What are the NCCN (National Comprehensive Cancer Network) guidelines for physical therapy in patients with bone metastases?

Physical Therapy for Bone Metastases: NCCN Guidelines

Direct Recommendation

Physical and occupational therapy may be beneficial in the prevention of complications associated with skeletal-related events (SREs) in patients with bone metastases 1. The NCCN guidelines emphasize that bone health management requires a multidisciplinary approach that includes systemic anticancer therapy, osteoclast-targeted therapy, pain control, imaging studies, surgery, radiation therapy, and rehabilitation interventions 1.

Core Management Framework

Pre-Exercise Risk Assessment

The NCCN framework requires evaluating three critical domains before initiating physical therapy 2:

• Lesion-related factors: Location of bone metastases, extent of cortical destruction, presence of impending fractures requiring orthopedic stabilization before fracture occurs 1
• Cancer treatment factors: Current systemic therapy regimens, bisphosphonate or denosumab use, radiation therapy status 1
• Patient-related factors: Pain levels, performance status, functional capacity, presence of spinal cord compression or pathologic fractures 1

Physical Therapy Indications and Goals

Physical therapy serves multiple therapeutic purposes 3, 4:

• Counteract treatment-related deconditioning: Systemic cancer treatments cause significant muscle strength loss, fatigue, and functional decline that exercise can reverse 3
• Maintain mobility and independence: Individually tailored programs preserve activities of daily living while respecting bone load-bearing capacity 4
• Reduce pain interference: Exercise decreases pain impact on daily activities when properly prescribed 1, 3
• Prevent skeletal complications: Appropriate activity maintains bone health and reduces SRE risk 1

Evidence-Based Exercise Prescription

Safety Profile

Exercise interventions in patients with bone metastases demonstrate favorable safety outcomes 3, 5. Studies show no high fracture incidence with exercise compared to control participants, and no association between exercise and increased fracture risk 3. Three serious adverse events occurred across 26 clinical trials, none likely related to bone metastases 5.

Exercise Parameters

The evidence supports specific programming approaches 3, 2, 5:

• Aerobic and resistance training: Both modalities improve functional capacity, muscle strength, lean mass, and cardiovascular function 5
• Individualized prescription: Exercise must be adapted to patient ability, bone lesion location, and presentation 3, 2
• Emphasis on technique: Postural alignment, controlled movement, and proper form are essential to minimize skeletal stress 2
• Qualified supervision: Exercise professionals with oncology education and prescription experience should deliver programs 2

Delivery Methods

Remote exercise delivery achieves 80.3% compliance, rivaling in-person and mixed supervision 5. Both in-person and remote delivery are safe and efficacious for patients with bone metastases 5.

Integration with Medical Management

Physical therapy must coordinate with concurrent treatments 1:

• Bone-modifying agents: Patients receiving zoledronic acid, pamidronate, or denosumab require dental examination before starting therapy and monitoring for osteonecrosis of the jaw 1
• Pain management: NSAIDs, acetaminophen, or steroids combined with opioids improve bone pain control during exercise programs 1
• Radiation therapy: Local radiation for pain relief or fracture prevention should be integrated with rehabilitation planning 1
• Surgical interventions: Impending fractures require orthopedic stabilization before initiating weight-bearing exercise 1

Contraindications and Precautions

Specific clinical scenarios require exercise modification or deferral 4, 2:

• Absolute contraindications: Untreated spinal cord compression, acute pathologic fracture, severe hypercalcemia requiring immediate treatment 1
• Relative contraindications: Impending fracture without surgical stabilization, uncontrolled pain limiting movement, platelet count <50,000/μL 4
• Avoid at tumor sites: Physical modalities increasing local blood flow (ultrasound therapy, thermotherapy, massage, electrotherapy) should not be performed directly at tumor locations 4

Risk-Benefit Decision Making

The perceived risk of skeletal complications must be weighed against potential health benefits through consultation between the patient, healthcare team, and exercise professionals 2. For patients with documented bone metastases and expected survival >3 months, the benefits of maintaining physical function and quality of life typically outweigh exercise-related risks when proper precautions are implemented 1, 3.

Clinical Pitfalls to Avoid

• Do not universally prohibit exercise: The historical practice of complete activity restriction causes unnecessary deconditioning and functional decline 3
• Do not prescribe without lesion assessment: Plain radiographs should identify impending fractures requiring orthopedic referral before exercise initiation 1
• Do not ignore pain patterns: Bone pain most prominent with movement requires modification of weight-bearing activities 1
• Do not proceed without qualified supervision: Complex decision-making requires exercise professionals with oncology-specific training 2