Spinal Stabilization Exercises for Cancer Patients with Spinal Metastases of High Fracture Risk: Feasibility of the DISPO-II Training Program

Clinical considerations for non-operative treatment of spinal metastases with intermediate instability

AIMS

To investigate the characteristics of spinal adverse events after non-operative treatment for spinal metastases with intermediate instability and to discuss clinical considerations when selecting non-operative treatment.

METHODS

This study included 56 patients with spinal metastases who had Spinal Instability Neoplastic Scores (SINS) of 7-12 and who underwent radiotherapy and intensive rehabilitation without a bed rest period as initial treatment between 2020 and 2023. We evaluated progression of paralysis and changes in spinal alignment before treatment, within 1 month, 1 to 6 months, and more than 6 months after treatment.

RESULTS

Paralysis progressed within 1 month after treatment in 7 of 56 patients (12.5%). Pre-treatment paralysis and SINS ≥ 11 were significantly associated with progression of paralysis. Alignment changes occurred in 18 of 56 patients (32.1%), with a similar incidence in patients with SINS ≥ 11 and ≤ 10. Fifteen of 44 patients (34.1%) without pre-treatment paralysis had alignment changes, but 1 patient (2.3%) experienced progression of paralysis due to increased instability within 1 month. All 3 patients whose paralysis progressed despite no evidence of malignant spinal cord compression before or after treatment had SINS ≥ 11 and showed vertebral height reduction and kyphosis progression within 1 month.

CONCLUSION

Patients with pre-treatment paralysis and SINS ≥ 11 can progress to paralysis early; therefore, careful observation and imaging examinations are recommended early after treatment. If spinal alignment worsens, the treatment plan should be reconsidered, including restrictions of activity and surgical treatment.

Understanding and Managing Fracture Risk in Patients With Cancer: A Literature Review

One of the most important complications of cancer and its treatments is the increased fracture risk. Fractures can have a significant impact on the patient's quality of life and may be associated with morbidity, mortality, and reduced functional status. The present study aims to investigate the mechanisms underlying the increased risk of fractures in cancer patients, the effect of cancer treatments on fracture risk, and strategies to prevent fractures in this population. This is a literature review using the PubMed - National Center for Biotechnology Information (NCBI), Web of Science, Cochrane Library, Scopus, and electronic internet databases. The search was based on the keywords "fracture risk" AND "cancer", NOT ("osteoporosis" OR "osteoporotic"). Inclusion criteria were clinical studies assessing fracture pathogenesis and prevention, along with fracture risk estimation in cancer patients. Non-human studies, pediatric studies, non-English studies, editorials, and study protocols were excluded. After the application of inclusion and exclusion criteria, 146 studies were finally included. Fracture risk is particularly increased in patients with malignancies. This is due to the direct effect of cancer cells on bone metabolism, the existence of cancer-related factors (bone metastases, hypercalcemia, malnutrition, and increased risk of falls), coexisting diseases (osteoporosis, diabetes mellitus, and rheumatoid arthritis), and the side effects of anticancer treatments (chemotherapy, radiotherapy, and hormone therapy). Fracture risk assessment is based on the measurement of bone mineral density (DXA), the use of the Fracture Risk Assessment Tool (FRAX), laboratory tests (measurement of calcium, phosphorus, vitamin D, alkaline phosphatase, parathyroid hormone, and biomarkers of bone metabolism), and imaging methods (X-rays, computed tomography, magnetic resonance imaging, and PET/CT of bones). To reduce fracture risk in cancer patients, lifestyle changes (exercise, smoking cessation) and anti-osteoclastic drugs such as bisphosphonates and denosumab are administered. Fracture risk in cancer patients is influenced by various factors, including the type of cancer, stage of disease, cancer treatments, bone health status, and presence of bone metastases. Overall, fracture risk in cancer patients is multifactorial and requires comprehensive evaluation and management to optimize bone health and quality of life.

Physical activity-related health competence and symptom burden for exercise prescription in patients with multiple myeloma: a latent profile analysis

The purpose of this study is to ensure best possible supply of exercise therapy to patients with multiple myeloma (MM); it is helpful to identify patient groups with similar symptom burden and physical activity-related health competences (PAHCO). Latent profile analyses (LPA) of MM patients were used to identify profiles of patients with similar PAHCO and symptom burden. Analysis of variance was applied to investigate group differences in important covariates. N = 98 MM patients (57% male, age 64 ± 9 years) could be assigned to three distinct PAHCO profiles: 46% were patients with high PAHCO, 48% patients with moderate, and 5% were patients with low PAHCO. The mean probability to be assigned to a certain profile was over 99%. The first group showed significant higher physical activity (PA) and lower comorbidities. Regarding symptom burden, three different profiles exist, including group one (32% of patients) with very low symptom burden, profile two (40%) with medium symptom burden, and group three (15%) with very high symptom burden (mean probability ≥ 98%). Patients in profile one had a lower number of treatment lines compared to the other profiles. Patients who were assigned to the high PAHCO profile were more likely to display a milder symptoms profile. In this exploratory analysis, we identified different patient profiles for PAHCO and symptom burden that may be used to individualize exercise recommendations and supervision modalities in MM patients. PAHCO and symptom burden level may be used to stratify MM patients in order to provide more personalized and effective exercise counseling. The profiles require individualized exercise recommendations and different supervision modalities, including educational instructions tailored particularly to every patient's needs, according to their PAHCO and symptom profile. TRIAL REGISTRATION NUMBER: NCT04328038.

