Integrative Oncology Services at Children’s Hospital of Philadelphia

Acupuncture

Tracey F. Jubelirer, MD: Now I'd like to introduce Dr. Douglas McDaniel, who's going to talk to us about acupuncture therapy that we recently started offering our hospitalized patients to support them in many ways.

Douglas McDaniel, DACM, L.Ac.: Hi, my name is Doug McDaniel. I'm a doctor of acupuncture and Chinese medicine and a licensed acupuncturist with the integrative oncology team here at CHOP. So acupuncture is the insertion of very thin needles into specific points on the body called acupoints, which help to balance the body's vital energy or chi.

Research shows that acupuncture may help reduce symptoms related to cancer treatment, including nausea and vomiting, pain, anxiety, fatigue, difficulty sleeping, neuropathy -- or numbness and tingling in the hands and feet -- loss of appetite and constipation, as well as helping to support general health and wellbeing during the continuum of cancer treatment.

Tracey F. Jubelirer, MD: So Doug, can you tell us, I think some people worry a little bit when children on neutropenic or their counts are low and they're thrombocytopenic, you know. How safe is acupuncture in the oncology setting?

Douglas McDaniel, DACM, L.Ac.: So acupuncture is very safe. All the needles are pre-sterilized, single use and disposable. All points are swapped with alcohol prior to insertion.

There have been both retrospective and prospective studies that have been done around safety of acupuncture in the setting of thrombocytopenia and neutropenia, and it has been shown to be a safe procedure.

Tracey F. Jubelirer, MD: Now, I know a lot of our kids get procedures and they're stuck with needles a lot, so, when they hear needles, they might run away from acupuncture.

So can you just tell us a little bit about just the needle size and does acupuncture hurt.

Douglas McDaniel, DACM, L.Ac.: So acupuncture is actually a very comfortable procedure. When the needle is inserted, it's inserted very quickly, and so you may feel nothing at all or a slight, slight pinch as the needle is inserted. I have an acupuncture needle here that I'll show you.

So there's a guide tube, a plastic tube around the needle. That tube is rested on the skin and then the needle is tapped in very quickly. And I don't know how, let's see. Can we see that? Yes, I think so. A very thin needle, right? And it's flexible. So it's a very, the insertion, as I said, was very quick and it's very comfortable once it's in. Typically the needles are retained for 20 to 30 minutes.

And the patient is just resting comfortably in a chair, on a massage table or in a bed, and most patients actually report this to be very relaxing. Our youngest patient right at the moment is seven years old. And, you know, loves to have acupunctures. So it's definitely viable and a viable option in a pediatric population.

Tracey F. Jubelirer, MD: And what, are there any other options that if a patient just really is afraid of the needles or just doesn't want to do acupuncture, are any other things that you can offer them?

Douglas McDaniel, DACM, L.Ac.: Yeah. So patients who are not, you know, if they're not quite ready to have acupuncture or decide that they don't want acupuncture at all, we can provide acupressure for them, which is basically applying pressure to the same point that would be needled with the acupuncture needle using either the thumb or the finger.

This also feels very good. It's very relaxing. It's something that can be taught to the patient and their caregiver so that the patient or the caregiver can provide this acupressure to themselves or to their loved one. You know and in setting, so that they actually have a tool to use no matter where they are, should a symptom arise.

Aroma Therapy

Tracey F. Jubelirer, MD: Now I'd like to transition over to Lisa Squires, who is a nurse in our Integrative Oncology Program and is talented in many areas. She is going to talk to us about her role as an aroma therapist and how aroma therapy can be helpful to you or your child through the cancer journey.

Lisa Squires, RN, BSN, CCRN, PHRN: Hi, my name is Lisa Squires and I'm a holistic nurse and professional aroma therapist.

Aroma therapy is actually just referring to the use of essential oils either by inhaling the smell or applying them topically to the skin. Essential oils come from different plant parts and they're very concentrated and very potent. But aroma therapy can help us feel less stressed and calmer as well as have many other benefits.

So we supply a therapy at CHOP using these sniffers or otherwise known as personal inhalers. We actually don't use diffusers at CHOP due to the risk of bacterial overgrowth in the water and the difficulty in knowing how much oil is being absorbed and dispersed into the air. Lavender and mandarin both can help decrease stress, increase calm, and digestive ease as well as aid and comfortable healing environment. Both lavender and mandarin have been well studied in children and are safe to use in children older than three.

Tracey F. Jubelirer, MD: So Lisa while I know we offer mandarin and lavender, are there any other oils that you can just talk about that patients may be able to use or use with their children?

