A diverse population of people live with bone metastases with complicated health histories including:
Those with mets to the bones, as well as other organs.
Those with bone mets throughout their spine, pelvis and ribs.
Those with a single metastatic spot.
Cancer Rehab Physio is to help people:
Optimise their physical capacity.
Maintain their independence.
Avoid falls.
Understand went to seek emergency care.
Learn to live with bone mets. An ongoing process as emotional and physical health changes and needs change also.
Cope with ongoing daily risk assessment.
Cope with grief and loss.
The spine is often the first bone metastatic site.
Clinical changes include:
Pain
Several metabolic disturbances
Increased fracture risk
Impaired mobility
Spinal cord compression
Hypercalcaemia
Suppression of bone marrow function
Other challenges include:
Skeletal muscle loss
Muscle weakness
Functional deficits
Osteoporosis and osteopenia
Pathological fractures:
Cause an increase in symptom burden and is linked to reduced survival.
Medical options to reduce fracture risk include:
Osteo protective medication
Prophylactic fixation surgery
Palliative radiotherapy
When older than 40 years of age the likelihood that a pathological fracture occurs from a metastatic lesion is 500 times more common than the likelihood of it being a primary bone sarcoma.
Greatest pathological fracture risk occurs in bone affected by metastases:
In the trochanter, near the hip, followed by lower limb, then upper limb.
With stronger pain levels.
With lytic, more than mixed and more than plastic appearance on X-ray.
With size of lesion greater than 2/3rds of the bone cortex, rather than less than 2/3rds to 1/3rd.
Pain with functional activity is associated with greater risk of pathological fracture.
Metastatic spinal cord compression is a medical emergency.
Symptoms include:
Pain, usually severe, at the level of the lesion, which progressively increases in intensity.
With worsening pain or neurological symptoms, recording, reporting and seeking medical advice is recommended.
If pain or neurological symptoms worsen during exercise, stop the activity and return to a spinal protective position which reverses the symptoms.
Pain with weight bearing activities can be a warning of pathological fractures, particularly of the legs.
Pain should be monitored throughout the exercise session and modified accordingly.
The highest prevalence of bone mets occurs in those with:
Advanced prostate cancer = 85%
Advanced breast cancer = 70%
Advanced lung cancer = 49%
Advanced kidney cancer = 40%
The most common sites for skeletal metastasis include:
Spine 87%
Ribs 77%
Pelvis 63%
Femur 53%
Skull 35%
What is the difference between Lytic and Plastic bone lesions in cancer?
Osteoblasts are generally bone building cells, but can also send messages to osteoclasts to mature. Blastic lesions build bone up.
Osteoclasts are generally bone breaking down cells. Lytic lesions break bone down
Those with osteolytic mets have the highest incidence of skeletal morbidities.
50% of breast cancer patients with bone mets experience fractures.
Bone fracture presents in 75% of patients with multiple myeloma.
How are bone metastases diagnosed?
By bone scan, plain X-ray and CT scan.
How are bone metastases managed?
The focus is on presenting progression and treating musculoskeletal morbidities.
Radiotherapy can successfully release sentence.
Large randomised trials have demonstrated 80% of patients receiving radiotherapy for osseous metastasis will experience complete to partial pain relief typically with a 10 to 14 days after the initiation therapy.
Pain reduction is associated with positive changes in physical function.
Studies prescribing exercise for patients receiving palliative radiation treatment report no adverse events.
Bone targeted agents, such as bisphosphonates and denosumab have been shown to:
Decrease the incidence of skeletal morbidity;
Improve progression free survival;
Reduce the need for palliative radiotherapy and surgery.
Acute phase reactions to bisphosphonates occur in 15-20% of patients, characterised by flu-like symptoms, such as low grade fever, fatigue, arthralgia, (joint pain) or myalgia, (muscle pain), increased bone pain and nausea.
What is Hypercalcaemia?
Hypercalcaemia is a medical emergency when an abnormally large amount of calcium is in the blood, affecting 10% of patients with advanced cancer.
How does Hypercalcaemia present?
Neurological changes, cognitive changes, gastrointestinal, renal and cardiovascular symptoms.
Hypercalcaemia with malignancy usually presents with marked elevated calcium levels, above 3.5 mol/L, is usually severely symptomatic and considered and oncology emergency.
When is surgery required?
To prevent impending fractures or to stabilise a pathological fracture.
What treatment is required after bone stabilising surgery?
Weight bearing postoperatively depends on bone quality, types of fractures pattern, surgical procedure.
A collaborative approach to post operative mobilisation is paramount between the surgical and rehabilitation team.
Physical inactivity is associated with a loss in:
Physical function,
Mobility,
Balance,
Protective muscle mass,
Strength,
Bone mineral density.
The loss of these hampers quality of life and increases fracture risk.
What are the Current Research Recommendations?
