide there with a good care that is not being provided at this point. So one of the things that kind of got me mad in the sense is that when I see patients and they come to my clinic and they say that their provider, their oncology provider, said that you have to get used to this new normal, and they have pain and they have fatigue and they have all these issues secondary to their treatment, but you're alive, so you just have to get used to it. And that's not true. As a rehabilitation physician, we know that that's not true. Our job is trying to implement that quality of life back, that independence back, to try to recover a little bit better that functionality. So one of the big things that I decide to see patients is because I feel that they're not being taken care of by other colleagues, and rehabilitation is not being offered. Number two, seeing patients with cancer actually is great. They want to get better, they're very appreciative, they follow your recommendations, you tell them to exercise, they exercise, and you see them back and they ask you what else they can be doing, compared to other kind of patients that I see in my clinic that are in more chronic pain, that they don't follow recommendations, and it's kind of even more frustrating. These patients actually, it's very kind of rewarding to see them, and they're very appreciative in the care. So one of the things that we did back in my residency is that I tried to investigate why we're not seeing patients with cancer in PM&R. And we interviewed some oncologists there, and we found that 88% of oncologists have zero or minimal education about cancer rehabilitation and its benefits. That provides that 72% of them referred less than 50% of their patients, and one-third of them referred less than 5% of their patients. So they're not referring patients, however, we asked them if they think this rehabilitation is extremely important in their care, and 92% said yes. However, they're not sending the patient to rehabilitation. So that's why I, it kind of sparked my interest to try to educate our colleagues and try to help this population. So the second point that I want to make is that try to complement your interest and practice. Like if you are a sports doctor, I like a lot musculoskeletal problems. I like using ultrasound. So I try to implement that and try to help patients, but if you are more into brain injury or spine care or such, oh, there's a cancer that you can definitely get into that you can provide care, and you feel that you still have the knowledge to take care of that. So as a sports physician, a sports fan, I always bring this quote from Stuart Scott. He was an ESPN anchor, and he died of cancer in 2015. So in one of his last speech, he said that you beat cancer by how you live, why you live, and in the manner in which you live. So it's not just living, it's also the quality of life, how you're living, your independence. So I always try to bring this when I talk to oncologists, that this is extremely important in the care of the patient. So now to get into more details about what kind of conditions I'm seeing in my clinic. So you can divide this kind of different complication in different circles, and you can have your neurological, neuromuscular, your musculoskeletal, your pain, your treatment complications, your functional complications as a rehab doctor. As a sports physician, I kind of focus a lot in my outpatient clinic. So another thing is that you can do inpatient or outpatient, and you can kind of pursue any of this. In my case, I do outpatient rehabilitation. So I see a lot of musculoskeletal complication. I want to tell you a little bit of my experience on how do I kind of learn to do this by myself, basically. And it was not that hard. The first point that I want to make when you're evaluating musculoskeletal pain is that you have to distinguish if the pain is coming from the primary cancer, from the cancer itself, from the tumor, the malignancy, from the treatment, the radiation, the chemotherapy, the surgery, or it's just a degenerative benign problem that is just happening, doesn't have nothing to do with the cancer. The most challenging part is to make sure that the pain is not coming from the cancer. That's the first point I always try to answer. That's the first question. And I bring this x-ray from one of my patients. This patient was sent to my clinic from the Breast Center. She was treated in another institution. She was establishing care with us. They evaluated the patient. She was having this chronic pain in the breast region, and they sent to my clinic to try to help with that. When I see the patient, she comes with a one-point cane. And as a PM&R, we always ask functionality. So I ask her, what's going on with the cane? And she said that for the last two months, she's having this pain in the hip, and she's using the cane to help with that. And with a patient with cancer, that's kind of a red flag for me, that I want to investigate faster than any other patient. So I got concerned. Even though she didn't come for that, she had not told anybody about this pain. We did the x-ray, and I ordered an MRI at the same time because my suspicion was high. And the radiologist called me that there's some metastatic involvement in the acetabulum and the femurs. We did eventually, like, bone scan, and you can see the involvement in the spine and in the pelvis a lot, and also in the MRI with and without contrast. So we were able to identify metastatic problems. We were able to coordinate this care with oncology team and let them know, and they took care of the patient to try to optimize the treatment because the problem was that she was lost to follow-up, and that's why she developed this problem. However, this is not every patient, okay? This is the exception. This is the thing that I think the first, but it's not the majority of the patient that I see in my clinic. So when I see a patient with cancer, these are the things that I see more commonly in the musculoskeletal symptoms. And as you can see, the majority of the list, you already see as part of your PMNR musculoskeletal problem. There's encapsulitis, rotator cuff dysfunction, tendinopathy, carpal tunnel, all the things you already know how to treat. There's a few diagnoses here that might be new, and those are the one that I learned by myself, and that's the one that I want to bring in order for you to feel a little more comfortable in seeing patients. So I just brought this example because this is one of the most common complaints that I see in my clinic. They send the patient with, I see a lot of breast cancer, so they send the patient with a lot of shoulder pain and chest wall pain. So this is kind of my differential diagnosis that I go through it, okay? So in terms of going through that differential diagnosis, one of the most common thing that I see is shoulder dysfunction or rotator cuff impingement syndrome. And this can happen a lot with the surgery and the radiation treatment that can develop tightness of the pectoralis muscles and then weakness of the scapular