Bone Metastasis and the Role of Exercise
Bone metastasis is an unfortunate complication of breast, lung and prostate cancer amongst others. It can go undiagnosed until an unfortunate event occurs such as a pathological fracture of the hip, severely impacting quality of life. A good cancer physio should always be screening for bone metastasis, along with providing proactive education. From my experience, patients often want to know:
It is important for patients to understand the signs and symptoms of bone metastasis, as follow up screening can be limited. In addition, x-rays have limitations as they can only detect metastasis when there is minimum of 40-50% bone loss. Bone scans are more sensitive with a 97% accuracy, while CT scans are best for proximal femurs and the pelvis. Not surprisingly, MRIs are gold standard.
As bone metastasis can go undiagnosed for some time, and once diagnosed is a dynamic condition. There for, it’s important to understand that not all exercise is safe. Clinical support is needed to understand the location of the mets and the type. This blog will shed light on why exercise outweighs the risks of inactivity while providing science backed tools on how to do it safely.
Bone Metastasis Explained
Cancer cells can break away from a primary tumuor site, and then be transported to bone tissue. The most common sites of metastasis are the pelvis, ribs and spine. The weakening of the bone tissue can lead to swelling, hypercalcemia (increased calcium in the blood), pain and increased risk of fracture.
The most Common Areas of Bone Metastasis are:
Ribs
Pelvis
Spine
Symptoms of Bone Metastasis may Include:
Swelling or tenderness in the area
Persistent bone pain
Weakness or numbness
Fractures with minimal trauma
It’s not uncommon that after cancer, patients can experience worry when having symptoms of pain; fearing that it may be bone metastasis. I like to help patients understand how to differentiate a red flag from MSK related pain, helping them to know when to worry and when not to.
Having Pain? Consider the Following:
If you are experiencing persistent pain in your back, neck or pelvis:
For 3 weeks or more
The symptoms are steady or worsening
The symptoms are worse at night
You don’t have a known mechanism such as a fall
Please consider seeking timely clinical help, such as booking an appointment with your primary physician or a cancer physiotherapist. Consider booking a cancer rehab session allowing us to diagnosis the symptoms as mechanical MSK pain or a red flag that warrants more investigation. Together we can create your care plan in a timely manner. Your family physician can also order the necessary imaging and blood tests if deemed necessary according to the gold standards mentioned above. You may consider a private Bone scan, CT or MRI if the waitlist is too long.
The prognosis for bone metastasis varies a lot. Many factors impact prognosis such as the type of cancer, the type of bone mets, health history and the location of the metastasis. New systemic therapies along with improved bio-phosphonates are coming to market. These innovations are impacting longevity; and may help stabilize metastatic bone cancer.
The Role of Exercise in Managing Bone Metastasis
There was a time not that long ago that those with bone metastasis were put on bed rest and exercise was not encouraged. With the aims to reduce any risk of pathological fracture, patients weren’t provided a lot of options. Science and the guidelines regarding exercise and bone mets have now changed.
Exercise is Medicine and it doesn’t STOP with Bone Metastasis.
The International Bone Metastases Exercise Working Group (IBMEWG) have developed best practice recommendations for exercise programming for those with bone metastases consolidating published research, clinical experience and expert opinion.
Exercise offers numerous benefits as we come to understand through the exercise is medicine movement and this doesn’t stop with bone metastasis. In short, the benefits of exercise outweigh the risks of inactivity. Exercise however needs to be performed safely, with clinical consideration to reduce the risks of fracture.
A personalized rehab plan designed for the individual’s cancer diagnosis, bone metastasis type and location are vital to minimizing risks and maximizing benefits.
The Benefits of Exercising with Bone Metastasis Include:
1. Pain Management
Exercise supports physical and mental well-being. It can help improve muscle strength, stamina, balance and circulation. This can help with pain management while reducing inflammation. In addition, exercise promotes hormone release akin to cold therapy, detailed in previous blogs, helping with mental well-being and stress reduction. These hormones (dopamine, catecholamines, epinephrine) are mother nature’s pain killers, and can help de-sensitize pain responses, shifting your brains perception of what is painful.