Exercise Intervention for Bone Metastasis: Safety, Efficacy and Method of Delivery

Background: The benefits of exercise for patients with cancer are well-established, however, for patients with bone metastases, exercise as adjuvant therapy is underutilised due to concerns for safety, efficacy and other barriers such as the method of delivery. This scoping review explores these barriers by reviewing the results of clinical trials conducted on participants with bone metastases. Methods: A thorough literature search was undertaken using PubMed, Scopus, NIH Clinical Trials and Google Scholar databases. Articles that involved an exercise intervention and patients with bone metastases were included. Data were pooled, charted, analysed and reported according to PRISMA-ScR standards. Results: A total of 26 trials were reviewed with interventions that included aerobic and resistance training. Only three serious adverse events occurred, not likely related to bone metastases. Nine trials (34.6%) involved unsupervised exercise sessions. Remote exercise delivery had an average of 80.3% compliance, rivalling in-person and mixed supervision. The results of this review reaffirm that exercise helps improve functional capacity, muscle strength, lean mass and cardiovascular function, and is safe in patients with bone metastases irrespective of in-person or remote delivery. Conclusions: Exercise therapy, whether delivered in person or remotely, is safe and efficacious for patients with bone metastases.

Benefícios e Segurança dos Exercícios Físicos em Pacientes com Metástases Ósseas: Revisão Sistemática da Literatura e Metanálise

Introdução: A expectativa de vida de pessoas com câncer metastático está aumentando, mas esse grupo de pacientes corre um risco considerável de apresentar problemas psicológicos e de saúde física. Nesse sentido, o exercício físico tem sido um aliado no tratamento de pacientes com metástases ósseas. Objetivo: Realizar uma revisão sistemática e metanálise sobre a segurança e os benefícios do exercício físico em pacientes com metástases ósseas. Método: Metanálise com pesquisa bibliográfica realizada nas bases eletrônicas: PubMed, LILACS, PEDro e Embase. Resultados: Dos 396 estudos, somente dez foram incluídos, com um total de 531 indivíduos. Não foi observado nenhum efeito adverso musculoesquelético durante a intervenção, sendo significativamente seguro o exercício em indivíduos com metástases ósseas. Não houve melhora considerável na capacidade aeróbica, progressão da doença, qualidade de vida, massa magra e gordura corporal. Três dos estudos incluídos avaliaram a dor durante e após a intervenção, demonstrando melhora no escore de dor, assim como a diminuição do uso do analgésico no grupo intervenção. Conclusão: A terapia com exercícios aeróbicos e isométricos e segura para pacientes com metástases ósseas, além de apresentar melhora da dor, mas sem evolução relevante na capacidade aeróbica, na progressão da doença, na massa corporal e na qualidade de vida.

Interventional and Non-interventional Medical Rehabilitation Approaches to Axial Spine Pain in Vertebral Metastatic Disease

As targeted therapies help patients with advanced cancer live longer, interventions for management of axial spine pain will become more common. Unfortunately, the indications for and safety of these procedures have been relatively unexplored compared with non-cancer adults. This review focuses on the following aspects of axial spine pain management in patients with vertebral metastatic disease: (1) pathophysiology and symptoms of cancer- and non-cancer-related spine pain; (2) safety and efficacy of non-interventional rehabilitation approaches to treat this pain; (3) considerations for interventional pain approaches to acute and chronic pain in patients with vertebral metastatic disease. This review also summarizes gaps in the literature and describes specific cases in which the described interventions have been applied.

Muscle wasting in cancer: opportunities and challenges for exercise in clinical cancer trials

BACKGROUND

Low muscle in cancer is associated with an increase in treatment-related toxicities and is a predictor of cancer-related and all-cause mortality. The mechanisms of cancer-related muscle loss are multifactorial, including anorexia, hypogonadism, anaemia, inflammation, malnutrition, and aberrations in skeletal muscle protein turnover and metabolism.

METHODS

In this narrative review, we summarise relevant literature to (i) review the factors influencing skeletal muscle mass regulation, (ii) provide an overview of how cancer/treatments negatively impact these, (iii) review factors beyond muscle signalling that can impact the ability to participate in and respond to an exercise intervention to counteract muscle loss in cancer, and (iv) provide perspectives on critical areas of future research.

RESULTS

Despite the well-known benefits of exercise, there remains a paucity of clinical evidence supporting the impact of exercise in cancer-related muscle loss. There are numerous challenges to reversing muscle loss with exercise in clinical cancer settings, ranging from the impact of cancer/treatments on the molecular regulation of muscle mass, to clinical challenges in responsiveness to an exercise intervention. For example, tumour-related/treatment-related factors (e.g. nausea, pain, anaemia, and neutropenia), presence of comorbidities (e.g. diabetes, arthritis, and chronic obstructive pulmonary disease), injuries, disease progression and bone metastases, concomitant medications (e.g., metformin), can negatively affect an individual's ability to exercise safely and limit subsequent adaptation.

CONCLUSIONS

This review identifies numerous gaps and oppportunities in the area of low muscle and muscle loss in cancer. Collaborative efforts between preclinical and clinical researchers are imperative to both understanding the mechanisms of atrophy, and develop appropriate therapeutic interventions.