Elise Cantu (00:19)
Hey, Onco PT and welcome to this episode of TheOncoPT podcast. Now we need to get something out of the way right at the top of this episode, which is the sound may be a little different in this episode. And you may notice if you’re watching this later on YouTube, that the background is different than my usual office setup that I’ve been operating out of literally, I think, since the inception of the Onco PT podcast.

or maybe at least very close to it. And that is because we have actually moved. We have purchased a home. We are officially moved into it after a month of being this back and forth between our old house and our new house. And we are finally here. And I’m so, so excited. It’s so fun to be in this new environment and to be able to…

kind of get back into the swing of things. I pre-recorded a bunch of podcast episodes for this last batch, knowing that we were going to be packing up and moving everything. And this is the first episode that I’m recording where I actually got up my microphone and I have my little recording table set up and everything. So I’m really, really excited to get to transform this space into what is going to be the new home of the Onco PT and for you to come along on this ride with me.

So with that said, let’s get back to some oncology physical therapy content, right? That’s what we’re really here to talk about. Not Elise’s new blank walls that you can see behind me that are pretty boring. We’ll make them pretty soon. We’ll make them beautiful for you to look at. But for now, you’re just going to have to sit with me and my voice and my face. Now in today’s episode of the podcast, we’re going to talk about something that isn’t talked about enough within oncology rehab, oncology physical therapy.

And that is the mental weight of treating patients who have bone metastasis. Now, I think we have been doing a better job generally of talking more about bone metastasis because it’s not a matter of if you’ll encounter them, it’s when, much like much of oncology physical therapy. But I think there’s very much an acceptance and understanding of oncology physical therapists, you and me understanding that this is something that patients are going to encounter.

and it is safe for us to work with patients who have bone metastasis. Now with that, I’m going to introduce some nuance, some caveats to this conversation because there’s a lot of really good information out there that can help guide us on what not to do with patients who have bone metastasis, right? We of course want to prioritize that we are staying out of

activities or positions or zones, if you will, where that would put a person in danger of experiencing a pathologic fracture, right? That is still absolutely one of the things that we are going to talk about. But there’s a lot more of what not to do. There’s a lot more talked about within cancer rehab, which is don’t do this with a person who has bone metastasis. And less information and less explicit guidance on

What can we actually do for the person who has bone metastasis? And so this dichotomy of, you know, there’s more of what not to do and less about what to do, kind of puts you in a pickle when you start working with these patients who have bone metastasis. You know that physical therapy, you know that exercise can be safe and effective for people with bone metastasis, but what do we actually do? What can we actually implement?

to this person reach their goals of XYZ while still making sure that they’re safe. And so that’s what we’re really gonna lean into today, which is the mental load of having to sift through all of this information and sometimes lack of information ⁓ to the point where we get to the title of today’s episode, excuse me, which is why bone metastasis or why bony metastasis keep you up at night. It’s not the bone metastasis.

that are keeping you up at night as an oncology physical therapist, it is the, my gosh, did I do the right thing in today’s session with that patient who has a bone metastasis here? Because you can learn the precautions. You can reference the scoring systems, right? Thinking of morels or thinking of the spinal instability neoplastic score, you can reference those.

But those are very black and white, which is good. We need black and white when it comes to these kind of standards, scoring systems. But that black and white scoring system does not translate to the gray, but often, mean, like gray is so boring, right? I mean, again, look at my walls behind me. The rainbow of actual clinical reality and the nuance and the uniqueness and the unique-ities, I don’t even know if that’s a real word.

of working with an actual human in front of you who has very human things that they want to go out and do. And it certainly doesn’t include sitting in bubble wrap for the rest of their life because they have a bone metastasis here. So how do we take that black and white of the scoring systems and really marry it to the rainbow of clinical reality? And where this gets really fuzzy is again, when you’re starting to practice, you’re starting to this into actual, you know, work with a real life human.

