Oncology Rehabilitation

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: May 1, 2024

Expiration Date: May 1, 2025

Estimated Time of Completion: 25 minutes

Oncology Rehabilitation

Eileen Slavin, DO

Description

Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience

Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation

A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)

Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director

Imad Najm, MD
Epilepsy Center

Additional Planner/Reviewer

Cindy Willis, DNP

Faculty

Eileen Slavin, DO
Physical Medicine and Rehabilitation

Host

Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Oncology Rehabilitation

Eileen Slavin, DO

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

The following faculty have indicated they have no relationship which, in the context of their presentation(s), could be perceived as a potential conflict of interest: Cindy Willis, DNP and Eileen Slavin, DO

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast May 1, 2024 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research, discoveries and clinical advances in the fields of neurology, neurosurgery, neurorehab, and psychiatry.

Glen Stevens, DO, PhD: Cancer and its treatments can result in an array of adverse side effects, including pain, mobility issues, and cognitive impairments. In this episode of Neuro Pathways, we're discussing oncology rehabilitation and how it can be integrated effectively into a patient's care plan to manage these side effects and support quality of life. I'm your host, Glen Stevens, DO, PhD, neurologist neuro-oncologist in Cleveland Clinic's Neurological Institute. And joining me for today's conversation is Eileen Slavin, DO. Dr. Slavin is an oncologic rehabilitation physician in the Department of Physical Medicine and Rehabilitation within Cleveland Clinic's Neurological Institute. Eileen, welcome to Neuro Pathways.

Eileen Slavin, DO: Thank you so much. Thank you for having me today.

Glen Stevens, DO, PhD: So Eileen, I know you're fairly new to the Cleveland Clinic, so tell us a little bit about yourself: where you come from, where you did your training, how you made your way to the Clinic, and what your interests are.

Eileen Slavin, DO: Yes, I'm actually a Cleveland native, so it's really nice to be home working for this institution. I did my medical school at Ohio University Heritage College of Osteopathic Medicine. So I'm a DO, and I did some of my medical school rotations also within the Cleveland Clinic system, so it's a homecoming in more ways than one. My residency training was at a community hospital in South Florida called Larkin Community Hospital. That was for physical medicine and rehabilitation. And then I did my year of fellowship training at Georgetown for cancer rehabilitation.

Glen Stevens, DO, PhD: So how many cancer rehabilitation programs are there in the country?

Eileen Slavin, DO: That's a good question. I believe now we are at 11. One recently closed, another recently opened, so I believe 11.

Glen Stevens, DO, PhD: And did anybody else train with you or there's one per year or they take a couple per year or...?

Eileen Slavin, DO: It's one per year. Yes.

Glen Stevens, DO, PhD: And for your work at the Cleveland Clinic, what percentage of your time is spent in oncologic rehab versus doing general rehab?

Eileen Slavin, DO: So for starters, I have two half days a week, and so that's until my clinic gets busy enough that I can do... Probably two to three full days is what we're aiming for right now. The other days of the week I'm at Mellen Center, so treating patients who have spasticity, and also on the consult service, too, so helping patients, planning their disposition, and also I've had a few oncology consults from several of the teams while on that service as well.

Glen Stevens, DO, PhD: So I take it that you live... Your oncologic stuff, you live in Taussig?

Eileen Slavin, DO: Yes.

Glen Stevens, DO, PhD: Is that right?

Eileen Slavin, DO: Yes.

Glen Stevens, DO, PhD: In the cancer center?

Eileen Slavin, DO: Mm-hmm.

Glen Stevens, DO, PhD: So before we get too much into this, if somebody wants to refer a patient to you, how would they do that?

Eileen Slavin, DO: Yes. So there's an order in the system for consult, physical medicine and rehabilitation. Then when the order opens, that dialog box pops open, they actually, in EPIC, created a button for me. So you would click oncology rehabilitation, and then reason for referral can be helpful. Just a few words: spasticity, range of motion, mobility problem, neurogenic bladder bowel, or maybe a specific question that you want me to answer. And then you hit submit, and if patients have EPIC, the ticket goes to their EPIC, or they get a phone call from scheduling.

Glen Stevens, DO, PhD: And how long would it take someone to get in to see you?

Eileen Slavin, DO: I would say within probably a week, sometimes even same day. Some days have been busier than others as I build. So hoping to get busier as time moves on. 

Glen Stevens, DO, PhD: Prior to you coming, if we had someone that had a specific problem, we would occasionally send people over to physiatry. Mostly if they had a lot of spasticity and they needed Botox or this or that type of stuff, we'd have some people do driving evaluations, but that's mostly through OT as opposed to rehab itself, or we would refer the patients to palliative care. So how are you different than the things that the palliative care would look after, or is there overlap in what you're doing together? Are you working specifically with the palliative care folks? Tell me that.