muscles, and this creates a biomechanical problem that can affect and create shoulder pain. So this is something that, as we know, we emphasize in rehabilitation and exercise, we can use some pain control medications to try to help with the patient and eventually improve their biomechanics and their pain. Another condition that I see that might be new for you is axillary web syndrome or cording. This is basically a development of a palpable cord-like subcutaneous tissue that can extend from the axilla to the elbow and sometimes even to the hand. And you can see in the picture right there, it's that cord that nobody's sure why that happened, but it's kind of being thought that it's the lymphatic sclerotic system or a vein that gets thickened and damaged, and it creates this kind of cord in that area. Usually it's not painful, but it can restrict the range of motion and decrease the activities of daily living of the patients. We treat this conservatively with rehabilitation and physical therapy. Sending a patient that feels comfortable seeing a patient with cancer is better because a normal shoulder orthopedic therapy might not be, do not know what to do with this patient. For example, a lymphedema therapist that sees this more frequently might have the knowledge to try to incorporate manual mobilization and help the patient. Post-breast surgery pain syndrome or post-mastectomy pain syndrome is something that I see very common. I like the post-breast surgery pain syndrome name because it incorporates any type of surgery in the breast region. It's not just mastectomy, it's not just lumpectomy, it can be reconstruction, it can be implants, it can be prosthetic surgery that can cause pain like this. It's basically this persistent pain in the lateral chest wall and breast region, even longer than it's supposed to from the recovery of the surgery. The patient described this burning, stabbing, and neuropathic pain. Usually I see it more in the lateral chest wall. It can be also in the proximal arm because the intercostal brachial nerve can get injured in there and cause this problem. The big issue with this condition is that this is one of the big condition that the surgeon tell the patient that that's okay, that's your new normal. And 52% of woman diagnosed with this at four years after surgery still have pain and problems seven to 12 years after. So this is something that is not being taken care of and we have some option that we can offer the patient. Like always, we start with a good rehab program, evaluating the biomechanics, improving the shoulder dysfunction, incorporating desensitization techniques. Then we can consider oral pain management medication or injections. In my experience, my patients with cancer are tired of taking medication already. So we kind of jump recently in doing the injections and maybe using the oral medication as a third option. I'm having better result with Cymbalta or Duloxetine. So that's something that can be considered, especially in patient that don't want the injection. We're going to talk a little bit more, but the serratus anterior plain block is a procedure that I'm doing with this chronic pain under ultrasound guidance and I'm having 75% results, which is good for this population, which can be challenging. Another condition that is very common is the aromatase inhibitor associated musculoskeletal syndrome. So aromatase inhibitors are medication that are given to patients, especially breast cancer patients, to try to decrease the estrogen coming from the fat. By doing that, they can develop pain in the joints and stiffness and it's kind of a phyromyology kind of presentation that they have pain, symmetric pain, all around the body. And the problem is that this pain can be so bad that the patient needs to stop the medication. And they're not receiving the benefits because this medication can decrease the recurrence of the breast cancer. So we have to find a way that we can decrease these side effects so they can take advantage of taking the medication. Something that I see very commonly in this population is a lot of trigger fingers and a lot of carpal tunnel, which is something that I have interest in. So I do a lot of procedures in these patients and I have patients that have like four trigger fingers in one hand and three in the other at the same time with this medication. So it's something that I see very frequently. Treatment, exercise, exercise, exercise is the best treatment. So I try to educate them in terms of how to create and optimize an exercise routine. Oral medication can be considered rehabilitation, steroid in special locations, and acupuncture. Another diagnosis that you might see is radiation fibrosis syndrome. So basically, this is a clinical manifestation of progressive fibrotic sclerosis after radiation treatment. And this can be challenging. It's basically accumulation of thrombin that can affect the muscle, the ligament, the tendons, the nerve, anything that can get basically the radiation can affect it. We see this a lot in different type of cancer. Head and neck is very, very common. The big problem is that when they send it to my clinic, usually it's too late. They already have contractures. They already have a limited range of motion. So early physical therapy and occupational therapy rehabilitation is key. So basically, educating the surgeons to send this patient very quickly after surgery is kind of the main treatment to try to prevent this from happening. Cancer-related fatigue is one of the most common thing that I see because I like exercise. I like talking about exercise. So I spend 30 minutes talking about exercise with these patients. So it's something that 60 to 90% of patient with cancer can develop. It's this persistent and subjective feeling of feeling tired and exhausted all the time, even though you're not doing anything to make you tired. So the first thing that I like to do is order some basic labs because I want to rule out another reason that can cause fatigue. And I have a few patient that we have found like hypothyroidism that we can manage and that can help with the fatigue. So I always try to screen for other reason. And if everything is normal, then I start counseling and educating the patient about cancer-related fatigue. I explain to them what's going on. Most of them, nobody have talked to them about what's going on. So I tell them that this is common. It's not normal, but it's common. We need to exercise as the main treatment. And sometimes we use pharmacological, but in my practice, I haven't used it yet. Usually with a good exercise program. And we're going to talk a little bit at the end of what our exercise program entails. Another point that I want to make is the psychological and psychiatric impairments. So as PMNR, we cannot forget about the cognitive dysfunction, the psychological state, and the mood of the patient. And not just the patient and also the family members. I have one patient that she had metastatic breast cancer. She was doing pretty well under the sense of her condition. But then I asked her husband how