Lisa Squires, RN, BSN, CCRN, PHRN: Sure. There actually are a lot of oils, and usable oils, somewhere between 250 and 350 oils. Unfortunately, there's really very little research to tell us which oils are safe in children, or safe especially in children with cancer. So it's also difficult to tell which products are, have pure and high quality because they are not FDA regulated. So if you have questions about essential oils, please consider coming to our interdisciplinary clinic and we can help you choose some of the safe and, and use oils in the safest way possible.

It is really important to say that no one should ever be ingesting or taking orally any essential oils.

Tracey F. Jubelirer, MD: Thanks Lisa. All that information is so important and I do think we really want you to know that we're here to offer our expertise with regarding aroma therapy. There is a lot out there on the market, but if you have any questions, please feel free, come to our clinic, or we can put you in touch with Lisa who has these expertise.

So the last thing I have to ask you, Lisa is, how can our patients receive these aroma therapy inhalers when they're in the hospital?

Lisa Squires, RN, BSN, CCRN, PHRN: Currently in both inpatient and the outpatient clinics for oncology, the nurses have all been trained in aroma therapy. So all you need to do is ask your child's nurse and they should be able to bring you either a lavender or mandarin sniffer.

Massage Therapy

Tracey F. Jubelirer, MD: I'm glad to introduce Tiffany Silliman Cohen, who is a licensed massage therapist. So Tiffany, when I think of massage, I think we often don't think about the vast array of benefits that it can provide aside from relaxation, one traditionally thinks of when say you're getting a massage at a spa. So can you better inform us how massage therapy can help us? Can help our patients?

Tiffany Silliman: Absolutely. Great question. There are many ways that massage can benefit children and young adults. Some of the biggest benefits come from reducing stress and anxiety, but massage can also help with pain, muscle tightness, sleep, fatigue, nausea, headaches, and on building resiliency skills as well.

Research has been done that verifies that massage offers a vast array of benefits. We see the benefits in our patients and love to get the tools to not only our patients, but our patient's families to help them at home.

Tracey F. Jubelirer, MD: Thanks, Tiffany. That's great. So where, you know, what does it look like when a child gets a massage? Like where do they go? What's the environment like.

Tiffany Silliman: So typically a massage is offered in connection with their care and treatment in either the outpatient or the inpatient setting. So it means that I work with the child or young adults and their family in either the outpatient office or inpatient and offer massage while clothed, and without the use of oil. I collaborate with the patient, the family, the medical team, the psychosocial team, to develop a plan for each patient. If a child doesn't want a massage that day, I will typically teach a parent how to do some simple massage strokes that they can do at home. Sometimes I teach self massage ideas for the older children or young adults.

And all of this is offered in a very, a way that is really meeting patients where they're at, knowing that there's a lot going on and that it can be a time that we really need to be careful around, really having it patient-led. So in a clinically supportive model, best support of each and every child and family in their unique situation.

Tracey F. Jubelirer, MD: Thanks, Tiffany. That's really important. Informative. So where in the Cancer Center is massage provided and how do patients go about seeing you?

Tiffany Silliman: Well, we currently offer massage at Voorhees Hematology/Oncology Outpatient Clinic, the King of Prussia Hematology/Oncology Clinic. So I'm at Voorhees on Monday and Wednesdays and at King of Prussia on Fridays.

And then we also are on Thursdays in the oncology unit, inpatient as well. We also are able to do some tele-health visits and support patients that way, if you are not able to see me in one of those other settings.

Tracey F. Jubelirer, MD: Thank you. And hopefully at some point we'll be expanding to our Buerger Clinic. So if you can just chat a little bit more with us, just talking about if parents or patients concerned about massage, like what are the risks that we need to worry about?

Tiffany Silliman: So typically all the massage that's offered is adapted and safe and as supportive as possible. Main risks are muscle soreness, and possibly bruising, but very rare, really does that happen.

Generally there's no major risks with proper adaptations and precautions followed. That's why we work very closely with the whole team and the family.

Tracey F. Jubelirer, MD: Great. Yes. And as you said, we work with the primary oncology team and, you know, as in our team in integrative oncology too, so we can provide a personalized approach to patients' care. Thanks so much, Tiffany. That's been really informative.

Nutrition

Tracey F. Jubelirer, MD: And now I'm going to go back to Dr. Mascarenhas, who is going to talk a little bit about nutrition specifically from an integrative perspective and how that is a vital part of supporting patients' cancer treatment and beyond.