Eileen Slavin, DO: Yes. Palliative care and oncology rehabilitation at some institutions are seen as being almost on a continuum. So at places where both services are available, we work in tandem. At other places where oncology rehab wouldn't be available of course, like you say, the patients would go to palliative. So the way that I've conceptualized my role here is that palliative care is awesome, by the way, and they help us with goals of care discussions, they're very helpful when patients have a very heavy burden, for example, of metastatic disease or in a myeloma patient, many lytic lesions. So someone that has head to toe, very severe pain that wouldn't necessarily be helped just by one intervention. Maybe this person needs regular follow-up, needs to be on opioid therapy to control the very high pain levels that they have. My role is evaluating patients from the neuromusculoskeletal perspective and treating that focal pain, looking at mobility impairments, looking at how we can use prosthetics and orthoses to help patients, how can we collaborate with other teams, how we can work on lymphedema or prehabilitation for patients who might undergo transplant or surgery.

Glen Stevens, DO, PhD: I think that one real growth area that you'll have, as people become accustomed to having you around and start working with you, is this concept of this prehabilitation, which is something I've never really thought about a whole lot. And as a brain tumor person, that doesn't really come into our area that much, but I'm sure some of the cancer patients it is more. So tell me what your role would be there. I guess you would identify someone's having a problem, they're going to have some surgery or something done, you do ounce of prevention. I guess you look at that, so tell me a little bit about that concept.

Eileen Slavin, DO: Yes, so the concept of prehabilitation is for patients prepared for transplant, a big surgery, particularly when we know that the outcomes could be potentially devastating, that a patient could end up with lymphedema, could have major mobility issues, could lose a lot of weight, might have a lower functional status. We try to identify patients who perhaps have four to six weeks until they're having their surgery or their transplant. That is better, of course, for solid tumor for patients undergoing neoadjuvant chemo, because we can buy some time, and it's essentially optimizing them from three different perspectives. So it's looking at psychological health, so referring them to psychology, making sure they have good psychosocial support, no transportation issues if we can help with that. Helping with the physical activity, physical functioning piece. So talking about exercise counseling, safety recommendations, things to watch out for, giving them actual exercise prescriptions using the FITT principle.

And then that third piece is the nutrition piece. So collaborating with our dietitian colleagues, making sure, okay, we know this patient will lose weight. We know this patient will lose muscle mass. Sarcopenia is a hot topic buzzword right now, but it's very relevant in terms of making sure, okay, how can we get this patient to consume enough protein, maintain caloric intake, maintain muscle mass? Because all of these things will be affected. And the idea is if you build someone up before you "beat them up" with all these treatments to try to treat their cancer, or even in a palliative sense to treat their cancer, that you're bringing their baseline down not to a level that it would be had you just done nothing and said, okay, go through this.

Glen Stevens, DO, PhD: I expect this will be quite a growth area for you as people are familiar with having you around.

Eileen Slavin, DO: Yes, I'm really excited. I've already had some discussions, made some headway to work on projects for prehab. A few of our teams here have actually started projects, too, that they've involved me in. One of my goals, many lofty goals, is to have prehab for any cancer patient as appropriate throughout the system.

Glen Stevens, DO, PhD: There was some interesting data came out of Duke quite a few years ago, I think it was by one of the physical therapists there, but they looked at their grade three and grade four glioblastoma patients, and they compared populations, but patients that were able to exercise 30 minutes a day at a brisk walk pace, five days per week on average, live twice as long as those that did not. And again, it's always hard to know the chicken and the egg, but one would think that there's something there, that we should be doing a better job on all of our patients having this as a standard, this is what you should be doing. I even thought at one point, should we be buying everybody a step counter and telling them, boy, we'd like to see you do 5,000 steps a day or 10,000, whatever it is, right?

Eileen Slavin, DO: Yes. So that's also something that I'm working on too, is how to operationalize that in a way that makes sense, that's easy to understand, of course. We have patients with health literacy concerns, psychosocial concerns, transportation issues, so all of these extra layers can make prehab a little bit complicated. Depending on what cancer type you're looking at and the size of this study, there's always this debate of is supervised physical activity superior to unsupervised physical activity? I think some of that boils down to patient preference. We have some data that supervised is better. Of course, in some institutions, in some disease groups, that can be really hard to make happen depending on your patient and their particular factors. And of course, we're moving towards personalized cancer medicine just like the rest of medicine, too. So we have to be cognizant of that fact as well.

Glen Stevens, DO, PhD: So what are you seeing mostly your first couple of months? What types of things are you looking after mostly?

