Physical Therapy for Metastatic Bone Cancer

Mandatory Pre-Exercise Risk Stratification

The American College of Physical Medicine and Rehabilitation recommends using the Spinal Instability Neoplastic Score (SINS) to assess spinal lesions, with scores ≤6 indicating stability, 7-12 indicating potential instability, and ≥13 indicating instability 1
For long bone lesions, Mirels' score should be used, with scores ≤7 indicating low risk, 8 indicating moderate risk, and ≥9 indicating high risk 1
Absolute contraindications for exercise include acute spinal cord compression, severe hypercalcemia, and active infection (avoid until asymptomatic >48 hours) 1, 2

The American College of Sports Medicine recommends targeting 150 minutes per week of moderate-intensity aerobic activity, with walking, stationary cycling, and swimming as preferred modalities 1
Resistance training should be implemented 2-3 sessions per week, focusing on unaffected areas, with isometric exercises and low resistance/body weight exercises 1, 2
For patients with severe fatigue, light exercises only should be encouraged, and high-intensity activities should be avoided 2

For appendicular (limb) metastases, exercises should be modified to avoid deep hip flexion/extension with acetabular or femoral head involvement, and extremes of range of motion with shoulder metastases 2
For axial (spine) metastases, exercises should be modified to avoid excessive spinal flexion, extension, and torsion, and axial loading maneuvers 2

Functional and balance training are essential components for maintaining independence, with gait training, transfer training, and balance exercises to prevent falls 1, 2
Single leg balance and timed up-and-go tests should be used for assessment 2

Physical therapy should be coordinated within a multidisciplinary tumor board, including medical oncology, radiation oncology, orthopedic surgery, and rehabilitation specialists 1, 3
New bone pain and imaging should be regularly reviewed, and exercises should be modified based on patient tolerance and risk assessment 2

Bone-targeted therapies, such as bisphosphonates (zoledronic acid) or denosumab, should be administered to delay skeletal-related events and reduce pain 4, 5
Single-fraction radiotherapy (8 Gy) is recommended for painful bone metastases, and analgesic therapy should follow WHO guidelines 4, 6
Calcium and vitamin D supplementation are essential 4

Initiating exercise without validated risk assessment scores is a common error that compromises patient safety 1, 2
Applying heat, ultrasound, or massage directly at tumor sites, and prescribing high-impact or high-intensity exercises without proper screening, should be avoided 2

Continuous surveillance is required, with increased monitoring of mobility and activities of daily living, and regular functional capacity assessments 2, 1