And then you’re second guessing yourself. You’re questioning your judgment. And where this really hits a lot of times for lot of oncology physical therapists is when they get home and they let themselves sit for a minute. Maybe that is on the couch. Maybe that’s while you’re laying in bed and you think, no, I don’t know if I did the right thing here. Was that too much? Was I too aggressive in my dosing?

with this particular exercise or intervention that I did? Did I do the right thing for this person? And all of this really comes down to you could spend your time going through all of the research and all of the black and white guidelines and maybe come up with a checklist, like a self audit of, how do I go through this and make sure that I’m really being safe? But this episode, that checklist is not going to get you to the point of saying, I feel good about

this intervention that I’m dosing. It’s going to just make you get to the point of, have checked all the boxes, but those checking of boxes do not necessarily equate or help you arrive at the confidence and competence it takes in order to treat a person safely, effectively with bone metastasis. And so this episode is not about giving you another checklist. Again, the research is full of these scoring systems, these checklists that you can talk about.

we’re gonna really get down to the nuance of it all and how do you actually marry the research to the road, like where the rubber meets the road where we’re actually putting this into practice with patients. So bone metastasis in general feel different as an oncology physical therapist because the concept of fracture, it’s not even a concept anymore. It is a very real, tangible experience that a person could experience as a result of having

this advanced cancer where that tumor has invaded the bone and is causing issues with bony integrity. And in some cases, the stakes can feel quite visible in that regard. Not that we can necessarily, you know, x-ray vision into a person’s skin right then and there, but sometimes we have the imaging that shows us exactly where that metastasis is and where that concern for bony integrity is. The consequences

of this because we know that pathologic fractures are bad, right? That like that is still reality. That can lead the consequences of bony metastasis leading to pathologic fracture feel very catastrophic. And in no way am I trying to diminish that. Like bone metastasis and pathologic fractures are very serious business. And I am not trying to downplay that at all.

But with this kind of catastrophic, the world is ending, the sky is falling thinking, there’s no room in all of this as a new Onco PT for you to really have this casual thinking or casual approach. Like it feels very serious all the time. And because of that, because you are a very caring individual who deeply, deeply cares for your patients and shows up and does the work and believes in being the best possible Onco PT you can for your patients,

That puts a lot of pressure on you. That is you putting a lot of pressure on you in all of this. Hence why it’s keeping you up at night. Now, early oncology physical therapists in my practice often internalize this thought of if something goes wrong, it’s on me. Like it’s a reflection of you being a bad oncology physical therapist. And that really heavy responsibility creates a sense of hypervigilance.

I have to be watching out all the time. And maybe not physically, but almost mentally, we start to really bubble wrap our patience in, don’t want to hurt them. I want to make sure that they’re safe. I want to make sure that I then don’t cause a pathologic fracture. I don’t cause the fracture in this case because we have put ourselves in the, am in control of this. You are the one who is strong enough to make all of this happen and the weight is entirely on you.

This supercharged responsibility that you’ve put on yourself creates this hypervigilance and this hypervigilance is going to feed into the second guessing of you constantly wondering, my God, was that the right call? Was that what I should be doing with this person at this time? This is not a sign of incompetence. This is hypervigilance.

Now, incompetence would be that you show up, you don’t have any regard whatsoever for, you know, this person’s medical history and their oncologic history and, you know, whether there’s even metastasis or not, and you just go through your flow and you don’t really care too much to look into it. I have seen that. I have had other therapists cover for me when I have been out.

And I have seen that, I would say, incompetence and going so far as to negligence. That’s not what we’re talking about here. And if you’re listening to this podcast, I’m not talking to you about that. Okay. If you’re here showing up because you want to get better, you are not in this incompetent zone, my friend. You were in the hyper vigilance state that is feeding into the second guessing that we need to get out of this, this hurricane or the cyclone of second guessing. So

what I would instead encourage you to think about. So when I’m evaluating a patient who has bone metastasis, there’s a quiet kind of list or kind of flow that I’m running through in my brain as I’m, you know, ask, as I’m getting the subjective from this person, as I’m putting kind of that information that they’re giving me together with

you know, if I have imaging available or what the latest oncology note says about the status of their, you know, bone metastases, et cetera. So I’m looking first and foremost at the mechanical integrity of that bone. And this is again, where we would really, you know, pull from imaging or pull from the interpretation of that imaging to say, okay, what are we actually working with here? Is that bone cortex less than a third involved? If we’re thinking about the Morel’s criteria here,

