(Guest Lecture) November 2022 - Physiatry: A New Approach Incorporating Proven Ideas

Thank you. Hi everyone. Thanks for staying all day. Hopefully we can wrap this up. So I'm Jessica Chang, Assistant Professor and first physiatrist, we have, aka rehab physician at city of Hope Orange County. Alright, so today I will talk about what PM and R is, talk a little bit about exercise and if we have enough time, we'll talk about spine hygiene. So, a little preface, this is a highly interactive lecture. So I want you to be ready to raise your hands, shout your answer, whip out your phone for a QR code. Stand up, sit down, stand up, maybe walk a little bit. Okay. Are you guys ready. Alright, so this first one, I want you to raise your hand. If you or you know your loved one has had this thought at diagnosis. Will I be able to work again. This guy, this person's a ship captain or smoker occupation. What about play tennis again, or something recreational. Lots of hands there. Travel again. That's a popular one. See my daughter graduate. A lot of you play with my grandson. I encourage you guys to look around to eat at a restaurant again. See my son get married. Wipe my bottom by myself. There's a few hands. But in essence what I'm trying to point out is, we often have questions of will I be able to return to my life again. I want you to be able to function. This is my favorite type of F word, function. So what is PMNR? It stands for physical medicine and rehabilitation, also known as physiatry or physiatry, not to be confused with psychiatry, and you can just call it rehab medicine. I'm not sure if you're feeling confused right now. Who am I? I am a rehab physician or a rehab doctor. That's what I like to tell people. Or the fancy way to say it is physiatrist. But I won't hold any of you guys to that. So I'm going to jump straight to the summary. The summary is that I like to talk about function. And I think psychologists refer to function as performance status, which often is used to determine whether you qualify for certain chemotherapy or stem cell transplant. And what we talked about earlier, trouble doing fill in the blank, certain activities, that is what I'm interested in. My goal as a PMNR physician is to enhance and restore function, to maximize independence in your ability to do the activities that you want to do, and to improve your overall quality of life. So how do we do that? So you can see here, we're a non-surgical specialty that specializes in muscle, bones, joints, ligaments, nervous system, brain, spine, taking into account your cardiovascular health, your rheumatological health. A lot of things contribute to a person's ability to function, especially the musculoskeletal and the neurological systems. So what to expect as a physician, I think about medications. Some of us, including myself, can do some injections, like joint injections, trigger point injections, Botox injections for spasticity, not for cosmetic purposes. And so that's something I think about all the time. So I work very closely with physical therapy, occupational therapy, speech therapy, and there's many subspecialties within each of those fields. And it's my job to direct you to the right one and make sure that it's a good fit and we're doing the right things to optimize your function in the right timing, kind of in conjunction with all the medical oncologic things that are going on. What makes the most sense for you? This is one of my favorite tools. It's a theracane to massage trigger points out by yourself so you don't have to have your loved one do this for you all the time, or come see me for an injection or heating pads. So anything conservative to help you move better is what I like to take a look at. So eating is also a physical activity. And playing games or cognition, memory, attention, all of those have to do with function and activity. The tools around you, your social support, your family, your friends, to encourage you, to motivate you, to help you give you a hand when you need it. These are all important factors I consider. And you're probably all wondering what that unicorn is. Let's see if this works. No, it's not working. How many of you guys know this? You know this. Okay. Yes. Okay, just for not too long though. It's okay. Watch it at home. So the message here is that pelvic floor is also, your pelvic floor function is also an activity, like, you know, pelvic pain, urinary or bowel incontinence. That's also in the realm of activity function and their specialized therapy for that. All right, so this is a picture of, hopefully you have a sense already that we like to collaborate, we like to talk to everybody, get the full picture of what matters to you and how do we get you functioning better. All right. QR code, time, phones, phones out. So while you're getting this, I'm going to ask questions to make sure you looked at this. So make sure you get this before I move on. This is a list of physical impairments or disabilities or conditions from my professional society, which is down here called AAPMNR. So you can go there for more information as well that I cannot, don't have the time to cover today. Everyone got it? Almost. Okay. So quick list of subspecialties here, take a quick look, scroll through that list of conditions. So my subspecialty is cancer rehabilitation. There's not that many people who are fellowship trained in the nation, but it is quickly growing field. And all of these subspecialties we have some training in throughout our residency. You can find us in outpatient settings and inpatient settings. Right now I am working in a purely outpatient setting. Usually you will find them embedded into orthopedic multidisciplinary practices or neurosurgery practices