Maria R. Mascarenhas, MBBS: Thanks Tracey. Nutrition is a key component of integrative medicine.

We are now recognizing how much nutrition can contribute to healing. Our goal is to help our patients during their cancer journey, with symptom control and weight maintenance. We have registered dieticians who can help our patients and are planning our culinary medicine sessions, where we will teach children and their families how to cook nutritious, tasty food that's fun to make. With our medical chefs at CHOP, we have created several recipes and would love to share them with you.

Physical Activity

Tracey F. Jubelirer, MD: Now we're going to move on to talking a little bit about physical activity, which I think is so important through the cancer journey from diagnosis and hopefully into survivorship. So I'd like to introduce two members of our team. First of all, Kristen DeVirgilio, she's our physical therapist in oncology, and then Dr. Brian Vernau, who's a sports medicine doctor, and they can talk about how they can work with you or your child to promote physical activity. So Kristen, if you want to get started.

Kristen DeVirgilio, PT, DPT: Hi, my name is Kristen DeVirgilio, and I'm a doctor of physical therapy with the integrative oncology team here at CHOP. I'd like to talk a little bit about what physical therapy is.

Physical therapy is the use of exercise with movement, coordination, balance, strength, and endurance. Physical therapists promote health and wellness for children from infancy through adolescence and support a child's motor development and participation in physical activity.

Tracey F. Jubelirer, MD: So Kristen, can you talk about the safety of exercise during cancer therapy? Is it okay for our patients to be doing physical activity?

Kristen DeVirgilio, PT, DPT: Great question and one that I often receive from patients and families. Exercise is an integral part of a pediatric cancer treatment plan and has been proven to be safe and possible during cancer treatment. A physical therapist can provide an individualized assessment for your child to determine an appropriate exercise prescription that is both safe and enjoyable. This exercise plan takes into account your child's current level of activity, any physical limits they may have, as well as their current medical plan.

Our sports medicine physician, Dr. Vernau and I, collaborate to develop personalized exercise programs for our patients in the Integrative Oncology Program.

Tracey F. Jubelirer, MD: So I think sometimes exercise gets put to the bottom of the list with everything that patients are going through. And I really think this is a topic, like I said, that's so important.

Can you just tell us why it is so important for patients to participate in physical activity, during and after cancer therapy?

Kristen DeVirgilio, PT, DPT: Absolutely. Exercise is medicine. Most people know that physical activity is good for health, however, for children with cancer, it is even more important. A growing amount of research shows that regular physical activity can improve physical health, such as increasing cardiopulmonary fitness and muscle strength; mental health, by reducing depression and anxiety; improving sleep; energy and mood; as well as quality of life. These benefits in children can be seen during every phase of treatment.

The goal is really to stay as active and as fit as possible. A variety of different types of exercise is the key to a safe and effective exercise program, both during and after cancer treatment. In general, a complete program should follow the CDC guidelines for physical activity in children and include aerobic training, muscle strength training, and bone strength training. This can be achieved through lifestyle activity, structured exercise, active play, and sports.

Tracey F. Jubelirer, MD: So Kristen, where can patients be seen for physical therapy?

Kristen DeVirgilio, PT, DPT: So your child can be seen in a multitude of settings for physical therapy. We provide services, both inpatient during hospitals stays, as well as in our outpatient oncology clinic, Monday through Friday at main campus, as well as out at our King of Prussia site on Wednesdays and our Voorhees, New Jersey site on Fridays.

We're also available through our Integrative Oncology Clinic, as well as in our outpatient physical therapy gym. For our patients in the hospital, we now have equipment that can be used throughout their admission to support their physical activity.

Tracey F. Jubelirer, MD: Thanks Kristen. Now I'm going to transition over to Dr. Brian Vernau, who's our sports medicine doctor who works closely with Kristen and our integrative oncology team. And we'll probably reiterate a lot of what Chris or Kristen has just said.

Brian Vernau, MD, FAAP, CAQSM: Hi, I'm Brian Vernau and I'm a pediatrician with specialty in sports and exercise medicine. Since exercise is important for so many areas of our wellbeing, from sleep to mood, to helping the body heal, I work closely with our physical therapist, Kristen, and the rest of the team to review your child's treatment plan and develop a customized exercise prescription that is both safe and realistic.

For those who are involved in sports, I can help guide a safe return to sport when that athlete is ready. We enjoy designing creative ways to keep kids moving both during and after treatment to promote an active and healthy adulthood. I see patients in our Glen Mills and King of Prussia specialty care centers, as well as downtown at the Buerger Center with the integrative oncology team, and I look forward to meeting your family.

