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Deborah Howell (Host): Welcome. The Women's Cancer Center at Deaconess is always innovating. Today, we'll find out about prehabilitation or prehab and how it helps prevent lymphedema in cancer rehabilitation.

My guest today is Dusty Fiester, a physical therapist at High Pointe Therapy at Deaconess The Women's Hospital. Welcome, Dusty.

Dusty Fiester: Thank you for having me.

Deborah Howell (Host): Great to have you back. So what does prehab mean?

Dusty Fiester: Well, a very complicated definition of prehab is the process of improving functional capacity of a patient. Prior to their surgical procedure, the patient is assessed to know where their baseline mobility is. And we discuss things that will help them to withstand any post-surgical inactivity or decline. So for the breast cancer population, specifically functional capacity for them is best understood when thinking about their ability to use their arms for daily tasks.

Deborah Howell (Host): Okay. And what is assessed at a prehab appointment for a breast cancer patient?

Dusty Fiester: When they come in for their prehab appointment, we look at their range of motion of their arms, their strength of their upper body, what is their posture before surgery. We also really look at their medical history information as well, to look for any inflammatory conditions or chronic pain. Sometimes those things can be helpful in knowing how we can help them in that recovery process after surgery. And then we also discuss with them any upcoming adjunctive treatments that they may have, including radiation or chemotherapy. It's kind of a whole body assessment. In addition to that, I think the one benefit that we have at High Pointe is the ability to also do what's called a SOZO scan and that SOZO scan is something that we just have started doing since August of 2021.

Deborah Howell (Host): Can you tell us a little bit more about the SOZO scan and how it works?

Dusty Fiester: Yes, it's a very strange name, but I actually just recently learned from a patient that I was seeing that it actually has a significant meaning, which is really, really neat. So that's something if someone wanted to know the meaning, they could look that up. But it's a digital scale that we use in the clinic and it uses low level current, which the patient can't feel. They simply step on it like you would any type of, scale that you would weigh yourself on. The difference is that they will have their shoes and socks off and they step on with their feet on the two plates and then their hands are resting on two plates as well. And that machine measures the resistance and reactants to electric current in the body. It gives us a really objective way to assess fluid levels in the body, as well as tissue composition. So tissue composition means overall hydration levels, how the body is balancing fluid inside the cell versus outside the cell. So it gives us a really good baseline of their overall health status before they even have surgery.

Deborah Howell (Host): Now, that's a great leap forward. And we're talking about fluids in that balance. What is subclinical lymphedema?

Dusty Fiester: So subclinical lymphedema is swelling or an accumulation of fluid in the arm or leg after surgery. For a breast cancer patient, we would be looking specifically at their arms. For a pelvic or gynecological type cancer, we would be looking more specifically at the legs. But subclinical is just a small accumulation of fluids that, if we treat it before we can even measure a circumferential difference of their arm or leg, then that could prevent them from developing chronic long-term lymphedema. And with the SOZO, the SOZO can detect as small as a difference of 2.4 tablespoons of fluid, and that is something that we before the SOZO machine would never have been able to capture in an objective way to know that that fluid was there, to be able to just treat that patient early.

The benefit of having the SOZO scan in our clinic to utilize with patients is that studies have shown that there's an 81% lower rate of chronic lymphedema when we use the SOZO versus just monitoring with a tape measure to measure the patient's arms left to right or to measure their legs left to right along the way. So 81% lower chance of chronic swelling is huge.

Deborah Howell (Host): That is unbelievable. What an incredible advancement. What other areas are addressed in the prehab appointment that impact a patient's recovery after surgery?

Dusty Fiester: The other very, very important thing that we discuss when they come in to see us is exercises after surgery. A lot of times patients are very concerned about moving their arms or moving too much after surgery. And so I think just the reassurance that they can move their arms, they can move their legs if it's more of a pelvic cancer, after their surgery is helpful. But we do give them some guidelines to encourage safe return to function, so that they don't develop other side effects postop.

Deborah Howell (Host): Yeah. No breakdancing, no pushups, none of that right away, right?

Dusty Fiester: That's right.

Deborah Howell (Host): Okay. So what kind of restrictions might one to expect to have after a mastectomy or lumpectomy?

Dusty Fiester: So, like you said, no breakdancing. That's right. Then, we also encourage that they don't do a lot of push or pull or repetitive exercises. And it's kind of fun when we go over these with patients, because the very first question is, "So that means I can't clean my house for how long?" They love pushing that responsibility off on their spouse or significant other. So that push and pull is like a vacuum, mowing, repetitive exercises, so depending on their job, if they are doing a lot of repetitive movement, that's something that we really want to be cautious with for usually at least the first two to three weeks after surgery.

