Physical Activity in Metastatic Bone Disease

Original Editor - Candace Goh

Top Contributors - Candace Goh, Chloe Waller, Vidya Acharya, Kim Jackson and Shaimaa Eldib  

Introduction:

Metastatic Bone Disease (MBD) is a secondary cancer that has spread or metastasised to the bone from a cancerous organ. Primary cancers that most commonly metastasise to bone include cancers of the lungs, breasts, thyroid, kidneys, prostate. The skeletal areas commonly affected by MBD include upper arm bones, long bones of the leg, pelvis, ribs, spine, and skull.

Keeping physically active can bring many benefits to cancer patients of all stages and is widely recommended. See Physical activity in cancer for more information. As healthcare professionals, it is important for us to be knowledgeable on the principles, precautions, and contraindications when recommending exercises and advising people with MBD on physical activity. Not only can this improve the quality of care, it may also help to debunk myths on exercise and cancer such as "cancer patients only need rest".

Please watch the video below if you would like to know more on the biology of MBD:

General Principles

• Treat people as individuals - Take into account both the medical and social situation of the person. Keeping the patient's goals, desires, expectations, anxieties as a central part of care delivery. The views and anxieties of families and care givers should also be considered but the person’s own views comes first.
• Emphasise the importance of staying active - Understand the risks of sedentary lifestyle. Encourage people to get involve in valued occupations which require some extent of physical exertion. Challenge one another to #justkeepmoving
• Importance of rest and recovery - High-quality recovery periods between physical activity should be implemented to allow time for the body to recuperate. While sleep can be disrupted in cancer patients, it is known that staying active can improve sleep quality.
• Awareness of 'red flag' symptoms -
  
  • Bone pain in the vertebral column that worsens night: indicates high risk of spinal MBD and imminent fracture.
  • Bone pain on weight bearing (especially in the proximal femur): indicates high risk of MBD in the long bones and imminent fracture.
  • Worsening and intractable bone pain at any time.
• Awareness of symptoms that could indicate Metastatic Spinal Cord Compression (MSCC) -
  • Back or neck pain
  • Pain with a rapid crescendo and radiating in a band-like fashion around the chest or abdomen
  • Numbness or tingling sensation in toes, fingers or buttocks
  • Unsteadiness on feet
  • Progressive weakness in legs
  • Bladder or bowel problems

People at risk of MBD

Individuals that are at risk of MBD should be assessed with a plain X-ray followed by radiological review and if indicated, an orthopaedic opinion. Computer tomography (CT), and magnetic resonance imaging (MRI) provides information on osteoblastic activity, osseous stability, and bone skeletal vascularity.   A baseline assessment on general pain, fatigue, fear/anxiety, co-morbidities, adequate nutrition, motivational state, understanding the likely benefits of physical activity, should be done before and since the diagnosis. This can help individuals to set realistic and appropriate activity goals. If thereare no red flag symptoms, healthcare professionals should recommend global health guidelines of 150 minutes of moderate aerobic activity (or 75 minutes of vigorous exercise) per week plus strength exercises on two or more days per week.

People with asymptomatic MBD

A recent plain film X-ray could be reviewed for MBD lesions to determine the level of fracture risk in people with asymptomatic MBD. This can then be used to determine a baseline Mirels’ score, which will then indicate best practice for clinical treatment. If the Mirels’ score is 7 or under, people with MBD can be considered to be at low risk of fracture and should be encouraged to be as active as possible within pain-free limits. If it is 8 or above, the individual should be referred for an orthopaedic opinion.

People with symptomatic MBD

In people with symptomatic MBD and new onset of bone pain, or bone pain that has changed in nature or intensity, risk of fracture should be considered until proven otherwise. Functional pain which is pain on weight bearing should be of particular concern. Imaging, radiological review and an orthopaedic opinion should be sought in the first instance. However, this does not mean people with symptomatic MBD should remain sedentary.

As pain and fatigue negatively influence cancer patients' activity participation, a referral to cancer exercise specialists should be considered for the planning of personalized physical activity programs.

According to the American College of Sports Medicine, the regular physical activity consists of the followings elements (if patients show no contraindications for active exercise):

• 150 min/week of moderate-intensity or 75 min/week of the vigorous-intensity activity or an equivalent combination,
• Muscle-strengthening activities of at least moderate intensity at least 2 days/week for each major muscle group and stretching major muscle groups and tendons.

They should perform physical activity as per conditions and abilities allow. In fact, lack of activity can lead to muscle atrophy and also increase the likelihood of skeletal complications such as fractures and bone pain. A general advice would be to avoid stress on the affected limb. Locations with pathological fractures or a high risk of fracture are usually excluded from exercises. However, in stable bone metastasis cases, isometric exercises are indicated for the maintenance of painless mobility. Recommended exercise programmes should include resistance exercises targeting the unaffected limbs. People with MBD should be advised to restrict any movement that causes pain, and seek medical advice if pain does not resolve quickly or if there are increased episodes of breakthrough pain. They should also be advised against exercises that induce high torsion, such as yoga-style twists, using the rowing machine, and swinging in golf and tennis. Walking aids can be used to take the weight off affected lower limbs.

If people with MBD do undergo surgical fixation, prophylactic or otherwise, they should be encouraged to keep mobile as much as possible after the procedure in consultation with their orthopaedic surgeon. Orthopaedic fixation should enable immediate weight-bearing. Any adaptive equipment necessary for mobilization should be provided and the importance of reducing sedentary time should be emphasised.

Conclusion

The evidence of physical activity improving multiple outcomes in people living with cancer, including those with MBD, is considerable and growing. People with MBD/ at risk of MBD should be encouraged to be as active as realistically possible while being aware of worrying symptoms and signs that should lead them to seek medical attention.

Resources

• Physical activity in patients with metastatic bone disease: Guidance for healthcare professionals by the Macmillan Cancer Support.
• Metastatic Bone Disease: A Guide to Good Practice by British Orthopaedic Oncology Society & British Orthopaedic Association.