managing all the conservative management, all the non-surgical issues. And inpatient, there can be a consult service. You can find them in a rehab facility where you do intensive rehab for a few weeks or in skilled nursing facilities. So raise your hands if you have a PMNR physician already. Too wonderful. Let's talk later I want to know who it is. Oh, it's me. Smart. All right. How many of you guys have seen one? Okay, all of you guys should have your hands up by now. All of you? No, I'm not one. All right. Wait, can I take a picture? Is anyone? It's totally okay. But I thought maybe I could show my boss the answer to this question. You guys all saw the list already? The conditions? Okay, I won't take a picture if there's not that many hands. How about that? How many of you guys think that you might benefit from seeing a PMNR physician? Okay, give me a moment. Let me try not to trip. That's a lot of you. Okay, I'm showing Ed Kim this. All right. Thank you. Thanks for helping me. All right. So, is this new? So physical medicine and rehab has been around since 1929. And the first physiatrist embedded in a cancer center at MD Anderson and Memorial Sloan Kettering was actually in the 1960s. So I'll let you determine whether that's new or not. So what is cancer rehabilitation or prehabilitation? What does that mean? So basically, it's summarized by this up arrow. What we want to do is put an upward force on your physical abilities, your ability to function throughout the entire cancer journey from diagnosis to wherever life takes you. And so a concept within called cancer called prehabilitation is that before you have cancer treatment, or here it's a stem cell transplant, we want to put an upward force on your physical abilities. That way when you have a stem cell transplant, a chemo treatment, that your decline in function from that is not as bad and that you can bounce back from it faster. So this is very hot and new growing field is prehabilitation. And so rehab and exercise is guideline. I don't have time to go through all of them, but there's 69 guidelines that talk about rehab and exercise recommendations. There's 46 professional societies, including the one Dr. Richly mentioned, NCCN, that includes rehab and exercise. Every cancer type has a guideline that includes this, including myeloma. Cancer related fatigue is common. There's a guideline for that too. Bone metastasis. And this is pretty much everybody could benefit from some form of rehab or exercise. So question, this is a hand raising one. The exercise recommendation for cancer patients. Is it, raise your hand if you think it's A, it's more than the standard person, whatever standard person is. Oh, we got like two and a half, three takers, four. Okay, what about B, it's the same. Got more votes there. What about less? C, it's less. Some of you guys didn't vote, but the answer is, it is the same. So how are we doing as a multiple myeloma group. So first, let me tell you that the average American or among Americans, about 23% are meeting guidelines. So, multiple myeloma survivors during active treatment, it's around 7%, and that's rounding up. When you're off treatment, it's 20, around 20%. That's still lower than the average American, which is already really low. They're not doing very well. Maybe I should say we're not doing very well. So, our code again, this is a clinical resource for you. I will show some of these. I'll show some of the resources here in the next few slides, but I want you to have this so you can look through it on your own time. Okay, so if you scroll down, you should see these clinical resources. These are really great handouts I like to give to all my patients. We'll go through some of it. And so, before we even say what the recommendation is, why exercise, you might be thinking, you know, I'm tired. I have, come on, I have cancer. I have bone lesions. That sounds crazy. Maybe you've heard it from your family. But you know, the goal is so you can feel better, sleep better, and move better. And so, if you don't use it, what's the, what's the alternative? Yes, so you have a choice. You can choose to move, or you can choose to not move. You always have that choice. And if you're thinking, I'm not an exerciser, that sounds like way too much for me. At least start with avoiding inactivity. So without further ado, here are the guidelines for aerobic exercise it's at least 150 minutes per week at moderate intensity. What that means is you can talk during, while say you're walking quickly, you can talk but you cannot sing. For resistance exercise, this is whole body resistance exercise, it's at least two times per week. And here are some of the benefits that I'll go into detail on the next slide, but this is all in that QR code, it's all in those handouts so you don't have to take a picture now. All right, so this is for people who likes the details. And so it will tell you. The main thing I want you to notice is this has strong evidence in rehab management say like heating pack or no certain physical therapy like exercises like strengthening your quad. Those tend not to have very strong evidence. This stands out that it's strong evidence, especially for cancer related fatigue, where the strongest evidence is an exercise rather than any medication you can take. And so, cancer related fatigue, quality of life, physical function, mood, and lymphedema doesn't apply as much to you guys. So strong evidence for those, I want to point out bone health resistance exercises, two to three times a week, at least three to four times your body weight for at least 12 months can improve bone health. So let's talk about research, I'm a physician still. So let's talk about research. The short answer is, there