The ‘No-load’ approach, avoiding load on regions with bone lesions to enable safe exercise for all other parts of the body.
Exercise has been shown to preserve physical function in prostate cancer patients with bone metastases.
Outcome measures used:
1/ Patient rated physical functioning - The Medical Outcomes Study Short Form 36 Questionnaire.
2/ Objective tests to measure physical function -
Timed up and go test, (timed and performed 3x with recovery between tests).
6 metre walk test, testing usual and fast pace, (timed and performed 3x with recovery between tests).
400 metre walk.
For Muscle Strength: 1 rep maximum, *(1RM) knee extension and chest press exercises.
*Strength Testing -1 RM
The one-repetition maximum (1RM) test is often considered as the ‘gold standard’ for assessing the strength capacity of individuals in non-laboratory environments It is simply defined as the maximal weight an individual can lift for only one repetition with correct technique. Purpose of test:
To determine the maximum weight that can be lifted for one complete repetition of the movement
Equipment required:
• Weights dependent on muscle group testing.
Test procedure:
‘The following represents the basic steps in 1-RM (or any multiple RM) testing following familiarisation/practice sessions:
1) The subject should warm up, completing a number of sub maximal repetitions.
2) Determine the 1-RM (or any multiple RM) within four trials with rest periods of 3 to 5 minutes between trials.
3) Select an initial weight that is within the subject’s perceived capacity (~50%–70% of capacity).
4) Resistance is progressively increased by 2.5 kg to 20 kg until the subject cannot complete the selected repetition(s). All repetitions should be performed at the same speed of movement and range of motion to instil consistency between trials.
5) The final weight lifted successfully is recorded as the absolute 1-R or multiple RM.
Balance and risk of falling: Static and dynamic balance tests. Activities specific balance confidence scale.
3/ Bone pain nature, severity and impact - Bone Pain Questionnaire.
4/ Patient-reported physical functioning - Function Index.
5/ Cancer specific distress - Impact Events Scale.
6/ Fatigue - Questionnaire.
7/ Sleep Quality - Pittsburgh Sleep Quality Index.
8/ Tolerance of the exercise program -Participants ratings of perceived exertion on a Borg scale after every exercise session.
9/ The Safety of the exercise program - Recording the incidence and severity of any adverse events and skeletal complications.
10/ Bone pain according to the Common Terminology Criteria of the National Cancer Institute:
Grade 1 mild pain, not interfering with function.
Grade 2 moderate pain, interfering with function, but not interfering with their activities of daily living.
Grade 3 severe pain, severely interfering with their activities of daily living.
Exercise Prescription Guide for Bone Metastases:
Pelvic Metastases - Resistance training upper and lower limbs, (excluding hip flexion and extension, including knee flexion and extension), and trunk, non weight bearing aerobic exercise, eg cycling, and static flexibility.
Lumbar (lower back) Metastases - Resistance training upper and lower limbs, non weight bearing aerobic exercise, eg cycling, and static flexibility.
Thoracic (mid back) and Rib Metastases - Resistance training upper limbs, (excluding shoulder flexion, extension, abduction and adduction, including elbow flexion and extension), and lower limbs, weight bearing, eg walking and non weight bearing aerobic exercise, eg cycling, and static flexibility.
Proximal Femur, (upper thigh bone) Metastases - Resistance training upper and lower limbs, (excluding hip flexion and extension, including knee flexion and extension), and trunk, non weight bearing aerobic exercise eg, cycling, and static flexibility.
All regions - Resistance training upper limbs, (excluding shoulder flexion, extension, abduction and adduction, including elbow flexion and extension), and lower limbs, (excluding hip flexion and extension, including knee flexion and extension), and trunk, non weight bearing aerobic exercise, eg cycling, and static flexibility.
Current Research
1/ Exercise Prescription in the recent M3EP trial included:
Resistance Component: Increased by 5-15% increments if 3 sets of 12 reps achieved.
Aerobic Component: 20-30 mins of cardiovascular exercise with target intensity 60-85% of estimated maximum heart rate.
Flexibility Component: Static stretching using 2-4 reps for 30-60 seconds per stretch.
2/ The second approach being investigated: “Isometric Load Approach":
Specifically training muscles in the regions with bone lesions, therefore having the potential to elicit local adaptations.
Designed for patients with spinal metastases undergoing palliative pain relieving radiotherapy.
Free isometric spinal stabilisation exercises reveal positive effects on bone mineral density after radiotherapy, pain and pain medication use.
3/ A Cross sectional study of 50 patients living with a high burden of metastatic disease reported that 92% were interested in completing exercise programs and felt able to do so.
However exercise levels in this population are sub optimal, with only 29% of patients with bone metastases meeting the current aerobic exercise guidelines for cancer survivors.
What are the Predictors of Probability of Thoracic or Lumbar Vertebra Collapse?
