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Julie Nowicki PT, DPT, a physical therapist at Cleveland Clinic's Children’s, joins the 100th episode of the Cancer Advances podcast to talk about the Pediatric Hematology/Oncology Mobility Program. Listen as Julie discusses the program and the benefit of physical therapy for children undergoing cancer treatments.

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Pediatric Hematology/Oncology Mobility Program

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic Podcast for medical professionals, exploring the latest innovative research in clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase 1 and Sarcoma Programs. Today I'm happy to be joined by Julie Nowicki, a physical therapist at Cleveland Clinic Children's. She's here today to talk to us about the Hematology Oncology Mobility Program. Welcome Julie.

Julie Nowicki, PT, DPT: Hey, thank you Dr. Shepard.

Dale Shepard, MD, PhD: Let's just start out. What's your role here at Cleveland Clinic Children's?

Julie Nowicki, PT, DPT: So I have been a therapist here for just about seven years. I treat patients of all ages from birth to young adulthood. I work in an outpatient satellite in Westlake, and I also work downtown at the Cleveland Clinic Children's Outpatient Center and as part of the Hematology Oncology Mobility Program.

Dale Shepard, MD, PhD: All right, well, we're going to spend some time talking about this Hematology Oncology Mobility Program, but let's take a step back first and tell us a little bit about, just in general, the role of physical therapy in children who are undergoing cancer treatments.

Julie Nowicki, PT, DPT: Absolutely. So it's a crucial part of patients undergoing chemotherapy. All the medications that they're receiving have some serious side effects. Those can include weakness, decreased balance, numbness and tingling, decreased endurance. So our job as therapists is to help the patients get back to whatever they were able to do before they started this cancer treatment. So if it's a young kid and they were just learning to walk, or if it's slightly older school-aged kid who was participating in recreational sports and all the way up to adults who were trying to do some recreational or job-related activities, our goal is to get them back to that. So we work on different exercises, tailored to each individual patient to build up their strength, regain their endurance, help their balance, and essentially get them back to where they were before they had to start treatment.

Dale Shepard, MD, PhD: Excellent. So it sounds like there's a couple of components to this. One is patients who may be actively undergoing treatment and have issues related to their treatment and their disease itself. And then there's also long-term effects. So tell us a little bit about the differences there.

Julie Nowicki, PT, DPT: We're going to see some differences in what patients are able to do during treatment versus after treatment. There's a lot of studies out there right now that are looking at the effects of cancer treatment. And there's a lot of things that are saying that even five years out from cancer treatment and survivor hood that patients who've had cancer are four to five times more likely to report restrictions or limitations in their daily activities, whether that being going to school, going to work or just doing personal care items and daily chores. So our job doesn't stop when they stop their treatment. Our job continues on throughout the time that they need to get back to whatever that level of function was. So sometimes it takes a long time to regain that strength and endurance. Sometimes it's a little bit faster and we try to be there every step of the way.

Dale Shepard, MD, PhD: So let's go ahead and jump in and tell me about this Hematology Oncology Mobility Program. What is it?

Julie Nowicki, PT, DPT: Sure. So it is a program that was designed to make sure that all children who are coming through the Cleveland Clinic and receiving any type of care for either cancer or other blood related disorders are receiving care if they need it. We are trying to capture these kids when they're first diagnosed. Oftentimes they're coming in, this is a whole new ballgame. They have no idea what to expect. So we're trying to see these patients at baseline and get an understanding of, "Hey, what do you look like right now? How do you function? What do you like to do during the day?" And then we follow up with them as often as we need to throughout their treatment so that we can continue to monitor their progress, see what kinds of exercises we need to change or update, and then continue again throughout the continuum of care and through the time that they're finished so that they can continue to receive care if they need it.

We are able to refer out to outpatient therapies if they need it. So we only have physical therapy in the program at this time, but we're trying to screen for any possible side effects. So that might include issues with swallowing or language, issues with fine motor skills, such as buttoning buttons, or zippers, or self-feeding and grooming. So we're referring for our outpatient satellites so that these patients are getting care for occupational speech or physical therapy as they need.

Dale Shepard, MD, PhD: And the program itself, is it primarily centered on main campus?

Julie Nowicki, PT, DPT: It is at the Cleveland Clinic Children's Outpatient Center at the R Building.