Yoga Therapy

Tracey F. Jubelirer, MD: I'd like to now introduce you to Tonia Kulp, who is our yoga therapist at CHOP. We launched yoga therapy in July of 2019, and I think it's really been a huge success. So Tonia, take it away.

Tonia D. Kulp, MS, C-IAYT: Thank you, Dr. Jubelirer. Hi, my name is Tonia and I am a certified yoga therapist with the integrative oncology team here at Children's Hospital of Philadelphia.

So let's just talk a little bit about some of the benefits of yoga therapy. So although all yoga is potentially therapeutic and healing, yoga therapy is the specific application of yoga tools, things like postures and exercises, breath work, meditation techniques, and more to address an individual's physical, mental, and emotional needs.

Research shows that integrative therapies such as yoga can be beneficial in improving overall quality of life during cancer care. Yoga can be used to help manage a variety of physical symptoms, including pain, nausea, insomnia, and fatigue.

Tracey F. Jubelirer, MD: So Tonia, can you talk a little bit about what this yoga looks specifically like for an oncology patient? I think some people think when you think about yoga, I'm going to have to stretch like a pretzel, stand on your head or do crazy positions. So if you can just kind of offer some insight into what exactly you're doing with our patients.

Tonia D. Kulp, MS, C-IAYT: Sure. So here at CHOP, our yoga therapists work with patients and families and the patients medical care team to address specific goals while considering always any limitations that the patient may be feeling or experiencing.

We always offer modifications to postures, to breathing techniques. Really to anything that we offer the patient to meet them where they are in that moment. Yoga therapy can compliment physical therapy, occupational therapy, massage, psychotherapy, and more. The practices that your yoga therapist might recommend could include movement, ranging from gentle to more vigorous, depending on where the child is in their treatment; breath work, pranayama, which are breathing techniques; meditation and visualization practices; physical postures, that address specific areas of discomfort or musculoskeletal imbalances; or any combination of tools mentioned above.

Tracey F. Jubelirer, MD: Thanks. I know many of our patients have benefited from many of the things you have spoken about, and I know you've been very helpful, especially with procedural-related anxiety and how breath work and meditation can help with port accesses and things like that.

So this is great. Can you talk briefly about just some of the risks that some folks need to think about.

Tonia D. Kulp, MS, C-IAYT: Sure. So the yoga therapists have in-depth training to help assess and keep their patients safe. As I had mentioned, modifications are always made and plans are tailored to the specific patient.

Our yoga therapists work closely with the medical team to ensure absolute patient safety while making progress toward identified goals.

Tracey F. Jubelirer, MD: Great. Thank you. And again, can you let everyone know where your services are offered?

Tonia D. Kulp, MS, C-IAYT: Sure. So our services are offered both inpatient and outpatient. We have a yoga therapist that has time at the King of Prussia and at the Voorhees specialty care clinics as well as inpatient.

So if you think that your child would benefit from yoga therapy, you can just please ask your child's primary oncologists to place a consult. And we are also available to do some work via telehealth as well.

Integrative Oncology Services

Maria R. Mascarenhas, MBBS: Welcome to the series on integrative medicine for patients with oncologic conditions and their families. I am Dr. Maria Mascarenhas, the medical director of the Integrative Health Program at the Children's Hospital of Philadelphia. We are delighted to introduce you to integrative medicine. So, what is integrative medicine?

Integrative medicine is healing-oriented medicine, that takes account of the whole person, including all aspects of lifestyle and emphasizes the therapeutic relationship between the practitioner and patient. It makes use of all appropriate therapies to make, to achieve optimal health and healing. If a non-mainstream practice is used together with conventional medicine, it's considered complementary.

If a non-mainstream practice is used in place of conventional medicine, it's considered alternative. Integrative medicine involves bringing conventional and complementary approaches together in a coordinated way. Now I want to introduce Dr. Tracey Jubelirer, who heads up our Integrative Oncology Program at CHOP. Dr. Jubelirer.

Tracey F. Jubelirer, MD: Thanks so much, Dr. Mascarenhas. So my name is Tracey Jubelirer and I'm the Director of the Integrative Oncology Program as well as a pediatric oncologist here at CHOP. So in oncology, while our hope is for cure, our hope is also for healing, for strength and for providing care that encompasses all aspects of health from physical to psychological, to spiritual.