he's doing, and he starts crying in the middle of the clinic. So there I learned that also we have to help the family members. And so we kind of provided some resources for them. And that was a big surprise even for the patient. She didn't know he was dealing with that. So always don't forget to help the family member. And this is true for any other condition. So talking about procedures that we can perform. So I don't do electrodiagnosis anymore, but this is something inviolable for a patient with cancer. It can help the treatment plan of radiation, chemotherapy, and surgery. Because acquiring neuropathy is very common in this population. It can be secondary from compression of the tumor and the malignancy. Or it can be from the treatment, the radiation, the surgery, transection, chemotherapy, as you know, peripheral neuropathy. So if you like doing electrodiagnostic study, this can be maybe something that you might want to explore. Because you can identify radiculopathies. You can identify Lamberida myasthenic syndrome because there's some type of cancer that's associated with those. Polyneuropathies, mononeuropathies, like I said, with carpal tunnel, with aromatase inhibitor medication. And radiation plexopathies is something also that can be extremely helpful. As a sports physician, I do a lot of ultrasound. I love ultrasound. But the first point that I want to make is like, the goal is not to identify the tumor with the ultrasound. We're not diagnosing the cancer with the ultrasound. Basically, we're using ultrasound to diagnose other complications from the treatment and also guide procedures that can be helpful to the patient. For example, like I said, I see a lot of carpal tunnel. So I can do a high, in the picture on the left, high volume hydrodissection on the median nerve at the level of the carpal tunnel to help with their symptoms. I see a lot of trigger fingers. So we can do trigger finger injection. That's the video over here. And you can see the needle over here on the fluid under the A1 pulley going in that area to optimize the outcomes of there. I see a lot of adhesive capsulitis. I didn't get into too much detail. But I'm having great result with high volume hydrodissection on the shoulder capsule. And you can see the needle over here, needle tip with the capsule expanded over here. And it have been shown that it has better outcomes than just a simple steroid injection. And the one that I'm doing more recently, the serratus anterior plane block for post mastectomy pain. Basically I put the needle right there on top of the serratus anterior. And that's the area of the cutaneous nerve that gets injured with surgery. And the way that I visualize it is that those nerves are hypersensitive. So by doing like an aesthetic injection and steroid, we kind of decrease that sensitivity and the patient are having relatively good results. So we put it in between the latissimus dorsi and the serratus anterior muscle. And right now I'm following my outcomes. And I'm having 75% of patients are very satisfied with this injection. So just to finish up, I cannot stop talking without talking about exercise. So the first point I want to make is that 70% of patients with cancer do not meet the aerobic exercise guidelines. So 90% do not meet the resistant exercise guidelines. So these patients need to be exercising, but they actually are not doing it. So when is the best time to exercise? And what I say is like now, today, yesterday. At any point during the care, the patient needs to be exercising. There's evidence that exercise can decrease the primary cancer diagnosis. So it can decrease the chances of getting cancer. And every year more studies come with different type of cancer have been shown that can decrease the development of cancer. During treatment, exercise has been shown that it can decrease the side effects of the treatment. It can decrease the neuropathy. It can decrease the fatigue. It can decrease the complication for neuromatous inhibitors. It can get you stronger. So it can decrease your impairments in that sense. And after treatment, it has been shown that some cancer, it can decrease the recurrence of the cancer coming back. So all these patients, exercise can be part of the treatment. You're fighting cancer and you're helping your oncology by trying to optimize that exercise routine. And just to talk a little bit about the cancer prevention, this is the current list of the cancer. And in general sense, there's 10 to 24% of physical activity can decrease the risk of getting primary cancer. So what do I do? This is kind of the recommendation dose because I feel exercise also a medication. You need to do at least 150 minutes of aerobic exercise with moderate intensity and two to three times a day of strengthening exercise. And that would be a great exercise program. However, the majority of these patients are not exercised. So we're not going to start with this level. So what I'm doing, I'm telling the patient you need to exercise two or three times a week of 20 minutes of mild to moderate intensity exercise. If you want to do a little more intensity, I incorporate interval training in their routine. So they need to exercise for five minutes just walking. I tell them just walk for five minutes and then power walk for one minute. So you continue with this five to one ratio of interval training and then a couple of weeks later we can optimize that ratio or we can add another day in the week or we can add a little bit more intensity in their routine. Just to finish up, I'm getting tired of talking. So let's talk about the precautions and recommendations. The first thing that I want to point out is, especially in rheumatological compromised patients, you have to follow their labs a little more closely. There's different values and different things and you may feel more comfortable with different values. But in general sense, if you have an hemoglobin less than eight, then you've got a little more concern about a patient not tolerating exercise very well. So having a close monitoring with the oncology team, a great conversation with them is kind of key. If the patient have a low white blood cell count, then you may want to avoid public gyms and other public places to avoid the risk of infection. In terms of plaquette counts, if you're above 50,000 you're pretty safe. Studies show that if you're above 30,000 the risk of bleeding is extremely low so you can engage safely in more exercise with light resistive exercise. If it's less than 30, the risk of bleeding is higher so you have more concerns. Always monitor the sodium and potassium and other minerals, especially if the patient is vomiting and having diarrhea or the side effects from the treatment. Never forget about the cardiopulmonary toxicity of medications and if the patient already have a history of cardiac problems, you need to monitor more closely and maybe even consult some specialist. This patient can develop fracture risk. They can have metastasis to the bone so you have to take that into account when prescribing exercise. They can have