@TheOncoPT (00:19)
Hey, Onco PT and welcome back to this episode of the Onco PT podcast. I am so excited that I get to spend this time with you today. Genuinely, when I finished with the clinic, I went and taught and then I came home and as I’m driving home, I was really looking forward to recording this episode and spending this time with you. And I have to be honest, this is something that I have been trying to get back into my life for a long time.

Going behind the scenes here at the Onco PT, this podcast is a weekly podcast and I normally record like one to two at a time at most. Most of the time it’s usually like one week at a time and it’s meant that it’s a lot of kind of frantic work and this is all put on me. Like this is me putting stuff on me.

So when this new year hit, I told myself, I’m not doing this anymore. And my goal is to actually get a few months ahead with the podcast so that I don’t always feel this like frantic rushed stuff. And especially giving you a little more behind the scenes info. I know I mentioned it previously, but we actually just bought our first home and we have been moving into the home. We’re like firmly moved into the home now, but the process of unpacking and like

As you can see right now, my office is still pretty bare. I’m waiting on this wallpaper to get delivered. It will be here at some point. I just have to continue to be patient. And so it’s just kind of highlighted a lot of this of I can’t really operate like I’ve been operating the past few years if I want this podcast to be sustainable. And so I’m implementing this new method. I’m really enjoying it so far. And it’s bringing the joy of recording these podcast episodes back into it. Now, let me be clear. I have

loved this podcast from the beginning and my guests have been incredible. It’s also a lot of work and so kind of pivoting to doing this and just being in this new season of life, I’ve really enjoyed this challenge that I’ve put on myself to change things up and make things more efficient, more effective and ultimately better fitting into where I am in my life right now. So anyways, all this to say, I’m really excited.

to be here with you right now and to get to talk about this stuff that we’re going to talk about in today’s episode. Over the past few weeks, if you listen to our previous episodes, we have been talking about clinical decision making.

as an oncology specialist and not even as someone like board certified. I’m talking about as an emerging OncoPT specialist that you are because if you’re here, you are passionate and devoted and dedicated to improving oncology, physical therapy and the greater cancer rehab for your community and for the greater global community.

And that by my definition makes you a specialist or an emerging specialist. And so this arc that we’ve been doing on the podcast and on YouTube is all about how do we make these decisions? Oftentimes very tough decisions in these nuanced patient cases, especially when it comes to situations like advanced cancer, bone metastasis, multiple corobidities, et cetera.

that really add in layers to the clinical picture that can frankly complicate things, especially when we sometimes come into physical therapy. You know, there, I get it, right? We have to start somewhere, but coming into oncology, physical therapy, I think sometimes we are underprepared for just how complex and how dynamic this patient population can be. And it’s really not until you start practicing that you start to say, my goodness.

This is not quite what I thought it was gonna be, but in a good way. So in today’s podcast episode, I’m gonna take you a little deeper into a patient case that I’m sharing on YouTube later as part of our series. Now, let me be clear. All of the patient information is anonymized. have changed details to protect ⁓ the patient’s identity, et cetera. But I wanna talk about this case because it’s a really, really good example.

of what real life can look like for you as the oncology physical therapist and for your patient who is dealing with this life altering, life threatening sometimes diagnosis and how PTS is exceptionally important, but is also just part of the picture of all of this and how we can really work as a team to improve.

not just our patients, know, functional mobility, their independence, their quality of life. All of those are very good things. All of those are very important things. But also how can we work the team to really improve this patient’s just overall experience and life? And I know that kind of falls into the quality of life. This, I want you to think even bigger.

Because when we think bigger like this, this is how we really catapult cancer rehab and the quality of care that a person experiences, that they get to that next level from good to great, from great to excellent, from excellent to supreme, or whatever is above excellent in this case. So let’s talk about Pablo. So Pablo is a great example of a patient case that does not follow ⁓

framework. And when you first start practicing on oncology physical therapy, I don’t know about you, but I latched on to every framework, every decision-making algorithm, every checklist I could get my hands on as a way to try to make practice easier. And there are some situations in which those totally work. Awesome, amazing. It’s nice when things wrap up really cleanly.