In integrative oncology, our goal is to support you or your child with as evidence-based as possible integrative therapies, such as exercise, yoga, massage, acupuncture, and nutrition into conventional cancer care to promote healing and ease distress, and improve overall health. So we will work in collaboration with your oncology team to provide supportive care along the cancer journey that aligns with your goals.

Today, I'm delighted to introduce you to our team, so you can learn more about what integrative medicine is and how it may support you or your child's wellbeing in conjunction with cancer treatment. So, first off, I'm glad to introduce Tiffany Silliman Cohen, who is a licensed massage therapist. So Tiffany, when I think of massage, I think we often don't think about the vast array of benefits that it can provide aside from relaxation, one traditionally thinks of when say you're getting a massage at a spa. So can you better inform us how massage therapy can help us? Can help our patients?

Tiffany Silliman: Absolutely. Great question. There are many ways that massage can benefit children and young adults. Some of the biggest benefits come from reducing stress and anxiety, but massage can also help with pain, muscle tightness, sleep, fatigue, nausea, headaches, and on building resiliency skills as well.

Research has been done that verifies that massage offers a vast array of benefits. We see the benefits in our patients and love to get the tools to not only our patients, but our patient's families to help them at home.

Tracey F. Jubelirer, MD: Thanks, Tiffany. That's great. So where, you know, what does it look like when a child gets a massage? Like where do they go? What's the environment like.

Tiffany Silliman: So typically a massage is offered in connection with their care and treatment in either the outpatient or the inpatient setting. So it means that I work with the child or young adults and their family in either the outpatient office or inpatient and offer massage while clothed, and without the use of oil. I collaborate with the patient, the family, the medical team, the psychosocial team, to develop a plan for each patient. If a child doesn't want a massage that day, I will typically teach a parent how to do some simple massage strokes that they can do at home. Sometimes I teach self massage ideas for the older children or young adults.

And all of this is offered in a very, a way that is really meeting patients where they're at, knowing that there's a lot going on and that it can be a time that we really need to be careful around, really having it patient-led. So in a clinically supportive model, best support of each and every child and family in their unique situation.

Tracey F. Jubelirer, MD: Thanks, Tiffany. That's really important. Informative. So where in the Cancer Center is massage provided and how do patients go about seeing you?

Tiffany Silliman: Well, we currently offer massage at Voorhees Hematology/Oncology Outpatient Clinic, the King of Prussia Hematology/Oncology Clinic. So I'm at Voorhees on Monday and Wednesdays and at King of Prussia on Fridays.

And then we also are on Thursdays in the oncology unit, inpatient as well. We also are able to do some tele-health visits and support patients that way, if you are not able to see me in one of those other settings.

Tracey F. Jubelirer, MD: Thank you. And hopefully at some point we'll be expanding to our Buerger Clinic. So if you can just chat a little bit more with us, just talking about if parents or patients concerned about massage, like what are the risks that we need to worry about?

Tiffany Silliman: So typically all the massage that's offered is adapted and safe and as supportive as possible. Main risks are muscle soreness, and possibly bruising, but very rare, really does that happen.

Generally there's no major risks with proper adaptations and precautions followed. That's why we work very closely with the whole team and the family.

Tracey F. Jubelirer, MD: Great. Yes. And as you said, we work with the primary oncology team and, you know, as in our team in integrative oncology too, so we can provide a personalized approach to patients' care. Thanks so much, Tiffany. That's been really informative. Now I'd like to introduce Dr. Douglas McDaniel, who's going to talk to us about acupuncture therapy that we recently started offering our hospitalized patients to support them in many ways.

Douglas McDaniel, DACM, L.Ac.: Hi, my name is Doug McDaniel. I'm a doctor of acupuncture and Chinese medicine and a licensed acupuncturist with the integrative oncology team here at CHOP. So acupuncture is the insertion of very thin needles into specific points on the body called acupoints, which help to balance the body's vital energy or chi.

Research shows that acupuncture may help reduce symptoms related to cancer treatment, including nausea and vomiting, pain, anxiety, fatigue, difficulty sleeping, neuropathy -- or numbness and tingling in the hands and feet -- loss of appetite and constipation, as well as helping to support general health and wellbeing during the continuum of cancer treatment.

Tracey F. Jubelirer, MD: So Doug, can you tell us, I think some people worry a little bit when children on neutropenic or their counts are low and they're thrombocytopenic, you know. How safe is acupuncture in the oncology setting?

Douglas McDaniel, DACM, L.Ac.: So acupuncture is very safe. All the needles are pre-sterilized, single use and disposable. All points are swapped with alcohol prior to insertion.