ostomies. So swimming might be not a good idea for this patient. If they have severe pain, definitely you have to manage that pain before getting them into an exercise rehab program. If they receive radiation, they can have skin irritation so the sun can affect a little bit more that skin so that's something that you have to take into account. Maybe it's not a good idea to exercise outside. If you have neuropathy or numbness in the feet, that can affect your balance, especially in the older population. Risk of falling and then developing other complication is something that to take into account in your exercise so maybe a stationary bicycle would make more sense for them and if the patient is taking blood thinners, the bleeding risk is also something to consider. So just to finish up, many of these issues you already know from seeing other type of patients. We already have most likely all the skills but there's going to be a learning process of learning these perils of different things and slowly every patient that you see, you learn more. You learn more and then after a year, you feel very comfortable or less of seeing this patient like I'm doing with my breast cancer patient. At first, I was kind of concerned and now I feel very comfortable seeing it in my clinic and I spend a lot of time talking about exercise which is always fun. So just to finish up, I want to finish with this quote. Jimmy Valvano was a college coach that also died of cancer and in one of his speech that I encourage everybody to watch on YouTube, he said, cancer can take away all my physical abilities. It cannot touch my mind, it cannot touch my heart and it cannot touch my soul. And with that effect, with the lights, I finish my presentation. Very dramatic. That was a tough act to follow. Okay. Well, all right. You got that? We're going to do some lights, maybe some strobe and neon. We'll make it good, hopefully. So Sarah talked about the why, and Raul talked about the what, and both were really, really informative. Today, we're going to talk about the how to bring these cancer patients into the clinic room with you. And this is talking to everyone, in particular folks who are not necessarily in a practice like mine, which is cancer rehabilitation. I'm at a tertiary care academic center. This is really to talk about, are you in sports medicine? Are you neurorehab? Are you someone else? Or are you a cancer rehab physician who wants to expand their practice or hone maybe their sales pitch? And it's easy, but it's work, if that makes sense. All of us in this room sort of have had to justify what we do or explain what we do to other providers. Right? We're not a physical therapist. We're not this or that. And with cancer, it's no different. So this comes from just sort of this part of PM&R where we're a misunderstood specialty. So that said, the one thing you have to do to carry out what Sarah and Raul have encouraged you to do so is to convince the oncology providers that your service will benefit the patient. Maybe it sounds straightforward, but it's not. I assure you that. And this is somebody who's been doing this for a while. There's a few reasons why. One is the oncologist's attitude, right? So number one, as Sarah pointed out, there's a lot of impairments, but they usually aren't evaluating those, right? What's your blood counts? What's your disease status? Are you good? Okay. See ya. Is there anything major and obvious? Is your limb five times the size of the contralateral side? No. Okay. You're good. And there's reasons for that, right? They're curing their cancer or at least prolonging their life, hopefully, or trying. And those are all incredibly noble things. I don't mean to diminish that. But at the same time, they have to deal with these time constraints, right? Or they just don't know how to evaluate training. I had a referral the other day for wrist drop, but they called it carpal tunnel syndrome. So the stuff that is maybe easier for us is not necessarily easy for them, vice versa. And they play defensive medicine. Your hip hurts and you had cancer five years ago, let's get an MRI and a bone scan and a PET scan and all this stuff. So they do that, but then somehow in the weeds, the rehab referral gets lost. Even when those impairments are identified, though, we're not getting those referrals. That's sort of the one that hurts a bit more. So you have to break this cycle, if you will. And I'm citing a couple of studies, Raul referenced his own, which is quite good. There's others that talked to physiatrists and said, hey, what are your thoughts on cancer? And it's now a little bit dated of a study, but there are a large contingent who thought if cancer, don't do rehab, let's stick to the strokes, let's stick to this sort of thing. And that is also a bit jarring. There's attitudes of palliative care physicians that says that rehab gives false hope, you know, is one of the studies, right? And you know, I don't know how any hope can be false. I understand how we can maybe be too optimistic at times, but I think there's a way to sort of, you know, ingratiate patients with what we do. So those are a few of the attitudes, but you're also going to face those misconceptions, right? So I've been at Michigan for forever. You know, Raul read the boilerplate, you know, copy-pasted bio I give a bunch of places, you know, like I feel like I'm legit in terms of, in the eyes of a lot of oncology organizations. And on Wednesday when I flew here, you know, I got an angry message from a clinic nurse that was saying, why hasn't this patient been scheduled with you? And the referral said, schedule for physical therapy with Sean Smith. And you know, and it's just, it, right? Like there's always that sort of element that you have to deal with, right? Or this thought that we already do this, what do you mean? We have a lymphedema therapist 40 miles away, why do they need to see you, right? Or does insurance cover the referral? Yes, right? Does insurance cover a neurology referral? Then it will cover what we do. These sorts of things. But the good news is that you have a lot of folks, you know, with the wind at your back, okay, and pushing you forward. This is the alphabet soup of some organizations that are all saying, hey, get these patients to rehab, okay? And whether or not you're in a community or in your big ivory tower practice, the oncologists have trained and they have been following these guidelines. They still follow these guidelines and they see rehab mentioned here and there, okay? And you don't need to know all of this, but you do need to know that it's not just you or it's not just the AAPMNR saying, hey, give us these referrals. It's some pretty big heavy hitters that are, you know, encouraging our work for the patients. Now translating that is a different matter, okay? But everyone knows what this organization is, right? These are their survivorship facts and figures. This is the newest one, but going back since I started practicing, they've always had this, it's a rehabilitation. It's very clear right there and this is what the American