Is it more than a third? Is it more than two thirds? And there’s other characteristics, right? From these scoring systems that we’re saying, okay, what is the structural integrity of the bone that we’re looking at here? What is that mechanical integrity? So I’m considering this, but I don’t stop there because I need to have a full picture of what we’re actually working with when it comes to this human being. So depending on the location of the metastasis, then I’m not just saying like in the

the trochanteric region versus the non-trochanteric region. If you think about Morrell’s criteria, I’m talking about where in the body is this metastasis. So now that I’ve ascertained, okay, here’s the kind of mechanical integrity of the bone. Where is this metastasis? Is it in the humerus? Is it in the femur? Is it in the spine? And then I’m starting to think about,

If the person has a metastasis in this region, how might this start to impact what I want to do with this person? And how does this, you know, kind of line up with what are their goals? What do they want to do? Now I’m not creating my whole plan, right? Because I still have, you know, objective data that I want to get, but this is me starting to think about what are some maybe areas of concern that I want to

be careful around when I start doing my outcome measures, when I start doing my evaluation, my examination, and then ultimately when I’m then going to create a plan of care. So do I need to be careful of spinal precautions, right? If that person has a spinal metastasis, or am I maybe more concerned about single leg weight bearing? If it’s a pelvic metastasis, for example.

And then I also want to consider kind of this cumulative fatigue. And I know that’s a little outside at face value of what we’re talking about today with bony metastasis. But I really do want to look at kind of how is this person’s kind of physiologic vigor in a way. Are they dealing with cancer related fatigue? the bony metastasis

layer on top of this of physiologically, maybe they don’t have the gusto to kind of get through as much activity as what I would want even outside of that bony metastasis. And then the last thing I’m kind of considering in all of this is treatment timing. Now you are probably very aware by now of

There are going to be some days depending on when a person is going through treatment, what kind of treatment they’re undergoing that they’re going to have days they feel better and they’re going to have days that they don’t feel very good. And they may not be up for physical therapy. They may not be up for a really strenuous home exercise program. And so I’m putting kind of these factors all together into my mind to say, here’s kind of a big picture view.

of who this person is, what they’re dealing with, and what we really need to be aware of, and what we need to focus on in our plan of care as we’re planning our interventions together. Amidst all of this, I’m also on a subconscious level scanning how certain am I in all of this? How good do I feel? How ⁓ secure do I feel in this

knowledge to proceed forward. And I want to make it very clear that the goal of all of this, becoming an oncology physical therapist and working towards becoming a specialist in oncology physical therapy isn’t to eliminate uncertainty. That’s just not how oncology works period. That’s not how cancer rehab works.

because there is always going to be some degree of uncertainty. And this isn’t to put the responsibility, take the responsibility off of you, it’s to introduce the understanding that there is always going to be a little bit of unknown that we have to work with. But what’s important as we are working towards becoming the best on copete version of ourselves that we can be,

is not to eliminate the uncertainty, it’s to learn how to move within it without spiraling out of control. So again, thinking back to our why bony metastases keep you up at night as you are laying there and kind of replaying and rethinking about the choices that you made in your session with the person who has bone metastases, instead of you circling the drain on, my God, I don’t know if I did the right thing.

What if I should have done this? Well, if I’d have done that, then this, but then what about this factor? And I just don’t know. We’re not.

We’re not eliminating the uncertainty, but we are allowing you to move through it without losing yourself in the kind of like circle, the uncertainty spiral that we’re talking about here. And this can be really, really hard to get to. This is a skill. Okay, this is probably one of those.

I wouldn’t say soft skills. So we think about soft skills like interpersonal skills and how important those absolutely are in oncology, physical therapy. This also isn’t totally a skill like range of motion, right? Like you can do MMT until the cows come home, but this judgment, I think almost bridges the gap between like the quote, hard skills, range of motion, MMT, and then the soft skills of interpersonal skills. This judgment,

This decision-making area kind of bridges the both of those. And this is probably one of the absolutely just ongoing areas that you as an oncology physical therapist are going to continue to refine over time. Because realizing that comfort with uncertainty or at least sitting in the uncertainty is a learned skill. This sometimes does not feel good.