Dale Shepard, MD, PhD: I like the way you're looking at patients early on, because too often we get people on the adult side sent to physical therapy when they already had the debility. And it must be difficult to kind of know what baseline looked like.

Julie Nowicki, PT, DPT: Yeah, absolutely. You can hear what they say they were able to do, but it's so hard to see that person from, if they're already coming to you deconditioned. So it's great to see them early on so that we know what they like to do and what we can get them back to.

Dale Shepard, MD, PhD: Excellent. Tell me a little bit about the difference between patients coming in to do a program on main campus here versus having them go out and do home physical therapy. There have been some studies that have shown some benefits, is that right?

Julie Nowicki, PT, DPT: Absolutely. Yes. So a lot of the studies show that there's a huge increase in the results or the outcomes when they have individual one on one therapy versus just being sent home with a therapy program. So I feel like we're able to really help motivate them when we're face to face. We're one on one, we're treating them sometimes even during their infusions, sometimes just in between lab visits and doctor visits, but we're able to make sure they stay motivated throughout. Whereas if they went home, they have a higher likelihood of just kind of being a little more relaxed and not being pushed to work as hard. So the outcomes and the research shows that there's a great benefit to working one-on-one face to face versus home based.

Dale Shepard, MD, PhD: What have been the biggest challenges as you set up the program?

Julie Nowicki, PT, DPT: I feel like some of the hardest things right now are just trying to figure out where we fit in and not step on toes. As far as they've got so many appointments, we don't want to overwhelm families. We don't want to get in the way of all the important medical stuff. So like I said, we're trying to see them sometimes in their infusion rooms, sometimes between visits. So just scheduling at this point, making sure that we can get everybody in when they're here.

Dale Shepard, MD, PhD: So when we think about patient selection, you mentioned before that you're trying to get patients as they come into treatment and they're newly diagnosed. Are there particular patients that are better suited or are you really within the children's oncology group? Are you focusing on solid tumors or heme malignancies or anyone?

Julie Nowicki, PT, DPT: Everybody, all of them, everybody that's coming throughout that building is appropriate for this program. We're trying to capture everybody and sometimes we meet friends and they're doing great. So what we might do is just follow up with them in a month. So maybe they've either just started their treatment and they're still feeling really well and not having any side effects. So, "Hey, we don't need to see you all the time. Let me just follow up in a few weeks." So we try to do some routine follow up on everybody to see if they still don't need it, or if they're starting to qualify for more therapy.

Dale Shepard, MD, PhD: Have you found that there are any particular ages of patients that have seemingly benefited more?

Julie Nowicki, PT, DPT: You know what, no, I feel like we've run the gamut of ages. We've seen kids from, I think, three up through adults in their thirties. And I feel like everybody has benefited so far from this.

Dale Shepard, MD, PhD: And I guess in a similar line, any particular disease types or any particular treatments that you see either more debility or really more benefit from the program?

Julie Nowicki, PT, DPT: I would say not necessarily, every chemotherapy drug is different and everyone has different side effects, but we're able to tailor the exercises to each individual. So I think everybody is appropriate. Sometimes, patients with [inaudible] we come across a lot of peripheral neuropathy, but patients of any diagnosis and receiving any cancer drug are seeing some type of side effect that we can work on.

Dale Shepard, MD, PhD: So where are you doing therapy? Tell me a little bit about sort of the creativity and how you're actually seeing patients.

Julie Nowicki, PT, DPT: Yeah. It gets super creative where we are. Sometimes I'm in a little conference room, it's right next to the labs. It's just a floor space with carpet and chairs. And we do have a room upstairs in the R Building that gets shared by multiple different therapy departments. So there's some equipment up there. Oftentimes I just grab some equipment, whether it be a step, a BOSU ball, some THERABAND. I grab some equipment; I bring it down to whatever room I need to treat the patient in and we get really creative. So sometimes we're grabbing a yoga mat and doing some exercises on the floor.

With younger kids, we have these fun little toys called Squigz that we can stick on a hard surface and they can work on stepping over or jumping to reach them. So we just get really creative in the space that we're provided, because it's not like a therapy gym when you know, think, "Hey, I'm going to PT, there's going to be treadmills and bikes and weights." And it's definitely not like that. We have a room. Sometimes the kids are hooked up already to their IV or their infusion. So we're working around cords and wires and we just do the best we can. And I think they all still have fun with it.