Cancer Society says is necessary. You can see that we got the same amount of pub as palliative care. We're ahead of palliative care. We're ahead of psych onc, right? That's how important the ACS, American Cancer Society, thinks of us. That's pretty important, right? So these are some easy low-hanging fruit type of, you know, organizations you could reference when you're talking to folks, but it also should put in the back of your mind that you're not alone, okay? So practically speaking, what do we do? That's great that the American Cancer Society likes us, right? That's great that the Oncology Nursing Society says go rehab, but, you know, what are the practical sort of take-home messages you can have, you can pass on to your coworkers, you can pass on to the other folks at your institution, okay? I probably need an updated picture of an elevator, but you need your elevator speech, right? So when you're going to approach an oncologist, be it medical or radiation, or maybe you're talking to the orthopedic surgeon who operates on sarcomas, or the plastic surgeon who does breast reconstruction, right, sometimes you've got about 90 seconds before you lose their attention. So you can't say, like, well, there are going to be 24 million cancer survivors by 2027, and this is, you know, you're done, right? If they're at my institution, they're thinking about their lab. If they're somewhere else, they're thinking about their next patient they got to see, or, you know, what are they going to get for lunch, or something like that. So you have to very succinctly explain why PM&R is valuable, right? And cancer is just a microcosm of other, you know, other subspecialties we do that Sarah listed out. But, you know, one of the things, one of the ways I approached this, and it was, you know, pretty successful, was think of me as a neuro or musculoskeletal symptom management expert, right? So symptom management are those buzzwords that they say, oh, I know what that is, okay? I know symptom management, right? So no longer do they think of me as just someone who's going to get patients on a treadmill or something, or, you know, a personal trainer, right? Or maybe just, I only do lymphedema, right? So this is starting, the wheels are starting to turn, and then you still have their attention, then you can hit them if they're a breast oncologist with trigger finger and adhesive capsulitis and everything that Raul said. Even if you don't do those injections, this gets your foot in the door, right? And Michael Stubblefield, one of the, you know, big shots in our field, has sort of a phrase that's, you come for the impairment and you stay for the function, right? I know we do more than this. This isn't talking about cancer-related fatigue. I do a lot of cognitive rehab with folks, but if I just gave a big printout of 50 things that I do, I've lost them. But if you start with neuromusculoskeletal symptom management, your foot's in the door, and from there it branches out to what the oncologist might want, right? Another sort of buzzword catchphrase-y thing you can say to them is, we can help your patients get a higher performance status. So performance status is something that was invented around World War II, and it's still used today by oncologists, right? It's old enough to have fought in Vietnam and all this, you know, it's seen a lot of presidents come and go, but it's still used. It's a very kind of crude way of saying, how functional are you? How much assistance do you need? They use performance status for a few things. One is, it's a marker of mortality. The lower it is, the higher risk of mortality. But the bigger is, it can get you treatment or stay on treatment. So folks who need a lot of assistance get this lower performance status rating, and then they have to be pulled off of treatment, and maybe they start talking about hospice and all this stuff. If we can enhance that, or sustain somebody at a level without having them drop, that triggers in them, oh, oh, this is good, right? I don't like seeing patients hobble in with a walker and two family members lifting them anymore. Maybe rehab can help prevent that. So they're going to think of that. These are a couple of quick pitches that, you know, keeps their attention and it speaks their language more than anything. The last is, let me coordinate your symptom management, right, or your physical therapy. These, just like me, you know, oncologists don't like signing a bunch of paperwork to extend physical therapy out or occupational therapy and all that, but that's something they have to do. So if I'll take that off your plate and I'll get patients to the right physical or occupational therapist, or I'll give a home exercise program and save them six weeks of appointments and co-pays because they've already had a bunch, right, then all of a sudden you're in with them, right? They like that. Patients love that too. So these are some easy, effective ways to sort of get in their head about what it is that you can actually do that's not just this nebulous, like, exercise or, you know, lymphedema like so many oncologists think of cancer rehabilitation, right? This gets you to the trigger finger. This gets you to cancer-related fatigue, post-mastectomy pain, et cetera. So to do that, you've got to get FaceTime, and I don't think Sonal's here, but this is Sonal Oza. She's at Utah and soon to be at another place, but I had to Google somebody for cancer rehab and she got put up on the big screen here. But the important thing is to get FaceTime with these folks, right? So if you just like start somewhere, if you send an email, they might refer you to patients for a few days and then forget or, you know, something will happen. But if you show up and they remember your face, if you can connect with them, this goes a long way. And it sounds really, you know, obvious, why are we wasting time at, you know, our annual assembly talking about this stuff? But it's something that we don't necessarily do, you know, in terms of putting ourselves out there. Or if we do, maybe we do it once, but you kind of have to keep showing up. So examples could be oncology grand rounds or offer to give them. That was a big thing for when I started, right? And the people organizing grand rounds tend to want to have speakers, right? It's hard to get people lined up. So if you volunteer, they're probably gonna say yes, and then they're gonna send you referrals and you get a bigger platform to say this stuff. You get more than that 90 seconds before their attention span drips off. If you're at a teaching institution, talk to their fellows, talk to their residents, internal medicine residents, in addition to your own, about what it is you do, because then that kind of bubbles upstream. You can attend their tumor boards. So especially at a community setting or maybe not a big tertiary care setting, this is incredibly important. Where I am, most tumor boards are very just efficient machines. It's pathology, radiology, diagnosis, okay, stamp, we're doing chemo surgery, whatever, move on. And so there's some