Eileen Slavin, DO: Yes. So I've seen quite a few patients for prehabilitation concerns or physical deconditioning asking for exercise advice. I've seen a handful of patients who have chronic graft-versus-host disease after allogeneic bone marrow transplant, which is also a very exciting area. It's something that has been really hard to treat, of course, so I'm really interested in doing research, particularly with the allo stem cell group. I've also had a few patients who have experienced radiation fibrosis syndrome for head and neck cancer. So I've seen trismus, some range of motion issues that present sort of like cervical dystonia, and I have planned some botulinum toxin injections for those patients. And I would say the other big group that's been really supportive of me is the breast cancer team. So screening patients for lymphedema who are at risk, thinking about shoulder pain, range of motion abnormalities, aromatase inhibitor induced arthralgias for ERPR-positive patients, and the like.

Glen Stevens, DO, PhD: So if you're going to do injections, or will you do that at the Mellen Center, or will you be able to do injections, or someone needs a joint injection or...?

Eileen Slavin, DO: Yes. Great question. So right now my Pyxis is stocked for botulinum toxin at Taussig, also for lidocaine, some of the steroids that I use to be able to do joint injections, tendon sheath injections, also for spasticity.

Glen Stevens, DO, PhD: And we don't want to take away the stuff from the headache folks, but will you do occipital nerve blocks and those types of things as well?

Eileen Slavin, DO: Actually, yes. I have a patient who had a cancer diagnosis, sarcoma actually, and I have an injection plan for that particular patient.

Glen Stevens, DO, PhD: So peripheral neuropathy.

Eileen Slavin, DO: Yes.

Glen Stevens, DO, PhD: What options do we have for these patients?

Eileen Slavin, DO: Yes. So typically when I evaluate these patients, I want to know if the symptoms are more positive versus negative, just because I like to have a frank discussion with patients about, hey, you have numbness. We don't have a really good way right now to treat numbness, but in terms of the positive symptoms, so the annoying tingling sensations, burning, shooting pain, lancinating pain, however someone might describe it, we can use medications, we prescribe exercise. That's the number one advice per the literature right now in terms of evidence-based medicine. Palliative medicine, this is a plug for them. They're using a device, too, the scrambler therapy. And admittedly, I don't want to steal their thunder and go into that, because I want patient referrals my way too. But they have a really interesting device, too, that they're using, I believe it's neuromodulation, to help. So I don't think insurance covers it right now. I'd have to check with Dr. Patel about that. But that's another option for patients, too.

Glen Stevens, DO, PhD: And I think that I saw that you also will do some return to work evaluations.

Eileen Slavin, DO: Yes.

Glen Stevens, DO, PhD: So tell me, because this can sometimes be the bane of our existence. Can patients work? Can't they work?

Eileen Slavin, DO: Yes. So I don't do disability-specific evals, so that would be more of an IME referral, but for a patient who is motivated to return to work, but might have some level of disability and might need an evaluation or need some sort of paperwork that says, hey, I'm great to go back to work, but I need some level of accommodation or some recognition that this is a problem for me, we can evaluate patients that way and also send them to PT/OT as appropriate.

Glen Stevens, DO, PhD: In neuro-oncology, we have a very active spine program, and we probably do maybe about 150 spine radial surgery cases a year for patients that have mets to the spine. Now, some of them have had surgery, some of them have not. But as you can imagine, these patients would have a lot of the things that would be in your category. They'd have bowel and bladder difficulties, spasticity, those types of things. So certainly another area for us to think about how you could help engage our patients and get them involved in the care.

Eileen Slavin, DO: Yes, absolutely. I've been participating in the last couple of weeks in the spine tumor board, too.

Glen Stevens, DO, PhD: Oh, excellent.

Eileen Slavin, DO: Which has been good just to listen to what kinds of cases, what kinds of questions, concerns are coming up with the team, and it's been really interesting.

Glen Stevens, DO, PhD: So if somebody's out there thinking, should I send somebody to see you? What's your advice to them? I guess the way I always look at it is, if they're not sure, they probably should send. What should they send patients to you for?

Eileen Slavin, DO: Yes. So patients who have neuromusculoskeletal pain, of course related to the cancer or treatments. But also sometimes we see patients who might have knee pain, but perhaps their diagnosis was breast cancer, we're happy to see them. Happy to see patients from a prehabilitation perspective for exercise counseling, safety recommendations, anyone who has a mobility impairment, patients who are physically deconditioned, obviously that could be quite a few people and that might need a little bit of parsing out.

I've had a lot of really good messages and emails from many teams, from docs and APPs saying, hey, I have this patient, do you think he or she would be a good fit for what you could do, and I'm always happy to evaluate. And some of the times, most of the time, I'm helpful, but there are some cases where I've maybe done 90% and that other 10% is a very specific referral to another team. But I see myself as a really nice connection between rehab and some of the other teams that we have, and can certainly help facilitate referrals if it's not something that I can help with. Or maybe can help, like I said, 90% of the way. But hey, I just want the opinion of this expert to round out my findings and conclusion.