2. Mental Well-Being
I don’t think we can think of a more life altering event than being diagnosed with cancer, it often takes a significant toll on a patient’s mental health. To counteract stress and depression, exercise can be very helpful along with cold therapy. Exercise, particularly low impact aerobic activities like walking or swimming, have been shown to help reduce symptoms of anxiety, depression, and fatigue. Physical activity can improve overall mood, reduce pain and enhance cognitive function.
3. Improving and/or Stabilizing Bone Health
Bone metastasis unfortunately weakens bones as noted above. The good news is that resistance training and weight-bearing exercises can stimulate bone formation and reduce bone loss. This can lead to improved bone density, lowering the risk of fracture. However, it is imperative that these resistance-based exercise are low impact, safe and personalized to the patient. Not only do we have to be mindful of the areas of concern, but we also have to be specific with the type of exercises prescribed.
Mechanical forces need to be considered when performing loaded based exercises. In bone metastasis we aim to promote safe resistance training by minimizing the compressive forces and torque forces through the areas of metastasis. By considering biomechanics, we can prescribed safe exercise programs; high school physics wasn’t useless after all!
Safe Exercise Minimizes
Compression + Torque at t
he Metastatic Site
4. Boosting Circulation and Reducing Swelling
Personalized strength exercises in the effected limbs along with light aerobic activity promotes circulation, which can help reduce swelling in the effected limbs. Often Bone metastasis is often coupled with swelling in the effected area; safe exercise can help reduce edema and improve lymphatic drainage.
5. Maintaining Function
Function is a simple word but means all the important stuff. Function includes things like getting off the ground, toileting, self-care and walking. Being able to preserve function is correlated with longevity, hence it’s so important. As bone metastases progress, patients may notice stiffness, decreased mobility and some daily tasks getting tougher. A personalized rehab plan can help maintain independence and confidence in managing the day to day.
How to Exercise Safely with Bone Metastasis
Due to the risk of pathological fracture, biomechanics and medical history need to be considered within the exercise prescription. The expertise of a cancer physiotherapist is important when commencing an exercise program with bone metastasis.
Our SAFE EXERCISE+ BONE METS guidelines are as follows:
Consult with a cancer physiotherapist
They can assess your bone health, keep an eye on the condition over time and advise on what exercises are safe based on the location and extent of metastasis. Here at the cancer physio, we will also aim to educate you on how to screen metastatic pain from mechanical pain, helping you to understand when to worry and seek further help. Together we will create a health care plan aiming to be proactive instead of reactive.
Aerobic exercises should be low-impact and weight-bearing when able
Aim for low-impact activities such as walking or cycling. Consider Nordic walking poles. Working against gravity is what helps bones develop, and stay strong. Endurance based activities such as walking that be done for 30 minutes or more allow for those good hormones to be released that help with mental well being. If your walking tolerance and cycling tolerance is poor due to pain, then you may consider pool therapy as it has many other benefits. Together we can design a pool therapy program to better your joint and aerobic health.
Resistance exercises should be with caution and/or support
For patients with stable bone metastasis, resistance exercises using light weights or resistance bands can be beneficial. Always start with very light resistance; gradually progressing over time. Exercises should be modified to avoid excessive strain on affected bones, as mentioned above, compression forces or torque forces can be more risk than reward, putting patients at risk for further fracture.
Stretching and range-of-motion exercises may benefit joint health
Maintaining flexibility and mobility of the joints can help preserve function. Once again, consider understanding how a joint is being loaded in a stretch, and aim to keep the impacted areas under lighter load.
Avoid high-impact or contact sports: Due to the risk of fractures, exercises that involve running, jumping, or any activity that could lead to a fall should be avoided, especially if there are known fractures or areas of high-risk involvement.
Bone metastasis can be a debilitating condition; however, exercise can be a powerful tool in improving the well-being of patients with metastatic cancer. A rehab plan that includes a personalized approach and safe exercise prescription can target pain relief, enhance mobility, support bone health, and promotes mental wellness.
Patients can maintain functional independence and experience a much higher quality of life by engaging in exercise regularly. As with any rehab plan, exercise should be tailored to the individual's needs and performed under the guidance of a cancer physio through an initial assessment, to ensure safety and effectiveness. While exercise alone cannot cure bone metastasis, it can make a significant difference in helping patients feel stronger and more resilient throughout their cancer journey.
Thank you for your interest in science and rehab.
Kindly, The Cancer Physio
