Physical activity for people with bone metastases

Physical activity for people with bone metastases

Dr Michelle Nadler: Hi everyone. I'm excited to be here today to talk about an important topic: physical activity for people with bone metastases. 

In this talk, we hope to answer some key questions about being physically active when you have bone metastases, including: 

• What are bone metastases and how do they affect your ability to be active? 
• What are the benefits of physical activity if you have bone metastases? 
• How can you be physically active safely if you have bone metastases? 

The key message we want you to take away from today is that physical activity is safe and beneficial for most people with bone metastases. 

Today, we're here to explore the positive impact of staying active and to provide you with valuable information and resources. The goal of this webinar is to empower you with the knowledge you need to engage in physical activity as safely as possible. 

Let's start by understanding what bone metastases are. Metastases occur when cancer cells spread from where they started to a new part of the body. 

When cancer cells spread to the bones from another part of the body, this is called bone metastases. We still call this by the name of the primary cancer, so breast cancer or lung cancer with bone metastases – not "bone cancer."

Some kinds of cancer are more likely to spread to bones than others. The most common types of cancer that spread to bones are breast, prostate, lung, kidney and thyroid. 

Normally, our bones are in constant process of being formed and broken down. This cycle is crucial to keeping our bones healthy and strong. However, when you have bone metastases, this natural process gets disrupted. 

The cancer cells interfere with the normal cycle of bone breakdown and building, and this can make the affected bones weaker and can make somebody more likely to fracture a bone. 

Sometimes when people have bone metastases, they do not have any symptoms at all. They wouldn't even know they were there other than the scan showed them. However, other people can have symptoms. They could have pain in the area that is sometimes worse with use, or sometimes swelling. 

Recognizing the symptoms of bone metastases and talking to your healthcare provider about what you are feeling or experiencing is the best way to make sure you get the care you need. 

How do bone metastases affect bone health? The structural changes caused by bone metastases can make bones weaker and increase the likelihood of a bone break, called a fracture. This is why it's important to take precautions to protect your bones and minimize as much as possible the risk of fractures. 

In more serious cases, bone metastases may lead to cancer-related emergencies. One of these is called hypercalcemia, or too much calcium in the blood. This condition can arise from the breakdown of bones affected by metastases. Symptoms can include constipation, low appetite, nausea, the need to urinate, or pee, very often, extreme thirst and in more severe cases, confusion. 

The second emergency is called spinal cord compression. This occurs when there's pressure on the nerves of the spinal cord, often caused by damage to the vertebrae from bone metastases.  Symptoms can include numbness or tingling in the fingers or toes, depending on the location of the spine where this happens, or trouble with balance, weakness, and again in more serious cases, urinary retention, or loss of bowel control like incontinence. 

Now let's shift our focus to treating bone metastases. The medical treatment recommended by your doctor will target all areas of cancer in the body, including cancer that has spread to your bones.  Examples of these types of treatments include hormone therapy, targeted therapy or chemotherapy. The goal of these treatments is to target any cancer cells which may be in your body, preventing their growth and managing any symptoms you may have from your cancer. 

In addition, specific treatments may address issues related to bone metastases. This may be to help manage symptoms of bone metastases, such as pain, or to help prevent bone breaks or heal fractures that may already have occurred from bone metastases. These treatments can include regular pain medications such as Tylenol, ibuprofen, sometimes something stronger, or sometimes people need a special medication for nerve pain. 

Radiation therapy can help as a targeted treatment to affected bone metastases to reduce pain and slow growth of cancer cells in that area. And some medications are given to slow down the breakdown of bone, usually by injection or intravenous. Sometimes surgery or bone cement can help stabilize bones, reduce pain and prevent further complications. 

How do bone metastases affect your ability to be active? Some bone metastases do not cause pain or any problems with movement or activity. On the other hand, other people with bone metastases may have noticeable symptoms, and that can make it more difficult to complete their daily activities or to participate in physical activity or exercise.  As you can see in this figure, the impact of bone metastases varies from person to person. 

Understanding your risk of injury with bone metastases involves considering several factors, including:

1. Where are your bone metastases?
2. What is the severity or symptom from your bone metastases?
3. What are your individual medical factors and other medical problems? For example, do you already have low bone density or osteoporosis to start with? 
4. What is your individual physical fitness level? How strong are your other muscles supporting your bones? 

When it comes to activities, certain ones may increase your risk of injury. However, sometimes it's just bad luck, and sometimes somebody could just simply trip and fall and break a bone or accidentally turn the wrong way when they get out of bed. 