exceptions, like at our sarcoma tumor board, they want our input if it's like, should we salvage the limb or not? But for the most part, they don't really, function comes after that, right? The purpose of a tumor board is to come to consensus about disease status and treatment. At community places, that's a little different. You have more wiggle room. They might ask about function, right? There's usually food, you can go and attend, and they'd love for you to be there. It's been my experience when I did work at a community hospital, and it's been my experience talking to others who do, that there's a lot of room for like, oh, should we get this patient some physical therapy? Or should we get them into rehab to tune them up? They were kind of struggling walking into the clinic room. So there's a little more breathing room for you there, especially if you're not at one of these big centers like I am. You could attend patient support groups. So patient, if they won't listen to you, they'll listen to patients, right? The oncologist. So there's probably no shortage of these, and especially with Zoom and everything virtual now, you can show up, and patient support groups love hearing this. You know, I'm on the board of what's called our Cancer Support Community, and they give talks on like, what is immunotherapy? What to expect from chemo? But the most well-attended ones are the talks on peripheral neuropathy, on cognitive impairment, on lymphedema, that type of stuff that when the patient goes home, they still deal with. Okay, they can read enough about immunotherapy. They get the big, you know, kind of credit card legalese about side effects and all that, but they wanna hear about, how do I get living my life? So patients love hearing from you, and they will bubble that back up to the oncologists. Another strategy is to look at, where are the diagnoses? Like, what do I do? Okay, should I, you know, should I just get all the lung cancer patients? You know, it's kind of hard to know, you know, where to go. And it really is institution dependent, you know. This is a slide from a multi-center study that has nothing to do with kind of getting referrals, but, you know, we had six sites involved, and each site had a little bit different flavor in terms of the diagnoses that were coming. Number one, though, far and away was breast cancer, ranging from, you know, about a third to almost two thirds of their referrals. So chances are, for a lot of the reasons that Raul outlined, breast cancer is a very rehab-friendly referral source for you. There's a lot of survivors. Even if they don't survive, they live a long time. There's a lot of neurological, musculoskeletal, cognitive morbidity, lymphedema, everything. So this is a great place to start. In this study, head and neck and gynecologic were also high referrers. If you're at a big center, look for, like, the sarcomas and that sort of thing. If you're in a big city, you might end up seeing more lung prostate patients. But go to sort of where it's easiest, right? A river flows to the path of least resistance, and you should, too. Speaking of, I've talked a lot about how to, like, get on the level of the oncologist, right? But a lot of times, they might not be actually doing the referral, right? The patient sees them, and other folks are helping them. So this is a journal for advanced practitioners in oncology. So PAs, NPs in oncology are really, really good. They're really, really passionate about what they do. And they are the ones who hold the patient's hand. They're the shoulder to cry on a lot of times. And they're the ones who will get the patients to rehab. So nurture those relationships. That's critical. An MA in the clinic, an RN who answers the phone for the breast cancer clinic, not just the NP or the PA, those are the folks that are going to say, hey, you should go, you know, see Sean in rehab or something like that. That's incredibly important, and it sounds, I don't know, it might sound simplistic, but you could skip the physician in this and go straight to them. Remember, they'll also interface with them. Social workers and case managers are also really good. Resources, social workers will lead those patient support groups. Case managers, it goes without saying why that is important. So the other, you know, in order to sort of, you know, think like someone, you gotta, you know, write like somebody, so to speak. And so, you know, if you want to, you know, speak, if you want the referral, speaking their language helps. This is an example of a note that I have, and it's a lot of like gobbledygook, and this talk isn't for everyone. This is some researchy stuff that's in my notes, but all the oncologists see this, right? And so they see right off the bat, if I'm seeing, you know, Mr. Jones or whoever this is for, I don't expect everybody to necessarily have this much detail, but what it does is it gives me credibility when I say, okay, Mr. Jones just has, you know, a muscle strain for back pain, right? It tells the oncologist that I've actually looked at all the other stuff. It's not the radiation, it's not the bone med, it's not this and that, it's just something easy, right? And then they're like, okay. Or they'll next time say, wow, Sean really looks at everything. You know, he does a, you know, he's not just being superficial or being cavalier. You know, he's not, probably not missing anything even though I could be, right? This gives me a little bit of credibility with the oncologists. And, you know, I see my summary of treatment copy pasted into some of their notes or like the surgeon's notes sometimes, which is like the greatest feeling, right? Because it's good enough. And so doing this gets you that sort of credibility because if the physician isn't, then the NP or the PA might be looking at this or the fellow, right, if it's a training institution. So try to at least summarize what the treatment has been. You don't need to write like how much gray of radiation and EBRT. This is probably like, you know, a little OCD on my part being overkill, but just saying this is what they got. And because a lot of what we treat is really just from the treatment, right? It's peripheral neuropathy or it's, you know, fatigue or it's, you know, myositis from the immunotherapy, something like that. And then you can, it helps you with your differential diagnosis. You're also not fumbling like when you're talking to a patient being like, oh, your hip pain started here. When was your radiation? You know, that type of thing, right? You know it, or you can at least glance up at your screen if you kind of look at this beforehand. So I highly encourage you to review oncology treatment. However you want to translate that into your note is your business. But if you have the time or if it's easily accessible, I highly encourage you to put it. This is like almost right at the top of our notes at Michigan. And we do this, all the providers do a similar template. A few other pearls I'll share are return visits. So you are the fifth, sixth, however many physician that this patient's gonna see, you