We also encourage that they limit their shoulder range of motion to shoulder height or below, and that they're not doing any reaching overhead for those first two to three weeks. And that may vary depending on their surgeon's recommendations as well. So we always give the nod to the surgeon that if they feel the restrictions need to be more stringent, that the patient should always defer to them.

Deborah Howell (Host): Questions like can I really chop this big, huge carrot? Or can I pick up my cat? You know, there's so many questions. And again, just talk to your team and those questions will be answered individually. So why can't the patient just move as they wish?

Dusty Fiester: Well, there are certain side effects that can happen after surgery and, by giving them those restrictions, it really reduces significantly the risk of developing something called a seroma. And a seroma is just an increase of fluid accumulation at the surgery site. And a lot of times that happens at the chest wall or can happen, I shouldn't say a lot of times, but it can happen at the chest wall after surgery or in the axilla area, in the armpit area. They also will have drain tubes in after surgery. And they have to have their fluid levels down to, I believe, it's 30 cc of fluid before those drain tubes can come out. And the hope is, is that those drain tubes will come out when they follow up with their physician at their two-week followup appointment. But if they're moving too much, then that's going to keep their drainage higher.

So, limiting movement also helps the body to reabsorb and not have so much drainage for such a prolonged period of time. Limiting movement also helps with the wound healing. Too much movement just doesn't allow for normal necessary scarring, to have a nice solid incision site. And then in addition, this is something that we're really starting to learn and discover, is that by limiting movement, we also allow the lymphatic system its optimal chance to reconnect and regenerate in that surgical area.

Deborah Howell (Host): Okay, that makes perfect sense. Now, how do you feel the prehab program impacts outcomes for those preparing for breast cancer surgery?

Dusty Fiester: I think it is a great opportunity for individuals to have a sense of what their recovery might look like for them. We really talk about more than just what their baseline is, but we talk about pain management, and some things that they can do to help with pain management, such as diaphragmatic breathing, We talk about the purpose of why we're encouraging them to limit their range of motion. And I think when you know the why behind the restriction, it allows for better recovery, and understanding. And I think it just empowers them to feel educated and to understand the road that is in front of them and eases some of their concerns and worries. We've also found that it just gives them permission to allow healing, to take place before they feel like they need to go back to their normal routine and when to safely integrate those things back into their daily lives.

Deborah Howell (Host): Right. That makes perfect sense. It's always good to have a roadmap, no matter what you're doing. Do you see the patient again after surgery? And if so, how often?

Dusty Fiester: We do. So when we see them for their baseline visit or their prehab visit, we will also schedule them before they leave the clinic for a three-week followup. And it's not necessarily three weeks after we see them in the clinic, but three weeks after their scheduled surgery date. And then when they come back at that three-week point, that gives them a chance to let us know the things that went well, maybe the things that didn't go well, and we decide whether or not they do need to continue to come in to see us to improve their functionality and motion. And, also we would bring up if they're going to have radiation or chemotherapy, some possible reasons why they may return down the road to allow them to have optional functionality and recovery.

Ideally, we would love to touch base with them every three months during that initial two years. Receiving a diagnosis of cancer, it's a journey. And so having those frequent touch points along the way really helps to address issues quickly instead of allowing those to build up and become a bigger issue.

Deborah Howell (Host): As we're wrapping up, is there anything else you'd like to add to our conversation?

Dusty Fiester: I just want to say that I really, really appreciate you giving us the opportunity to share the benefits of the prehab program and the SOZO machine. And we're just so grateful for the opportunity to provide that at the Women's Hospital through High Pointe, and to be able to share that with our community. I just think we have so many wonderful assets within the community. It's just a matter of knowing where they are and who to call.

Deborah Howell (Host): And it's our privilege to spread the word for sure. Excellent info as always. Thanks so much for being with us again today, Dusty. Just a pleasure to have you on the podcast.

Dusty Fiester: Thank you so much.

Deborah Howell (Host): This is Deaconess, The Women's Hospital, a place for all your life. For more information, visit deaconess.com/highpointe or call 812-842-2820. That's all for this time. Please remember to subscribe, rate, and review this podcast and all the other Deaconess Women Hospital podcasts. For more health tips and updates, follow us on your social channels. I'm Deborah Howell. Thanks for listening and have yourself a great day.