It does not feel good, especially when you first get started with this. It does not feel good to sit in the uncertainty. We are uncomfortable. We are unsettled in uncertainty because you are a problem solver and you are an information seeker. And when we’re presented with a problem, when you are presented with an issue that you don’t know the answer to, you go out and find it. Right. That’s also why you’re listening to the Onkopiti podcast here, but that sitting with uncertainty.

is really, really hard as a newer oncology physical therapist and has to be worked on and refined over time. And you’re going to reach different levels, right? You’re going to get to a level of saying, you know what, I can sit with this and it’s okay. And I know how I’m gonna navigate this in one area. And then you might encounter a completely different patient scenario and say, my gosh, I’m not even there, right? And that’s okay, right? This is not a…

all umbrella encompassing area where you’re going to get this skill down. It’s going to be great forever. And it’s going to be easy in all areas. No, no, no, no, no, my friend. We’re going to get really good at sitting with the uncertainty and bone metastasis. And then you have that framework you can apply to other areas within OncoBT. So early on as an oncology physical therapist, you want

the guarantees. You want the black and white. You want the tried and true frameworks that you can follow to a T and you can check things off the checklist because that tells you what to do. It feels good to be told what to do and know that this is a good decision. This is the path that is going to help me help this patient. This is how I’m going to help this person get from point A to point B. And that feels good. And I feel like that is very

ortho in a way, right? Like we like our clinical practice boxes. Thinking back to PT school, we had these boxes that we learned for the most common types of back pain. And you know, this is how you evaluated to determine what kind of back pain a person was experiencing. And then these were the interventions that you would do that would help with that. It’s clean. It feels good to have a plan and to know that when a person meets these check boxes, these criteria,

Boom, this is the path. Well, we don’t have that same kind of black and white 100 % of the time when it comes to oncology physical therapy. And it’s really uncomfortable. It doesn’t feel good because you naturally want someone to tell you this is safe and this is what is not safe. Do this, do these things over here. Do not do these things over here. Stay away from them.

And again, it’s very black and white. It’s very clear what is good, what is bad. Oncology is gray. Oncology is the rainbow, right? It does not exist in this black and white paradigm that we would honestly like it to because there’s simply so many variables. And unfortunately, cancer is sometimes gonna do what cancer wants to do. And that’s, think, one of the suckiest parts about oncology physical therapy.

And this is why it’s so important for you as an oncology physical therapist to move out of this black and white thinking and more into this rainbow, you know, area of thinking of knowing that there is a spectrum, that there are gradients and whatnot. And that’s, that really kind of comes down to in oncology, physical therapy, you have to operate in these risk gradients, right? So really calculating.

mentally, not with a calculator, right? But really thinking about what is the more significant risk if I’m weighing between two different treatment options, for example. You’re operating in probabilities, right? Which of these situations is more likely to happen as a result of me doing this test and measure, for example? And we’re operating in changing physiology.

Right? As I mentioned previously, cancer sometimes is going to do what cancer is going to do. And we also have to understand that every person’s body, every body that we encounter is a little bit different. And so being able to move kind of in the stream of there are different factors that are at play here to ultimately arrive at the most informed

⁓ best thought out, best clinically judged decision to move forward with this person. As I mentioned, we’re not trying to eliminate the uncertainty because that’s not going to happen on oncology. We are trying to swim through the uncertainty without drowning in it, without getting lost, without spiraling in that uncertainty. And this is the skill.

that you truly need in order to work with a person who has bone metastasis so that you don’t stay up at night, just spinning in your mind, questioning, second guessing every choice that you made throughout the day.

And this skill does not come with memorizing more precautions or memorizing the morels or the spinal instability neoplastic score. I’m not saying those are not important. Those are really good things and they help to guide us. But when it comes to actually working with a human being in front of you, who is a rainbow, you cannot take a black and white.

protocol and squish it onto them and expect that this is going to take care of everything that I needed it to. And this is a really big maturity moment as an oncology physical therapist. And so I don’t want you to take away from this episode and say, well, I guess I’m just not a mature oncology physical therapist. My friend, you are putting in the work to get there. This is not a destination. This is a journey that you are constantly taking steps forward.

on in order to get to this point of being stable and being confident and comfortable in your skills so that you can sit in this uncertainty. So as we’ve talked about, we’ve been talking about a lot of spiraling at this point. So what do we actually do about this? How can we move forward? What can we implement to make it so that you’re not

spinning your wheels at night wondering what the heck am I even supposed to do the next time I see this patient when they come in to see me tomorrow morning. What is going to help reduce the spiral for you? Isn’t more fear, right? More fear because you are so worked up about all of these frameworks and whatnot is not going to help you actually put a plan into place and make it happen with your patient. It’s having a repeatable way to think

about these clinical scenarios. And when you know this sequence that you’re moving through, you don’t eliminate the risk altogether, but you’re going to help eliminate the chaos that can happen in your brain. And that’s the difference we’re looking for. Let me give you an example. When you were a student physical therapist and you were going through doing evaluations, like your very first evaluations with your patients, you probably felt a little all over the place, right?

you know what, I need to ask this question and my gosh, I need to make sure and do this special test and ⁓ well, what about this thing? And I remember, I mean, sometimes, you know, it was more internal, it was more mental. Sometimes it was also external. It was much more physically apparent of like my brain and my evaluation are scattered all over this clinic or this hospital right now.