Glen Stevens, DO, PhD: And talk to us a little bit about cognitive rehab. Do you offer that or this is done by the occupational therapist with cognitive behavioral, or are you involved with that or no?

Eileen Slavin, DO: Sure. We do somewhat. So patients will come to me with, they used to call it chemo brain or brain fog. We don't call it that as much anymore. It's more cancer-associated fatigue, just because we know that there's many aspects to the sense of cognitive impairment or fog as it were. Typically, those patients are referred to speech for evaluation, also, neuropsychology. I will usually assess, with history and physical exams, assess, okay, is there some other medical issue going on that this patient needs blood work, that this patient needs to go back to their oncologist? Do we need a neurologist to evaluate the patient and to have their opinion? But typically that's my role. Also, we know that exercise is some of the best evidence that we have for cancer-associated fatigue. So I jumpstart that discussion and provide exercise recommendations and tease out what patients have been doing exercise-wise, or not doing, and what's the barrier then to exercise, and using that motivational interviewing that we learned about in medical school in the best way possible.

Glen Stevens, DO, PhD: And if you're going to do a joint injection, do you use ultrasound or not? And do you have ultrasound in Taussig that you can use, or that's something that's coming?

Eileen Slavin, DO: Yes, I actually have a portable ultrasound, but it's quite nice. You can do injections without ultrasound. My preference is always to use ultrasound just because the way that I was trained and the way that my brain works is I don't like sticking needles into places that I can't absolutely see. So that's my preference and that's what I do usually 99% of the time. Every once in a blue moon, a subacromial shoulder injection you can do blind safely, but I prefer it.

Glen Stevens, DO, PhD: Are you doing EMGs or no?

Eileen Slavin, DO: No. I would love to, but no. Not every rehab doctor says that they like EMGs, but I love them. I find them quite fascinating.

Glen Stevens, DO, PhD: So the big growth area in oncology in the last several years, and certainly it's been a game changer in melanoma and a number of different types of disorders, the advent of immunotherapies. And for the good that the immunotherapies do, we also see a lot of itises, a lot of inflammation, GI tract, eyes, lungs, a lot of things can get inflamed with it. So it would probably beg the concern that if you give these drugs to do good, they can also cause inflammation and cause bad, which would sound like maybe they need someone to manage the complications and side effects. So have you seen or been seeing patients that have been on immunotherapies that have developed problems, or what types of problems do you anticipate seeing that you could help with?

Eileen Slavin, DO: Yes. I've seen a few patients even on consults who have had neurotoxicities from immunotherapies. So some pretty severe demyelinating neuropathies, for example, or some peripheral edema or unexplained sort of edema from these immunotherapies. And as I said before, when cancer treatments are becoming more personalized, I think our field will have to step up to the plate to be able to say, okay, well what new treatments do we have from a rehab perspective to help these patients? And also, what data are we collecting?

I participate every other month in a group that's a cancer rehab tumor board, primarily for our fellows, but also our attendings come on, too, to listen and to help facilitate the conversation. So we've already talked about this. Oh, have you tried botulinum toxin injections for a patient who had this particular immunotherapy? Yes. Okay. Well, I did it the second time for the patient after he had really good results the first time, but I noticed that after he received this immunotherapy, the injections weren't as effective. Is there some sort of underlying immune reason that the toxin isn't as effective? So I think the awareness is building. And so along with that will come the research, and all of us nationwide and internationally, putting our heads together to see how we can tackle those challenges.

Glen Stevens, DO, PhD: Well, I hope that when you go to the national meetings, the room starts filling up slowly a little more with people that are in your subspecialty area over time. It sounds like an important part of management of cancer patients as time goes on. So we're very happy to have you here at the Cleveland Clinic, and we hope to utilize your sources. And those that are out there, I suspect there's a low likelihood they have had access to somebody that does what you do. So it sounds like you're ready, willing, and able to see patients. So we hope that you get so busy that we have to hire another one of you.

Eileen Slavin, DO: Yes, that's the plan. It's a real honor and privilege to be here, as all of us have been affected by cancer in some way, by patients that we treat or family members. So really excited about this work, and it's very important, and I really appreciate the collaboration from all of our oncology teams and all of our therapy teams, neurology, P&O, nutrition, everyone who's been involved, nursing, it's been really great.

Glen Stevens, DO, PhD: Thank you for joining us today and look forward for the flood coming in.

Eileen Slavin, DO: Yes, thank you so much. Me too.

Closing: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's @CleClinicMD, all one word. And thank you for listening.