There have been both retrospective and prospective studies that have been done around safety of acupuncture in the setting of thrombocytopenia and neutropenia, and it has been shown to be a safe procedure.

Tracey F. Jubelirer, MD: Now, I know a lot of our kids get procedures and they're stuck with needles a lot, so, when they hear needles, they might run away from acupuncture.

So can you just tell us a little bit about just the needle size and does acupuncture hurt.

Douglas McDaniel, DACM, L.Ac.: So acupuncture is actually a very comfortable procedure. When the needle is inserted, it's inserted very quickly, and so you may feel nothing at all or a slight, slight pinch as the needle is inserted. I have an acupuncture needle here that I'll show you.

So there's a guide tube, a plastic tube around the needle. That tube is rested on the skin and then the needle is tapped in very quickly. And I don't know how, let's see. Can we see that? Yes, I think so. A very thin needle, right? And it's flexible. So it's a very, the insertion, as I said, was very quick and it's very comfortable once it's in. Typically the needles are retained for 20 to 30 minutes. And the patient is just resting comfortably in a chair, on a massage table or in a bed, and most patients actually report this to be very relaxing. Our youngest patient right at the moment is seven years old. And, you know, loves to have acupunctures. So it's definitely viable and a viable option in a pediatric population.

Tracey F. Jubelirer, MD: And what, are there any other options that if a patient just really is afraid of the needles or just doesn't want to do acupuncture, are any other things that you can offer them?

Douglas McDaniel, DACM, L.Ac.: Yeah. So patients who are not, you know, if they're not quite ready to have acupuncture or decide that they don't want acupuncture at all, we can provide acupressure for them, which is basically applying pressure to the same point that would be needled with the acupuncture needle using either the thumb or the finger.

This also feels very good. It's very relaxing. It's something that can be taught to the patient and their caregiver so that the patient or the caregiver can provide this acupressure to themselves or to their loved one. You know and in setting, so that they actually have a tool to use no matter where they are, should a symptom arise.

Tracey F. Jubelirer, MD: Thanks Doug, that's been great. Now I'd like to transition over to Lisa Squires, who is a nurse in our Integrative Oncology Program and is talented in many areas. She is going to talk to us about her role as an aroma therapist and how aroma therapy can be helpful to you or your child through the cancer journey.

Lisa Squires, RN, BSN, CCRN, PHRN: Hi, my name is Lisa Squires and I'm a holistic nurse and professional aroma therapist. Aroma therapy is actually just referring to the use of essential oils either by inhaling the smell or applying them topically to the skin. Essential oils come from different plant parts and they're very concentrated and very potent. But aroma therapy can help us feel less stressed and calmer as well as have many other benefits.

So we supply a therapy at CHOP using these sniffers or otherwise known as personal inhalers. We actually don't use diffusers at CHOP due to the risk of bacterial overgrowth in the water and the difficulty in knowing how much oil is being absorbed and dispersed into the air. Lavender and mandarin both can help decrease stress, increase calm, and digestive ease as well as aid and comfortable healing environment. Both lavender and mandarin have been well studied in children and are safe to use in children older than three.

Tracey F. Jubelirer, MD: So Lisa while I know we offer mandarin and lavender, are there any other oils that you can just talk about that patients may be able to use or use with their children?

Lisa Squires, RN, BSN, CCRN, PHRN: Sure. There actually are a lot of oils, and usable oils, somewhere between 250 and 350 oils. Unfortunately, there's really very little research to tell us which oils are safe in children, or safe especially in children with cancer. So it's also difficult to tell which products are, have pure and high quality because they are not FDA regulated. So if you have questions about essential oils, please consider coming to our interdisciplinary clinic and we can help you choose some of the safe and, and use oils in the safest way possible. It is really important to say that no one should ever be ingesting or taking orally any essential oils.

Tracey F. Jubelirer, MD: Thanks Lisa. All that information is so important and I do think we really want you to know that we're here to offer our expertise with regarding aroma therapy. There is a lot out there on the market, but if you have any questions, please feel free, come to our clinic, or we can put you in touch with Lisa who has these expertise. So the last thing I have to ask you, Lisa is, how can our patients receive these aroma therapy inhalers when they're in the hospital?

Lisa Squires, RN, BSN, CCRN, PHRN: Currently in both inpatient and the outpatient clinics for oncology, the nurses have all been trained in aroma therapy. So all you need to do is ask your child's nurse and they should be able to bring you either a lavender or mandarin sniffer.