is none. None, no published studies on exercise specifically in multiple myeloma. There are some studies on prehab protocols there's some that are completed that haven't been published yet, or some that are incomplete, but this. The research is really low here. So what is city of hope doing. So one of those studies is a city of hope study. I'm not directly involved in it, but I've talked to the person leading it, and it is a tele exercise program for eight weeks via an app targeted at patients with multiple myeloma after stem cell transplant in frail adults who have no specific limitation for exercise, and that they're not already exercising more than 60 minutes per week. And why would we do such a study. Well, decreasing all cause mortality is related to improving your physical function. Okay, but wait, Dr. Chang. Something hurts out something hurts you want me to exercise Are you crazy. Well, if it's not hurting more than mild pain and it's not hurting with weight bearing, like if it's your leg putting your weight on it, if it's your arm you know holding something. If that's. If this happens. Do stop what you're doing. And that's called load, meaning, you know, take that weight off, take weight off your leg, sit in a wheelchair. Find Dr. Christian on over there. We need an x ray, you might need radiation, you might need surgery to kind of stabilize the bone before it fractures. That doesn't mean you get to not exercise anymore. Because what's the alternative of not moving. You lose it. Yes. And so, keep exercising the other limbs I highly doubt there's three limbs that are, or for all four limbs are out at the same time with with lesions that follow this. So, yeah. Keep moving. All right, and not every people don't like surgery, especially if they feel like nothing's broken. So this is just to show that on the left side, you have increased survival these numbers are bigger than the numbers here. You can live longer, if you fix the bone stabilize the bone before it fractures, and the converse is immediate post op death there's less of that if you fix the fracture fix the bone before it fractures. So, do find your physician. Once you're having that more than mild pain with weight bearing. All right, I'm ready to move around a little bit. Okay, we'll start easy we'll start with sitting, and a little bit of a precaution if anything hurts more than mild with weight bearing, please don't do it, I won't judge you and your neighbors won't judge you. Okay, so here is good posture with lumbar support I didn't see anyone bring pillows today. So, you know a little bit of lumber support to restore the normal spine curvature can offload the spine. If you lean forward that increases the forces on your spinal column, at least two times compared to when you're standing. And so it's a significant amount especially if you have lesions in your spine already. So this is something that can be done preventively. Okay, now let's stand up and try this, this motion. Put your arms crossed across your chest to begin with. That's the, don't, don't do this. We like to do this all the time I like to do this too. And then the other one is, no, try, try holding your hands behind your back. See how that feels on your back. Here's another one. Give me a two thumbs up for this presentation. Give me everyone thumbs Okay, then put it down by your side. And then turn it because you changed your mind, turn them both back. And see how that feels on your back. Okay, this next one's a little more challenging this is try to pick something up from the ground or a virtual object, but in this position or a shortstop pretend you're a shortstop, keeping your spine and good alignment. No falls please don't do it if you're hesitant. Okay, this one's very challenging if you have any lesion in your leg or your arm that's hurting with weight bearing, do not do this, I'm not responsible. So, this is if you're picking up a light object, you can lift up your leg and pick it up like you're picking up a golf ball. It might be hard if there's peripheral neuropathy from the Velcade but maybe a good exercise just please don't fall hold on to something if you need to. And at the end of the day when you're brushing your teeth, I want you to remember, you can put your arm on the sink to offload the effects of gravity on your spine. How many of you guys are office workers. Me, me too. Okay, so we could do this exercise periodically. I put in my own version of a chair because this is a lot more stable I don't want anyone falling on this rolling chair. Okay, so things I think about. All right, and then walking, like we should all do for exercise. Right, you know, no slouchy posture, you know roll roll get those thumbs those hitchhiker thumbs. You know, you can turn them back, you know and turn them around. You want to swing at your shoulder, big steps and swing at your shoulder. So, lastly, you know my favorite thing to do is to remove exercise barriers in the clinic that's specifically, you know bones joints nerves that kind of thing. But a lot of the exercise barrier is that people just don't have fun with exercising. It's boring. And so we need to find a way to make it enjoyable for you to actually do it. And so right now I want you guys to turn to a new friend or someone next to you. And I want you guys to spend a few minutes to talk about what you're going to do differently, starting today, and how you're going to make that fun. All right, thank you everyone. Thanks for participating and talking to each other. I hope there were some great ideas that were that came from this. And so thank you so much for this opportunity to speak with you. And you can thank me by exercising together. All right, so I'll pass it back to Greg.