know, 10th. And, you know, on a certain level, the oncologist might be a bit protective. Like why am I gonna have them do a co-pay and have another visit? I gotta, you know, justify it. But let's say you get past that, right? With all that, those pearls I gave you are something you already knew. You got the referrals. Are the patients gonna actually wanna show up? So in addition to you, you know, hopefully demonstrating some value to patients, providing education and or an intervention, you gotta make it worth their while. So, you know, at least where I'm from, you know, we get patients from Pennsylvania, Ohio, Indiana. You know, we get, I've had patients from Europe, right? They come in, but they're not gonna come from the Netherlands just to see me. They're going to come to see the radiation oncologist, their surgeon, their medical oncologist, everyone. So one is try to plan your follow-up with these patients who live far away on the same day or days that they're seeing the other folks and don't make them have to come in for you. And that takes some planning and that might take some sacrifice on your part to squeeze patients in, but that's how you'll actually get these patients to show up and quite frankly, if you put them on your grid alone and they don't show up, you've wasted an appointment, which is no good anyway, right, that's for another patient. So this has benefits for you elsewhere. Virtual care has sort of revamped this to an extent. Now, if it's a trigger finger evaluation or a new patient evaluation for a pain syndrome, you probably need to see them in person, but there's a lot of virtual follow-ups that we do post-procedure or post this sort of intervention. And we do some new patient virtual visits. It could be cognition or fatigue or something like that. We can talk it out with minimal physical exam necessary. So just try to make it easier on the patients, both in travel, but in ease of just walking down the hall or driving across the street or the city to get to your clinic from somewhere else. And that takes some coordination with the oncologist, but that can come, okay. So I'm gonna close with a slide that's a bit, you know, a bit of a pivot about inpatient rehab, which a lot of us do, or if we don't do, we work with people who do. So cancer is sort of this, I think it's just thought of way too kind of broadly and sometimes a little too darkly, right? Like someone I used to work with said, like, you should really go and, you know, get CMS or whoever to put cancer on the 60% rule. And it's like, well, cancer is like a thousand different things, right? So it's not that. It's a matter of fitting a patient's cancer-related impairment into the 60% rule, then yes, probably advocating for broadening it a bit. But many of our patients are already fitting that, right? So if they, you know, had immunotherapy and myositis or any complication and they can't get up from a toilet seat, they probably have steroid myopathy. If they've had a remote bone marrow transplant and they have some weakness in their legs, they probably have steroid myopathy, which is a neuromuscular condition, which fits that rule and which also can get them more days on the insurance, covered by insurance on your unit than say, debility. Brain tumors are a longstanding, you know, 60% rule, you know, get a good amount of days type of patient. Peripheral neuropathy is one, although sometimes that's looked at a bit skeptically. There are some complicated orthopedic procedures, et cetera. So there are ways to get patients into your unit and to get them more time and to get you higher levels of reimbursement because these patients are so complicated, right? Maybe if they have thrombocytopenia or low white counts, that gets you a bump up in payment because it's a little bit harder, right? And so all of this, the more you kind of document and finesse and realize that these patients are actually quite easy to get on the unit sometimes, but also can help you in a lot of ways, it's really, really good. The other thing is these patients improve. This is a talk in and of itself, but consistently there's been, you know, studies, both small and large, looking at these patients in different populations, be it heme malignancies, solid tumor, CNS, et cetera. They do improve in function. There's some caveats. It might not be as fast as other similar cohorts or, you know, they do have issues with discharges off, which I'll get to on the other column, but this actually typically helps. We need to refine the science to see who it helps the most with. But this third bullet point under my good, why inpatient is good for these patients is that they're more likely to actually get stronger and keep fighting their cancer. So that's kind of the underlying unspoken, you know, the subtext of why oncologists might send, someone would say advanced cancer or active cancer to us is can we keep them strong enough so they don't dwindle and then I can't keep pumping them full of poison, right, and they're going to die. But if we keep them stronger, they could stay on treatment. It's unspoken and it hasn't been, there's not been, you know, a prospective randomized trial to this and I don't want to overstate the evidence, but there is evidence, you know, if you look at what I have here, there's a cohort that went to inpatient rehab and a cohort that went to SNF and only 4% of the cancer patients who went to SNF went on to get more chemotherapy. Many of them in that cohort ended up dying within six months. So which is a criteria for hospice, right? So if we get them to inpatient rehab and there's a lot, again, this isn't our talk, but if we get them there, 50% of them went on to more treatment, less of them died within six months, right? We got them hopefully going out and hanging out with their grandchildren even if they did pass away. We got hopefully more treatment so that they could live longer or get cured with inpatient rehab and one of the thoughts is if you're not sure, you know, and you have them go to a SNF, a lot of those patients don't do well there and that's not a good death if they die and it's not a good life if they don't die, you know, if they're kind of there for 100 days just kind of sitting there getting inadequate therapy or getting bounced back to the emergency room. So, you know, that said, even when they come to our inpatient unit, second to dysvascular amputations, cancer, again, it's a huge umbrella, has the second highest rate of acute care discharges and 30 day unplanned readmissions. So we have to, as a field, sort of study who it is that, you know, kind of bounces back and how to sort of hopefully preempt that or, you know, that needs some work. So I'm not trying to, you know, be Pollyanna and say all these patients do well. It still has a fairly high rate of complications. The other being that they might need expensive treatment when they're on the inpatient unit and that gets a little muddy. So you have to work with the hospital system or, you know, God willing insurance companies will somehow see the light and let patients, you