Dale Shepard, MD, PhD: Well, that's fantastic. And you don't really think about physical therapy in fusion rooms. We think about art therapy or music therapy or things, but physical therapy, that's pretty creative.

Julie Nowicki, PT, DPT: And speaking of you just brought up a great point. So the rec therapy or music and art therapy are great to work with too. Every once in a while, we're able to kind of collaborate. And the kids really, really love it when we can be in there providing physical therapy while the music therapist is in there or while the art therapist is in there. So it's really nice that they're all in the same building and we can work together.

Dale Shepard, MD, PhD: So when you think about expansion of this, what are the bigger goals? Are the bigger goals to provide this in a satellite setting where patients may not have to travel as much or to provide additional services? You mentioned occupational therapy or speech. What's the next big target?

Julie Nowicki, PT, DPT: Right now we're in the building three days a week and a few hours each day. What I'd really like to see is that we're expanding to all week long, that we're able to be there and for more hours. So we want to make sure that the nice thing about having PT in that building and the Mobility Program in there is that patients who are traveling a ton for their treatment, don't have to make an extra trip to an extra building. So I would love for it to expand there, maybe have a small space that we could take them, or just keep treating in infusion rooms and conference rooms, trying to make the burden a little easier on families, where they don't have to travel as much. So more hours, more days would be a goal. And then absolutely, also having speech and occupational there as well, so that we can target every patient that might have any side effects.

Dale Shepard, MD, PhD: Unfortunately, when we think about services and in any sort of healthcare, quite honestly, coverage issues are sometimes a factor. Have there been any issues with having this covered by insurance providers and getting this to the patients?

Julie Nowicki, PT, DPT: Thankfully, there's been no issues as far as getting coverage. However, we do typically have to wait for a script to be on file and to get preauthorization. So there may be some patients who come for a first visit that I would love to see right away, but we do have to wait for that prior off because of insurance and wait for the physician's script to be in before I can actually treat them.

Dale Shepard, MD, PhD: So, HIPAA compliant and all, but favorite success story. What do you see as a big win?

Julie Nowicki, PT, DPT: I've got a lot of those. I feel like it's hard to even say, but there's a little friend who when I first met him, he had a lengthy hospital stay. Wasn't able to even stand independently. And he's now running, playing soccer, jumping on the trampoline, back to school, playing with his siblings. It's a beautiful story. And he worked really hard to get there.

Dale Shepard, MD, PhD: That's great. And it sounds like he's had good support.

Julie Nowicki, PT, DPT: Yes, absolutely.

Dale Shepard, MD, PhD: I guess, ideally it sounds like the way this program is set up, you're working alongside the hematologists and the oncologists that are providing care. But with a lot of the services that we provide in other settings, people may get part of their care one place, but then utilize some of our services. Do you ever have situations where someone might be treated by another provider? Not necessarily in Cleveland Clinic Children's, but sort of work with them on a therapy standpoint?

Julie Nowicki, PT, DPT: You know what that hasn't happened yet, but not to say that, that couldn't happen. Certainly that's a possibility. And we've definitely had patients come to our outpatient satellites from outside of the clinic as well, but not quite in the Mobility Program.

Dale Shepard, MD, PhD: Yeah. I mean, it's a valuable service, so it just seems like people might want to take advantage of it.

Julie Nowicki, PT, DPT: We'd be more than willing to take them on.

Dale Shepard, MD, PhD: Great service you're providing. I can only imagine that people that are listening might say, "Hey, that'd be really cool to set up where I'm at." What kind of advice would you give?

Julie Nowicki, PT, DPT: Keep pushing for it. Keep going for it. Yeah. It's a great service. I think that everywhere should have it. Like you said, we've got great success stories. Patients have all been, I think, thankful to have it right there in the hospital where they're receiving their treatment so that they don't have to make this extra trip. So I would say if you're thinking about it, keep pushing for it. Keep talking to your oncologist or your administrative staff to try to get it going.

Dale Shepard, MD, PhD: That's great. Well, you're doing great work. Appreciate your insights. Thanks for being with us.

Julie Nowicki, PT, DPT: Absolutely. Thank you for having me. I appreciate it.

Dale Shepard, MD, PhD: To make a direct online referral to our Taussig Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled. This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real-time updates from Cleveland Clinic's cancer center experts on our consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.

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