Tracey F. Jubelirer, MD: Great. Thanks so much. So moving on, I'd like to now introduce you to Tonia Kulp, who is our yoga therapist at CHOP. We launched yoga therapy in July of 2019, and I think it's really been a huge success. So Tonia, take it away.

Tonia D. Kulp, MS, C-IAYT: Thank you, Dr. Jubelirer. Hi, my name is Tonia and I am a certified yoga therapist with the integrative oncology team here at Children's Hospital of Philadelphia.

So let's just talk a little bit about some of the benefits of yoga therapy. So although all yoga is potentially therapeutic and healing, yoga therapy is the specific application of yoga tools, things like postures and exercises, breath work, meditation techniques, and more to address an individual's physical, mental, and emotional needs.

Research shows that integrative therapies such as yoga can be beneficial in improving overall quality of life during cancer care. Yoga can be used to help manage a variety of physical symptoms, including pain, nausea, insomnia, and fatigue.

Tracey F. Jubelirer, MD: So Tonia, can you talk a little bit about what this yoga looks specifically like for an oncology patient? I think some people think when you think about yoga, I'm going to have to stretch like a pretzel, stand on your head or do crazy positions. So if you can just kind of offer some insight into what exactly you're doing with our patients.

Tonia D. Kulp, MS, C-IAYT: Sure. So here at CHOP, our yoga therapists work with patients and families and the patients medical care team to address specific goals while considering always any limitations that the patient may be feeling or experiencing.

We always offer modifications to postures, to breathing techniques. Really to anything that we offer the patient to meet them where they are in that moment. Yoga therapy can compliment physical therapy, occupational therapy, massage, psychotherapy, and more. The practices that your yoga therapist might recommend could include movement, ranging from gentle to more vigorous, depending on where the child is in their treatment; breath work, pranayama, which are breathing techniques; meditation and visualization practices; physical postures, that address specific areas of discomfort or musculoskeletal imbalances; or any combination of tools mentioned above.

Tracey F. Jubelirer, MD: Thanks. I know many of our patients have benefited from many of the things you have spoken about, and I know you've been very helpful, especially with procedural-related anxiety and how breath work and meditation can help with port accesses and things like that. So this is great. Can you talk briefly about just some of the risks that some folks need to think about.

Tonia D. Kulp, MS, C-IAYT: Sure. So the yoga therapists have in-depth training to help assess and keep their patients safe. As I had mentioned, modifications are always made and plans are tailored to the specific patient.

Our yoga therapists work closely with the medical team to ensure absolute patient safety while making progress toward identified goals.

Tracey F. Jubelirer, MD: Great. Thank you. And again, can you let everyone know where your services are offered?

Tonia D. Kulp, MS, C-IAYT: Sure. So our services are offered both inpatient and outpatient. We have a yoga therapist that has time at the King of Prussia and at the Voorhees specialty care clinics as well as inpatient.

So if you think that your child would benefit from yoga therapy, you can just please ask your child's primary oncologists to place a consult. And we are also available to do some work via telehealth as well.

Tracey F. Jubelirer, MD: Super. Thanks so much Tonia. Now we're going to move on to talking a little bit about physical activity, which I think is so important through the cancer journey from diagnosis and hopefully into survivorship. So I'd like to introduce two members of our team. First of all, Kristen DeVirgilio, she's our physical therapist in oncology, and then Dr. Brian Vernau, who's a sports medicine doctor, and they can talk about how they can work with you or your child to promote physical activity. So Kristen, if you want to get started.

Kristen DeVirgilio, PT, DPT: Hi, my name is Kristen DeVirgilio, and I'm a doctor of physical therapy with the integrative oncology team here at CHOP. I'd like to talk a little bit about what physical therapy is.

Physical therapy is the use of exercise with movement, coordination, balance, strength, and endurance. Physical therapists promote health and wellness for children from infancy through adolescence and support a child's motor development and participation in physical activity.

Tracey F. Jubelirer, MD: So Kristen, can you talk about the safety of exercise during cancer therapy? Is it okay for our patients to be doing physical activity?

Kristen DeVirgilio, PT, DPT: Great question and one that I often receive from patients and families. Exercise is an integral part of a pediatric cancer treatment plan and has been proven to be safe and possible during cancer treatment. A physical therapist can provide an individualized assessment for your child to determine an appropriate exercise prescription that is both safe and enjoyable. This exercise plan takes into account your child's current level of activity, any physical limits they may have, as well as their current medical plan.