Pablo’s case was not that. So Pablo, this is a fake name. Again, I have de-identified patient information. Pablo was a gentleman who was in his 70s diagnosed with ⁓ metastatic prostate cancer. He had bone metastasis in multiple locations, including his left humeral head, his lumbar vertebrae, I believe, and then his left pelvis. ⁓

And so this was information that I knew when he came to me for the first time. And I think he was referred for like balance problems, weakness. It was kind of some generic stuff. So Pablo is going through.

active treatment for his metastatic prostate cancer with bony metastasis. He was getting, I think, docetaxel chemotherapy, a couple other things that I mentioned actually in the YouTube video that’s coming out. I’m not going to repeat, I’m not going to just like word vomit word for word what I talked about in the YouTube video. I want to get to more of the nuance in the podcast because this is just the better medium in which to talk about this. So

When I started working with Pablo, initially I was very hesitant. As I imagine, maybe some of you were when you first started practicing with this patient population, or maybe you’re still in this case right now because of his bone metastasis. So when I first started seeing Pablo, it really was a like, oh my gosh, these are all the things that I cannot do with Pablo because he has bone metastasis here, here, and here.

And it wasn’t from a place of, has pain with these activities, so we can’t do them. It wasn’t even from a place of his medical team, his oncology team said, don’t do these things. These were purely self-limited by me, the physical therapist in the situation, not even by Pablo.

because Pablo was living his life. He still had things that he needed to do. And in fact, he had several things that he wanted to get back to that were quite active. He had a passion in his, ⁓ I think through his retirement, he had found…

youth sports refereeing to be a activity that he really enjoyed. It brought him a lot of fulfillment and he really liked that kids and young people were being active in sport and like he loved sports. And so that was something that since his diagnosis he was unable to participate in because he frankly just felt yucky all the time. He was weak, he was tired, fatigue was another big thing we were dealing with.

and he just didn’t have the energy or frankly the endurance to be able to keep up with the refereeing that he needed to do. And so this gentleman’s life changed tremendously as many of our patients do over the course of just a few months.

And on top of all of that, on top of this limitation that kind of life had brought to him, here I was the physical therapist even further limiting his activity because I was so afraid that I was going to cause a fracture.

or I was going to cause problems, et cetera, for Pablo and make everything worse. And for the first little bit of time that I worked with Pablo, this really was the perspective that I was taking, the approach I was taking with Pablo of extreme caution. I wasn’t doing hardly anything that I felt would even like challenge him a little bit because I was so afraid of causing problems. And after a while,

You know, we made like a little progress, but Pablo kind of called me out on it. He was like, I don’t feel like this is working.

I don’t feel like I’m getting better. I don’t feel like I’m actually getting to do the things that I want to do any better than when I started all of this. And that was a really hard pill to swallow because as physical therapists, our whole identity is around helping people and healing and, you know, making things easier, better, bigger for our patients, et cetera. And I was not doing hardly any of those things with Pablo.

And it took frankly a little bit of soul searching and a little bit of ego, not a little bit, a lot of ego checking to say, I need to reevaluate the procedure, like the process by which I’m trying to implement all of this. And I have to give Pablo major credit here because he totally could have just said like, PT’s not working for me, I’m done. But I think he saw.

that there was a potential benefit in all of this, if he could just kind of break through a little bit and like connect with me on that level. And I’m really, really fortunate that he did do that. Because what we started to do is, and his metastases were,

stable. Like there was not a concern for an impending pathologic fracture. Like he was by all medical, know, perspectives, he was cleared for activity. It was entirely me that was limiting that. And so then we started getting a little more aggressive with stuff for Pablo. So I started doing cone drills and ladder drills for Pablo with, ⁓ you know, working on his balance, a little bit of agility.

Honestly, some days it was just walking endurance that we were working on. And the reason that I initially straight like shied away from that was this thought of single leg balance was going to be the worst thing for Pablo. Pablo walked with no assistive device around his community. He’s already doing single leg stance.

I mean, sometimes in the clinic he would just like be shifted, you know, like weight shift off to one side because that was more comfortable for him on that side. had the metastasis again. It’s, it’s easy for me to look back on baby on copia T Elise and be like, my gosh, I can’t believe I did that. I’m also trying to have grace with myself. And I hope what I want you to take away from this is I want you to have grace with yourself too. As Dr. Lowery, Bo Wright says,

We do the best we can until we know better and then we do better. And I think this is one of the perfect examples of that is Pablo said, this is not working. We got to do something different. Little bit of reflection, a little bit of soul searching, a little bit of a deeper dive in the literature to really say, okay, this is probably not the right plan. Let’s change things up.

So like I mentioned, started doing cone drills, ladder drills. We brought more challenging balance drills and exercises into our program. It did include, I did more tandem stance stuff with Pablo. I still wasn’t super confident about doing totally single leg static stance on that left leg. And we were still doing things that challenged him, which was great. We were doing lots of like, you know, a lot more like aerobic conditioning.

etc. And we were making progress. It was really, really cool to see because it also not just from a like, hey, wow, like his strength is getting better, etc. He was also enjoying therapy more. He was also doing more things that he could directly tie to. This is going to help me do XYZ that I want to get back to. Now, after a while of working with Pablo, we were making good progress, but we kind of plateaued.

