Physical Activity in Metastatic Bone Disease

Original Editor - Candace Goh

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

Introduction[edit | edit source]

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 and prostate.[1] 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:

[2]

General Principles[edit | edit source]

  • Treat people as individuals - Personalise treatment prescription and adapt exercises to the patients' abilities.[3] Take into account both the medical and social situation of the person. Keeping the patient's goals, desires, expectations and 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[4].
  • Awareness of 'red flag' symptoms -
    Red flag.png
    • 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.[5]
  • Awareness of symptoms that could indicate Metastatic Spinal Cord Compression (MSCC) -
    • Back or neck pain
    • Progressive limb weakness
    • Numbness or tingling sensation in toes, fingers or buttocks
    • Bladder or bowel problems[1]

Treatment Considerations[edit | edit source]

People at risk of MBD[edit | edit source]

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. [6]

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.

People with asymptomatic MBD[edit | edit source]

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[7], 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[edit | edit source]

Prior to exercise, the static and dynamic capacity of the affected skeletal structures should be determined, by assessing the localization, type and size of bone defects, and pathological fractures and region with a risk of fracture.[6]The oncological treatment undergone should also be considered.[3]

As pain and fatigue negatively influence cancer patients' activity participation and lack of activity can lead to muscle atrophy and increased likelihood of skeletal complications, a referral to cancer exercise specialists should be considered for the planning of personalized physical activity programs.

Physiotherapy Management[edit | edit source]

Evidence supports the use of aerobic and resistance exercises for MBD patients to improve physical function and mental health: [6]

  • Isometric exercises can be used in stable bone metastasis cases.
  • Avoid overloading the affected areas.
  • Avoid sheering or rotation forces at the affected area.
  • Modalities increasing local blood flow, such as ultrasound therapy, heat, massage, or certain electrotherapies, should not performed at the affected area.
  • Seek medical advice if pain does not resolve quickly, there is new onset of bone pain, or bone pain that has changed in nature or intensity, due to risk of fracture [5]
  • Walking aids can be used to take the weight off affected lower limbs.

If there are 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 - although the patients health status and capabilities should be considered when making recommendations [8].

Role of the Multidisciplinary Team[edit | edit source]

The case management and referrals will be completed by the oncologist or surgeon. Fracture risk assessment will be completed by specialists in radiology, orthopedics, oncology, or radiation therapy. Pain management can be via medication, radiotherapy and physical medical modalities (e.g. transcutaneous electrical nerve stimulation). [9]Depending on patients needs and goals, they can be seen by dietitians, occupational therapists and nurses.[5]

Conclusion[edit | edit source]

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[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 Jayarangaiah A, Kemp AK, Theetha Kariyanna P. Bone Metastasis. [Updated 2022 Oct 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507911/
  2. Amgen The Biology of Metastatic Bone Disease. Available from https://www.youtube.com/watch?v=q7b55yQP4g4&feature=emb_logo
  3. 3.0 3.1 Sheill G, Guinan EM, Peat N, Hussey J. Considerations for Exercise Prescription in Patients With Bone Metastases: A Comprehensive Narrative Review. PM R. 2018 Aug;10(8):843-864.
  4. Mustian KM, Sprod LK, Janelsins M, Peppone LJ, Mohile S. Exercise recommendations for cancer-related fatigue, cognitive impairment, sleep problems, depression, pain, anxiety, and physical dysfunction: a review. Oncology & hematology review. 2012;8(2):81.
  5. 5.0 5.1 5.2 Macmillan Cancer Support. Physical activity for people with Metastatic Bone Disease. Available from: https://cdn.macmillan.org.uk/dfsmedia/1a6f23537f7f4519bb0cf14c45b2a629/1784-10061/physical-activity-for-people-with-metastatic-bone-disease-guidance-tcm9-326004 (Accessed 21/05/2023)
  6. 6.0 6.1 6.2 Keilani M, Kainberger F, Pataraia A, Hasenöhrl T, Wagner B, Palma S, Cenik F, Crevenna R. Typical aspects in the rehabilitation of cancer patients suffering from metastatic bone disease or multiple myeloma. Wiener klinische Wochenschrift. 2019 Nov 1;131(21-22):567-75.
  7. Jawad MU, Scully SP. In brief: classifications in brief: Mirels' classification: metastatic disease in long bones and impending pathologic fracture. Clin Orthop Relat Res. 2010 Oct;468(10):2825-7.
  8. Global Recommendations on Physical Activity for Health. Geneva: World Health Organization; 2010. Available from: https://pubmed.ncbi.nlm.nih.gov/26180873/
  9. Crevenna R, Hasenoehrl T, Wiltschke C, Kainberger F, Keilani M. Prescribing Exercise to Cancer Patients Suffering from Increased Bone Fracture Risk Due to Metastatic Bone Disease or Multiple Myeloma in Austria-An Inter- and Multidisciplinary Evaluation Measure. Cancers (Basel). 2023 Feb 15;15(4):1245.