Our sports medicine physician, Dr. Vernau and I, collaborate to develop personalized exercise programs for our patients in the Integrative Oncology Program.

Tracey F. Jubelirer, MD: So I think sometimes exercise gets put to the bottom of the list with everything that patients are going through. And I really think this is a topic, like I said, that's so important. Can you just tell us why it is so important for patients to participate in physical activity, during and after cancer therapy?

Kristen DeVirgilio, PT, DPT: Absolutely. Exercise is medicine. Most people know that physical activity is good for health, however, for children with cancer, it is even more important. A growing amount of research shows that regular physical activity can improve physical health, such as increasing cardiopulmonary fitness and muscle strength; mental health, by reducing depression and anxiety; improving sleep; energy and mood; as well as quality of life. These benefits in children can be seen during every phase of treatment.

The goal is really to stay as active and as fit as possible. A variety of different types of exercise is the key to a safe and effective exercise program, both during and after cancer treatment. In general, a complete program should follow the CDC guidelines for physical activity in children and include aerobic training, muscle strength training, and bone strength training.

This can be achieved through lifestyle activity, structured exercise, active play, and sports.

Tracey F. Jubelirer, MD: So Kristen, where can patients be seen for physical therapy?

Kristen DeVirgilio, PT, DPT: So your child can be seen in a multitude of settings for physical therapy. We provide services, both inpatient during hospitals stays, as well as in our outpatient oncology clinic, Monday through Friday at main campus, as well as out at our King of Prussia site on Wednesdays and our Voorhees, New Jersey site on Fridays.

We're also available through our Integrative Oncology Clinic, as well as in our outpatient physical therapy gym. For our patients in the hospital, we now have equipment that can be used throughout their admission to support their physical activity.

Tracey F. Jubelirer, MD: Thanks Kristen. Now I'm going to transition over to Dr. Brian Vernau, who's our sports medicine doctor who works closely with Kristen and our integrative oncology team. And we'll probably reiterate a lot of what Chris or Kristen has just said.

Brian Vernau, MD, FAAP, CAQSM: Hi, I'm Brian Vernau and I'm a pediatrician with specialty in sports and exercise medicine. Since exercise is important for so many areas of our wellbeing, from sleep to mood, to helping the body heal, I work closely with our physical therapist, Kristen, and the rest of the team to review your child's treatment plan and develop a customized exercise prescription that is both safe and realistic.

For those who are involved in sports, I can help guide a safe return to sport when that athlete is ready. We enjoy designing creative ways to keep kids moving both during and after treatment to promote an active and healthy adulthood. I see patients in our Glen Mills and King of Prussia specialty care centers, as well as downtown at the Buerger Center with the integrative oncology team, and I look forward to meeting your family.

Tracey F. Jubelirer, MD: Thanks so much. And now I'm going to go back to Dr. Mascarenhas, who is going to talk a little bit about nutrition specifically from an integrative perspective and how that is a vital part of supporting patients' cancer treatment and beyond.

Maria R. Mascarenhas, MBBS: Thanks Tracey. Nutrition is a key component of integrative medicine. We are now recognizing how much nutrition can contribute to healing. Our goal is to help our patients during their cancer journey, with symptom control and weight maintenance. We have registered dieticians who can help our patients and are planning our culinary medicine sessions, where we will teach children and their families how to cook nutritious, tasty food that's fun to make. With our medical chefs at CHOP, we have created several recipes and would love to share them with you. For now, these sessions will be virtual, but we are hoping to have in-person sessions once the pandemic is over.

Tracey F. Jubelirer, MD: Thanks Maria. I'm really excited about our culinary medicine and nutrition initiative, which hopefully we'll be launching sometime in the near future.

So I just want to thank everyone. We're so glad that you were able to join us for this brief overview of integrative medicine and what we're currently offering at CHOP's Integrative Oncology Program. As we wrap up, I would like to share that we do have our multidisciplinary clinic, which has offered the last Friday afternoon of each month. I know sometimes this is hard for families to come to a clinic that's offered only once a month. So you do have the option to come in person, or we can support you with a telehealth visit. And the nice thing about our clinic is that during your time, you're going to have the opportunity to meet with myself for a consultation, but all the members of the team who you have just met so that we can really create a personalized integrative oncology plan that supports you or your child through therapy. So to schedule an appointment, or for more information about our Integrative Oncology Program you can go to the cancer website and we do have an integrative oncology page. Just to note, you can also visit the integrative health website through chop.edu.

So thank you so much. We really appreciate your support.