And it wasn’t, it took time for us to kind of get to the heart of what was really contributing to all of this. Cause like I mentioned, Pablo was going through active treatment, which like that was definitely affecting his physiology, but there was another underlying factor that was making him more tired. He was just kind of sickly is not the right word.

but just kind of like didn’t feel great, was not at what should have been like his 100 % for the circumstances. And like I mentioned, it took a while for I think Pablo to trust me to have this conversation. And I say this, I share this not to be like, wow, Elisa is such a good PT, but a sometimes you have to work.

over time to really earn the trust of your patients. I know you’re a great on-call PT. I know you friend.

It still takes intentional effort and time on our part to ensure that we have earned and can hold that patient’s trust in us. And this was a perfect situation for that. So long story short, Pablo was not sleeping very well. And you might’ve heard me mention this previously, like years ago on the podcast.

Pablo was actually couch surfing between his adult children’s homes because he was not safe enough to live on his own. I think some of that was his adult children were concerned that he would maybe like have a fall at home.

at his home by himself and so they didn’t want him to go back to his home and so he would basically spend half the week at one child’s home and then half the week in the other child’s home. And this also meant that he didn’t have a bed that he was sleeping on for half the week and there were a lot of circumstances I’m sure at play but he was sleeping on an air mattress at one

adult child’s home and then he had like a cot or something that he was sleeping on in the other adult child’s home and this was significantly negatively impacting his sleep quality and we know how important sleep is for a person and how much healing and recovery really takes place during that restful sleep and if we’re not able to get that that totally affects us negatively.

This was absolutely happening to Pablo. In fact, like amplified on steroids almost based on how much this was an issue. And so at this point, Pablo is not making progress in physical therapy with me because the sleep is such a detrimental effect on his, on his function and on his just like overall existence. And so this was an opportunity. I thankfully was connected with the oncology social worker in

the facility that I worked in and So got together with the social worker and said hey, here’s the situation like I don’t know what to do as a physical therapist beyond like hey we got to get you in a in a bed right like we have to get you in a bed because This is not working. And so social work was actually able to secure a mattress for him

and they were able to move that into one of his adult children’s homes. So he at least wasn’t sleeping on the floor, which was sometimes the case depending on the situation here. And so when he was able to actually have a dedicated sleep place for him to sleep in, sleep at, sleep on,

and get that quality rest, he was able to better show up fully in our physical therapy sessions. His body was able to rise to the occasion, know, like rise to the challenge that we were putting on him so that we could continue to actually work forward, you know, building his strength, his endurance, improving his balance, et cetera, all the things. And so I say all this again, to just kind of paint you a little more of a picture of

Pablo who I briefly talk about in this week’s YouTube video, but also to really highlight that this kind of specialist thinking even way back, this was like my first or second year of practice y’all like I was baby baby on co PT even going far back. I can see the specialist thinking that’s emerging as it totally is for you. If you’re not already a specialist, right? But there was also a cap.

There is also an upper limit to what I could get to, what I could achieve, where I could really get my mind to go on my own. And this was challenged and I think pushed in a positive way first by Pablo because Pablo, as I mentioned previously, totally called me out on, this isn’t working.

This isn’t, I’m not headed in the right direction of where I want to be. I think we can do better. if, like, Pablo was not in healthcare. Pablo did not know all the ins and outs of physical therapy and oncology, physical therapy and cancer rehab. He didn’t have to. He just knew that where he was and where he wanted to go, there was a huge canyon.

between the two, and the path that we were taking was not going to get him from point A to point B anytime soon. In fact, probably ever.

And so he identified that and said, this is not working. I think this can be better. Even if he didn’t totally know what that path was, he knew that this was not the right path. And the second time that there was an opportunity for this kind of like expansion of thinking or upleveling of thinking was when I was working with that social worker. And again,

All I knew as the physical therapist in the situation is my patient is not sleeping well. I don’t know what to do about it. Maybe social work can help and social work was able to get together with their vast wealth of knowledge and connections and whatnot in order to secure a mattress for Pablo so that he could go home and sleep well so then he could show up rested and ready for tomorrow morning’s physical therapy appointment.

