Where should patients with bone metastases (bone mets) be referred for physical therapy?

Referral Pathway for Physical Therapy in Patients with Bone Metastases

Patients with bone metastases should be referred to a multidisciplinary bone metastasis tumor board that includes rehabilitation specialists, where physical therapy is coordinated with medical oncology, radiation oncology, orthopedic surgery, and physiatry. 1, 2

Mandatory Pre-Referral Risk Assessment

Before any physical therapy referral, fracture and neurological risk must be stratified using validated scoring systems 1, 2:

For Spinal Lesions - Use SINS (Spinal Instability Neoplastic Score)

• SINS ≤6 (Stable): Safe for physical therapy referral 1, 2, 3
• SINS 7-12 (Potentially Unstable): Requires neurosurgical consultation before physical therapy; may need bracing or corset support 1, 2, 3
• SINS ≥13 (Unstable): Absolute contraindication to physical therapy until surgical stabilization is completed 1, 2, 3

For Long Bone Lesions - Use Mirels' Score

• Mirels' ≤7 (Low Risk): Safe for physical therapy referral 1, 2, 4
• Mirels' 8 (Moderate Risk): Requires orthopedic consultation before physical therapy 1, 2, 4
• Mirels' ≥9 (High Risk): Absolute contraindication to physical therapy until surgical stabilization 1, 2, 4

Where to Refer: Specific Settings

Primary Referral Destination

Refer to a multidisciplinary bone metastatic tumor board that coordinates rehabilitation within comprehensive cancer care 1, 2. This board should include 1, 2, 4:

• Rehabilitation medicine specialists (physiatrists)
• Physical therapists with oncology expertise
• Medical oncologists
• Radiation oncologists
• Orthopedic or neurosurgeons
• Pain management specialists

Alternative Referral Options Based on Clinical Context

For patients requiring immediate functional assessment: Refer to cancer rehabilitation specialists or physiatrists who can perform comprehensive evaluation of mobility, activities of daily living, balance/gait, and functional capacity 1, 2

For patients with compromised ADLs or balance/gait deficits: Direct referral to physical therapy (PT) is appropriate after risk stratification confirms stability 1

For patients in palliative care settings: Refer to multidisciplinary palliative care teams that include rehabilitation providers 1

Absolute Contraindications to Physical Therapy Referral

Do not refer until these conditions are resolved or stabilized 2, 4:

• Acute spinal cord compression or metastatic epidural spinal cord compression (MESCC) 1, 2
• Severe hypercalcemia 2, 4
• SINS ≥13 or Mirels' ≥9 without surgical stabilization 1, 2, 4
• Active infection (wait until asymptomatic >48 hours) 4

Clinical Pathway Algorithm

1. Obtain imaging: CT scan first-line; MRI mandatory if neurological symptoms present 1
2. Calculate risk scores: SINS for spine, Mirels' for long bones 1, 2
3. If stable scores (SINS ≤6, Mirels' ≤7): Refer directly to multidisciplinary tumor board or cancer rehabilitation specialist 1, 2
4. If potentially unstable (SINS 7-12, Mirels' 8): Refer to neurosurgery/orthopedics first, then to rehabilitation after clearance 1, 2, 3
5. If unstable (SINS ≥13, Mirels' ≥9): Refer to surgery for stabilization; defer physical therapy until post-operative clearance 1, 2

Evidence Supporting Rehabilitation Safety

The risk of producing pathological fractures through physical therapy is low when appropriate risk stratification is performed 5. Rehabilitation can be safely accomplished with satisfactory outcomes in pain control, physical function, and quality of life 2, 5. However, this safety profile depends entirely on proper pre-referral assessment using validated scoring systems 2, 4.

Critical Pitfalls to Avoid

Never refer to physical therapy without documented SINS or Mirels' scores - this is the most common error that compromises patient safety 2, 4. Plain radiographs alone are insufficient, as they miss 30-50% of bone matrix involvement 6. Bone scan results should be reviewed before establishing any rehabilitation program 6. Any new pain complaints or progressive weakness require physician evaluation and repeat imaging before continuing physical therapy 6, 7.