Probability of Thoracic Vertebra Collapse is higher the higher percentage occupancy of the tumour in the vertebral body and the destruction of costovertebral joint, then pedicle, then posterior elements.
Probability of Lumbar Vertebra Collapse is higher the higher percentage occupancy of the tumour in the vertebral body and the destruction of the pedicle, then posterior elements.
What are the key considerations for exercise prescription for someone with bone mets in their lower spine?
Don’t challenge this part of the spine with exercises. Exercises to challenge other parts of the body eg/ exercise bike rather than rower, as less force on lumbar spine.
As increased fracture risk avoid falls, prioritise balance retraining in a safe, supported environment.
Focus on static muscle contraction and avoid compression of lumbar spine.
Avoid flexion and extension exercises involving the lumbar spine.
Avoid twisting when exercising.
Exercises to strengthen quads to assist with getting up and down, eg lunges and squats with ball behind back on wall with safe, non slip, foot positioning, maintaining neutral spine.
Strengthen upper body with supine, unloaded chest press if no thoracic spine involvement.
Static strengthening of core muscles in 4 point kneeling with leg slides, progressed to leg lifts, arm lifts, then opposite arm to leg lifts, maintaining neutral spine. (75% of patients tested were able to achieve these in all sessions and were found to be beneficial so continually encouraged).
Static strengthening of core in elbow plank, swimmer lying on front with arms overhead or with elbows bent and upper arms lower, as tolerated, with opposite arm to leg lifts. (42-54% of patients tested were unable to achieve these in all sessions but were found to be beneficial so continually encouraged).
Static strengthening of upper back muscles in standing with theraband. (75% of patients tested were able to achieve these in all sessions and were found to be beneficial so continually encouraged).
Accept will have pain and still important to exercise safely.
Need to learn to live with bone mets, as an ongoing process and as emotional and physical health changes, needs will change also.
Ongoing risk assessment daily, understanding when to seek emergency care.
Monitor pain and manage risk assessment throughout exercise sessions and modify treatments accordingly.
Summary of Exercise Interventions:
Resistance exercise is prescribed systematically based on location of bone metastases, ensuring affected regions are not targeted and mechanical force at areas of metastases is minimised. This is important for those with more than one metastasis, limiting loads to multiple areas of the body.
Circuit exercise classes tailored to individuals and exercise programs, determined by baseline functional ability, have been prescribed with no exercise related adverse events reported.
Tuition and monitoring of correct, effective exercise techniques is important, and guidance on exercise intensity, monitoring heart rate and perceived exertion.
Safety precautions include:
Medical history
Comorbidities
Treatment related side effects
Peripheral neuropathy
Pathological fracture risk
Immunosuppression
Lymphodema risk
Cardiopulmonary issues
Impact of Bone Metastases on Quality of Life:
Mortality considerations aside, bone metastases can also significantly impact quality of life as a consequence of their associated effects.
Whereas fatigue is the most stressful symptom cited by men with metastatic prostate cancer, patients with bone metastases may also experience pain as well as activity limiting lifestyle, discomfort, extremity weakness, neurological impairment, dyspnea, impaired mobility, loss of bladder and bowel function, mild sensory loss or numbness, loss of appetite, sleep disturbance.
A 2015 US survey commissioned by BayerHealth Care suggests that (68%) of men with advanced prostate cancer ignore or under-report their symptoms to their healthcare providers.
The most commonly reported symptoms by survey participants included:
Fatigue: 85%
All over body pain or aches: 55%
Numbness or weakness: 55%
Difficulty sleeping as a result of pain: 42%
Difficulty performing normal activities: 40%
Anxiety or distress as a result of pain: 40%
Vomiting: 25%
Loss of appetite
What are the subjective red flags with bone mets?
Pain with weight bearing activities indicating pathological fractures, particularly in the lower limbs
Change in pain intensity levels
New onset of pain
A band of pain
Unremitting night pain
Change in pain medications
Pain during their prescribed exercises
Pain on movements
Movements becoming more difficult, eg walking, getting in and out of bed, or chair
New continence issues, bladder or bowel dysfunction
Pain on sleep breaths or straining
Limb weakness
Pins and needles or numbness
Is Manual therapy indicated for advanced cancer appropriate and are there precautions or contraindications?
Soft tissue work to unaffected extremities.
Adhesive scar massage, post surgery, avoiding areas of disease and previous radiated areas due to skin thinning.
Manual lymphatic drainage techniques for self and family to assist.
Joint stiffness causing pain and/or loss of function not at level of bone mets - gentle mobilisations if nil osteoporosis/ fracture risk.
Muscular tension causing pain - gentle massage avoiding areas of bone mets.
Precautions-
If unsure check with your oncologist.
X-ray/bone scan to exclude bony mets and fractures in area of treatment.
Contraindication -
Joint mobilisations or manipulation over or adjacent to bone met sites.
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