If I had tried to just do this, work through this patient case entirely on my own, I don’t think I would have kept Pablo as a patient. I think he would have said, like, I’m not getting anywhere, or maybe he would have stayed with me because he liked my personality or whatever that is. But he would have stayed at that exact same level for who knows how long, maybe forever.

And then if I had not had that interaction, that connection made with that social worker who could expand my frankly mind in what’s available, again, Pablo would have had trashy sleep.

for who knows how long and how much that would have affected not just his time with me in physical therapy, but also in general, right? How would that have affected his ability to tolerate treatment? How would that have affected his overall like inflammation status? I mean, just like this cascade of potentials when it comes to Pablo’s case, it’s really, it’s a really wonderful reflection.

and kind of perspective shifting case that has been one of like the defining ones of my practice. And all this to say,

It’s nice when patients fall into these very like black and white boxes and they flow really well with the, you know, the frameworks or the, you know, decision making algorithms or clinical boxes. Like I remember, my gosh, in PT school when we did ⁓ like the (spine – I forgot the word for spine y’all) in orthopedics or.

Yeah, I think it was orthopedics. my gosh, guys, it was so long. But when we did that unit in ortho, you know, we talked about low back pain and we had these nice clean, like four or five boxes on if a person presents with this, you know, these criteria, this is likely what the diagnosis is. These are the treatments that you can get started with that are going to help with all of this. And I remember thinking like, wow, this is so clean. This is so

Simple. This is so easy to follow. And then coming into oncology, I feel like none of my patients, or very, very few of my patients have fit into these boxes that I thought or imagined would be present in oncology. That’s just not how this works. It’s nice when it happens, but more often than not, we don’t have that nice, clean, black and white, simple framework.

that our patients fit into. We have frameworks and then our patients show us that, you know what, they are way more layered, they are way more dynamic and they don’t fit into those nice clean boxes. We really have to think outside of it. And when you’re first starting in oncology physical therapy, that can be very, very challenging and sometimes even impossible when you’re working on your own. And when you work in these silos,

You know, unless you’re really plugged into a community that helps you up level that thinking, like Pablo pushed me on, like social work expanded my, you know, even just like awareness of these, you know, of these things, there, all this to say there’s only so much refining that you can do for your thinking alone. If you really want…

to expand how you approach oncology, physical therapy, and cancer rehab, that cannot happen by yourself. You have to be connected. You have to be plugged in with others who are going to push you, who are going to challenge you, who are sometimes going to make you uncomfortable. Again, when Pablo called me out, that was uncomfortable.

That was a little embarrassing. I’m not saying I want you to be embarrassed. I needed that to pull me out of this comfortable, cautious, frankly afraid rut that I had burrowed myself into. If I was going to become a better physical therapist for Pablo and therefore my other patients who needed me.

There is only so much you can do by yourself to really refine your thinking like this. Yes, you can read articles. Those are wonderful. Those are very helpful. Yes, you can read textbooks. Those are wonderful. Those are helpful. Continuing education courses. Those I would argue are a little better, but they don’t necessarily have that community and that challenge built into them. Because let’s face it, y’all.

a lot of the continuing education courses that you can take. You go somewhere for a weekend on your weekend, right? After you’re already tired from working the whole week, you’re going to sit in the classroom with fluorescent lights for eight hours on Saturday and eight hours on Sunday. And then you get back to the clinic on Monday morning. You can’t remember what you learned and you’re tired because you spent the whole weekend learning at a continuing education course that I’m sure was great.

but we’re just not meant to operate like that as humans, and you don’t have that support to take that information and then implement it into your practice. Exposure to these kinds of clinical challenges where you can be in communion, in groups with, in community with other.

cancer rehab enthusiasts, other cancer rehab professionals is how you are really going to accelerate this specialist level thinking that you are after. This kind of exposure allows you into the world of other people to see.

how they reason, how they adjust in real time with patient scenarios, like with Pablo’s, where they hesitate, what they document, and how they recover from, know what, that was not the best decision. That was not what my patient needed at that time. I’m going to fix it. I’m going to make it better. And this is why immersive, connective, collaborative environments matter.

in cancer rehab and oncology physical therapy. And this is also why we created the cancer rehab community because Kelly and I, Dr. Kelly Sturm, my co-founder over at the cancer rehab community, we both worked for very long time where we were isolated. We were the only oncology physical therapist for what feels like miles around, not able.

to get that help, to get that feedback, to get that pushback from others in the field who get it, who can make us better, who can see the log that is in our own eye so that we can get out of our own way and get better at oncology rehab so that we can better show up for our patients in our own communities. We cannot do that alone. This only happens when you are able to be in

community when you are truly able to be in that collaborative environment with other oncology physical therapists, other oncology rehab professionals who get it. This is not about giving you more checklists. Like I said previously, if you want more checklists, read some articles, read some textbooks. But to normalize specialist level thinking out loud.

with others to see how they’re practicing, this is how we make cancer rehab better.

