Physical Activity in Metastatic Bone Disease

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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. 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 there is 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.

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 advice.

Resources

• Physical activity in patients with metastatic bone disease: Guidance for healthcare professionals by the Macmillan Cancer Support.