And sometimes I would even be leaving the evaluation room multiple times to get equipment because I just didn’t have a streamlined way to think about my evaluations. Fast forward now, I can do evaluations really well as an oncology physical therapist. And you can too, because you have put in the work, you have done this time and time again.

that you now have a structure, you now have a system, you now have a flow or a sequence that you can move through to where you can do these evaluations from start to finish, get the information that you need in order to formulate an appropriate plan of care, and I would say probably even get started treating this day. And I know you’re like, well, yeah, Elise, but genuinely think back to your first evaluations.

they probably took a whole hour plus leaving you with no time for treatment at the end. Now you can breeze through your evaluations, you can get started treating and you know that you have started this relationship off with your patient on the right foot and they’re set up for success to when they come in to see you the next time you can hit that ground really running if you haven’t already. So again,

We’re working on reducing the chaos, the internal chaos that we can feel that you can experience in this uncertainty of bone metastasis so that you can move forward in a predictable way and reduce that spiraling that we’ve been talking about. Now, if you have been feeling the weight of these decisions around bony metastasis and treatment planning, et cetera,

more than you expected. Because I certainly know that was my experience when I first started practicing. This does not mean that you are behind. This does not mean that you are incompetent. In fact, I would argue the opposite because if you’re aware of this, this means that you are a discerning individual who cares deeply about getting better every single day to better show up for your patients in your community.

I know you. I know this is who you are.

This doesn’t mean that you are behind. It means that you are stepping into the level of practice where these decisions really matter. You are making these decisions now that really are going to make or break how much of a difference you can really make with this person. And this comfort with uncertainty is a learned skill. It comes with practice and practice and practice and sitting in that discomfort.

and sitting in that uncertainty many, many times. Many, many times.

So the more that you sit with this, the more that you really, really, like I said, discern to think this through, the better you are going to get. It’s not going to come overnight, but these are the steps that you can put into place. This is kind of the sequence or the framework that you can start to think about when you are working with a person who has bone metastasis so that you can feel 2 % more comfortable with the uncertainty tomorrow. And that is going to compound over time.

but we have to get started with sitting with the discomfort and the uncertainty today. So this week on YouTube, I’m going to walk through the exact sequence that I use when deciding whether bone metastases in a particular patient are safe to load or if they’re not. And this is not giving you more precautions to follow, right? Like more of the black and white, here’s what to do.

This is the structured way that I use to think and proceed through my patient interactions with a person who just happens to have bone metastasis. So if you need that clarity, it is there on my YouTube channel.

In closing, one of the reasons that we even created the cancer rehab community was because this kind of reasoning is rarely modeled out loud. You know, and what’s so great is that again, we have a lot of really wonderful literature and research that shows us these are the things we need to stay away from when it comes to bone metastasis. And we have some research that says here are some good things to do.

but it’s still a very black and white and we don’t have that, how do we actually do this in practice? How is this actually, how is this reasoning modeled out loud so you can see what other clinicians who are doing this work and is seeing the results, how can I take that and then put that into my own practice, right? It’s hard to refine your thinking, especially about this topic of bone metastasis in isolation.

which is why we are talking about this, which is why we are going to continue talking about this throughout this week and over the next couple of weeks here on the Onco PT podcast. So if you have been replaying your sessions at night where you’ve encountered a person with bony metastasis, this does not mean that you are not cut out for oncology. In fact, the opposite, it means that you care very deeply about being the best oncology physical therapist and showing up.

day after day for your patients in your community. The next step is not caring more, right? It’s thinking more clearly so that you can proceed with these situations of uncertainty and still know at the end of the day that you made the most appropriate decision for your patient in that moment.

That’s what really matters. So we’ll keep building on that. We will talk more about this, like I said, on this week’s YouTube video, also throughout the next few episodes of the Onco PT podcast. But until next time, 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.