If you, if this is resonating with you, if you are saying to yourself, I am ready to be that next level of oncology physical therapist. I’m ready to be the better version of OncoPT, the better clinician for my patients because I’m tired of showing up and struggling through things, which is so real. That is so, so real, my friend.

And I remember those days. remember showing up to those sessions with Pablo because he was literally my 8 a.m. on the days that he would come to see me. First patient of the day. I remember coming into the clinic and not dreading seeing him. In fact, the opposite.

dreading that I would feel inadequate yet again, not prepared, no matter how much reading I would do the night before, how much researching I would do, what kind of, you know, latest and greatest checklist, algorithm, framework, et cetera, it still didn’t help me meet the human in front of me with their very not black and white human challenges in all of this. This is what we do this for.

This is what the cancer rehab community and what the cancer rehab community conference are all about. So you can see the specialist level thinking in action so that you can then take that and implement it into your own practice to where you can go back and get that feedback, get that community, get that pushback, get that challenge from other oncology physical therapists and rehab professionals who are in the field doing the work with their own patients in their own community. That’s what this is about. my gosh.

I wish it, like that’s why we founded this. I wish I had this community eight years ago when I started practicing. I think it really would have changed the trajectory of my entire career. I’m not upset at where I am today.

I wish I didn’t have to struggle so much those first few years to get to this point of being comfortable, that I can truly tackle whatever comes through my door. Even if I don’t totally know what I’m getting myself into, I still feel good that I can at least get started with this patient. And then I can go and ask my community for help when I need it.

And that feels really good. And I want that for you too, Because I love this profession. I love this field. I love this work that we do. I love the patience that we get to encounter. I also love feeling confident, showing up to do this kind of work. And not uncertain.

and not worried all the time that I’m going to completely mess things up beyond all recognition, which like, that’s such a small baby PT.

OncoPT thinking coming out and I recognize her and I know that she wants the best for her patients. I’m also glad that I can approach things as a specialist level thinker and feel comfortable with my decisions and confident with my decisions that I’m making the most appropriate treatment decisions for my patients. Honestly, like damn that feels good. It really does. So if this

podcast series, if this, you know, series that we’re doing on the podcast and YouTube has pushed you a little bit, if it’s stretched you, if it has challenged you.

even just a little bit. Good. This growth that we are after does not and should not feel perfectly comfortable. If we’re growing, we need to be a little uncomfortable because it means that we are growing out of this little burrow, this little rut that we have created for ourselves. Becoming an oncology specialist.

Becoming an oncology specialist level thinker is not about eliminating the complexity in oncology. That’s unavoidable. Complexity is part of the territory when it comes to working with our oncology patients. This level of thinking is about learning to navigate complexity with clarity. And this is a skill that is built over time, but that’s not where that line ends.

This is a skill that is built over time and in community with others. Because one of the things that I reject so deeply within me is this idea that you have to struggle through the first few years of your practice before you kind of like earn your stripes or earn your wings or whatever, whatever you want to call that. That’s baloney. We don’t eat our young here in the Onco PT.

We don’t let our newer oncology physical therapist flounder because that’s how we did it. And so we think others should do it. That is not what we’re about here at the Onco PT. I want you to have an easier time than I did. And I know Kelly feels the same way. I want you to have an easier time so you can get down to helping people get better faster.

to do more things so that they can get back to refereeing youth sports faster than what they did with me. I want that for you. I want that for your patients. I want that for your community. Because when your patients get better care, it literally raises the expectation of excellence for all of our patients. And that only helps cancer rehab get better and better and better.

We’re gonna keep building. I sincerely hope if you haven’t already joined the Cancer Rehab Community, which is our free online community for cancer rehab professionals and future cancer rehab professionals, if you’re a student out there, I would highly encourage you to join. You can do that for free, as I mentioned, at the oncopT.com slash community. And then I would also love to see you at this year’s Cancer Rehab Community Conference.

This year’s conference is taking place November 6th and 7th, 2026. That is Friday and Saturday yet again. This is a virtual conference and I really, really hope I get to see you there because we are putting together another amazing conference that you’re going to love. But until then, this is Elise with the Onco PT. And remember, you are exactly the physical therapist that your patients with cancer need. So let’s get to work.