know, have a separate DRG or, you know, fund for say radiation or immunotherapy that doesn't come out of our cut. So there are some areas we need to finesse but I encourage you to think about this population for inpatient rehab as well. So with that, we're gonna take any questions you all have and thanks for your attention. Thank you. Thank you very much for that great session, great insights and real world tips and experience. So I have experienced a lot of the barriers that you have identified but the question that I have is at that final step is where I tend to hear most of the resistance, I'm not sure resistance is quite the right word but they never pull the trigger because they're in the office, they have 10 seconds left till the next patient, how do they make the referral? And, you know, most EMR referrals are, you know, unwieldy, tens of drop down boxes and it's really problematic for them. So how do you get the referrals? Do you have multiple streams? You know, do they text you, call you, email you, put something in the EMR? Do you have you try to get your providers to use one method so you can track things? Tell me how you're actually getting the referral. We have 10 methods because we try to catch it all. You know, they text me, they email me but we have a separate, like, so at our institution at least there's, if you type in PMNR or PMR, you know, of course you get like 50 things dropped down but it'll say PMR cancer, you know, so that comes up and cancer is high up in the alphabet so, you know, they get seen pretty early, you know, when it's compared to, say, musculoskeletal or spine and that has worked fairly well but not without its challenges. Yeah, the same thing, our PMNR order has like an oncology subsection that only goes to the provider to see. So what I did is I did like a print screen of a step by step, click this button and it will open this next section and then it says cancer, so click cancer. So I do that, I put that in a PowerPoint, I just send it to them in the email. So they have like a step by step way of how to order the PMNR consoles under cancer. I've done the same things. I would say the other things that helped me initially, I sort of did a lot of FaceTime, got on a first name basis with folks and gave them my cell phone and I said, if you have a patient that you want to see me, please text me and then I'll help you put in the order. I also took the time to teach the residents and the NPs and PAs how to put in the order. So once they did it a few times, it just became very streamlined. And the other point I want to make is your own patient. Once you see the first patient, you're going to say, hey, do you think this was helpful? And they say, yeah, it was great. I feel that it was very helpful. Tell your oncologist, tell your team and they go back hopefully and they tell, hey, this console was great, this experience. So they start hitting positive feedback from their own patients and then they start putting more consoles because that's how I did it in the Breast Center. One provider was sending it and then I was saying all the patients, hey, go back and say that if this was helpful for you and now they send me a lot of patients from the Breast Center for that. It was slow though, it was a slow process. Thanks. Again, great presentation. I hate smart people like y'all, but a quick question, just for simple, do you have any simple rules of thumbs you see a patient, whether they have appendicular or axial skeletal metastasis and it's always weight bearing? Can they weight bear? Can they not? Any simple rules of thumb for us? Yeah, simple, I don't know. Yeah, simple, I don't know. I mean, but, you know, there are scoring systems for this that we'll sometimes use that's like, you know, low risk, intermediate high, but then the high risk people get sent to us if they've seen neurosurgery anyway. I mean, if they're not having a ton of weight bearing pain and they're neurologically stable, then I tend to be more lax. If they just received acute treatment, which is typically radiation and sometimes surgery as well, then obviously we kind of wait until maybe that's done cooking. And, you know, is their disease recently progressed or not to, meaning are those lesions active and is the MRI that I'm seeing gonna look worse in two weeks if the chemo doesn't work, then I kind of just take it a little easy, but I don't put them on, you know, bed rest by any means. But if, you know, their last progression was three or more months ago and, you know, the chemo shows some stability or improvement, then, you know, it's kind of a green light minus those symptoms. Yeah, I would agree completely. I had the pleasure of rotating with orthopedic oncology when I was a fellow at Anderson, and I remember asking one of the physicians about this and his advice was really the same, that if they're having a lot of pain, it's not to be ignored, essentially because of the anatomy of the bone and, you know, once you get the extension to the cortex and that's when you're at risk for fracture and that's also where you have the most pain. So that's what I'll tell my patients too, you know, I don't wanna keep you in a bubble. There's so many complications for not moving that we want you to move, but especially with long bone, you know, metastasis, if you have a femur or tibia or humeral lesion that I'm kind of keeping an eye on, I'll just really empower the patient to be a self-advocate and if they notice that their pain is overnight, it's increasing, it's achy, I just tell them not to ignore that. Yeah, and at some point, if you have concern, you can always discuss it with your colleagues, right, in orthopedics or spine. When I have doubts, I send them a quick message in your institution and say, hey, can you take a look at this MRI and give me your thoughts and give me some feedback about it and also using like aqua therapy, like exercising water that is not weight-bearing if you are higher up in terms of your body and buoyancy. So that's an alternative to keep them active even though maybe you're not putting weight on those joints. One rule of thumb just in general I would say is that oncology in general is a huge team sport and so one thing I learned as a fellow also is that they like to be included in discussions and so I'll send email or a portal message to their whole oncology team, say this is the update, you know, they're having a little more pain here, so if anyone sees them in the next few weeks and it's getting worse, just FYI. And I think it keeps my name present as part of the team as well to kind of be pinging them and it's very normal in oncology culture to have a lot of communication, so I feel like it's been easy to fit in that way also. Any other questions? Perfect, so I appreciate everybody for joining and some of us have to catch a flight, so. Thank you.

cancer rehabilitation

physiatry

musculoskeletal complications

exercise programs

electrodiagnostic studies

ultrasound-guided interventions

oncology teams

monitoring patients' conditions

bringing cancer patients

inpatient rehabilitation