Despite taking precautions, accidents can happen and injuries sometimes occur unexpectedly. We hope this doesn't stop you from engaging in physical activity and exercise as safely as possible. 

I'll now pass it over to Dr Kristin Campbell to discuss the safety of physical activity and important benefits. 

Dr Kristin Campbell: Thank you, Dr Nadler. I want to start by highlighting a pivotal moment in the understanding of physical activity for people with bone metastases. 

A group of researchers and healthcare providers came together to explore a fundamental question: Is physical activity safe and beneficial for people with bone metastases? 

The researchers took 3 key steps to develop their recommendations. 

1. The first step involves a Delphi survey. This type of survey gathers insights and perspectives from a diverse group of experts globally and aims to see what they agree on. In this case, we asked their perspective on safety of physical activity for individuals with bone metastases. 
2. Next, a systematic review of exercise studies was conducted. It involved a comprehensive analysis of all published research studies to learn about the safety and benefits of physical activity in people with bone metastases.
3. Lastly, a survey was conducted among doctors and nurses to gather the views of those on the front line who are treating people with bone metastases.

Next, all the information gathered was reviewed and discussed at an in-person meeting by researchers, healthcare providers and patients to generate physical activity recommendations for people with bone metastases. The final recommendations were published in a peer-reviewed medical journal by the team in 2022.

So what did the recommendations state? Overall, the recommendations stated that physical activity for people with metastatic cancer, including bone metastases, is largely safe and beneficial in many ways. 

Physical activity can help you to improve fatigue or prevent fatigue from getting worse, improve or maintain muscular strength, improve or maintain physical function, which is the ability to perform activities of daily living, and improve or maintain quality of life. 

Now let's address safety. Based on all the published research studies that were used to generate the recommendations, no studies found that physical activity caused injuries in the area of the bone with metastases.  However, it's important to note that studies do not always report injuries in the same way. 

In addition, studies all included some level of physical activity supervision by a university-trained exercise professional, such as a physiotherapist or clinical exercise physiologist. 

This means that participants in the studies had access to exercise professionals to ask questions and ensure they were performing physical activity in a safe manner based on their individual physical fitness levels and health history. 

The overall message is encouraging. Physical activity, especially when undertaken with proper supervision and guidance, can offer a range of benefits for people with metastatic cancer, including those with bone metastases. 

To get started, our message is simple yet powerful. Move more and sit less. This is a small but impactful shift that can . . . may help make a significant difference in how you feel both physically and mentally. Almost everyone can benefit from adding more movement to their day. 

However, if you want more specific recommendations, you should look to incorporate aerobic exercise, strength training, or a combination of both, into your routine. We know from the scientific evidence that these types of exercise are the most effective at helping to manage symptoms, improve your physical and mental well-being, and improve your overall quality of life. 

Aerobic exercise aims to increase your cardiorespiratory fitness by increasing your heart rate and the amount of oxygen your body is using. It is a fantastic way to enhance cardiovascular health and overall stamina. 

Examples of aerobic exercise include activities that get your heart pumping and your body moving. Walking, jogging, swimming and cycling are excellent examples. 

Strength training, which is also known as resistance training, is a form of exercise that aims to increase muscle strength by making your muscles work against a weight or a force. It's a valuable component for maintaining and improving overall physical strength. 

Examples of strength training exercises include activities that use resistance bands, weightlifting using dumbbells or machines, or body weight exercises like squats or getting in and out of a chair without using your arms. 

If you are new to physical activity or haven't been active recently, start by introducing aerobic exercise or strength training that is shortened duration and at a lighter intensity. 

Light intensity physical activity can include leisurely walking, which can also be done with a mobility aid, light yard work or household chores, easy cycling on a stationary bike, or gentle weightlifting or strength exercises, which could be performed seated in a chair if you have balance concerns. 

After starting with lighter intensity physical activity, you can gradually progress your activity. This means extending the duration of your physical activity or trying moderate to vigorous physical activity if you feel comfortable doing so. 

Moderate to vigorous intensity activity means you should feel your heart rate increase, but you still should be able to carry on a conversation. 

Examples of moderate to vigorous physical activity include brisk walking or hiking, dancing, moderate cycling on a stationary bike, or moderate weightlifting or strength exercises. 

Regardless of the specific type of physical activity you choose, consistency is key. Performing physical activity regularly is a key to experiencing longer lasting physical and mental benefits. 

How much physical activity should you aim for overall? 

These are the current guidelines for people with cancer from the American College of Sports Medicine. These guidelines are based on scientific evidence that suggest this is how much physical activity is recommended to experience significant health benefits and manage the symptoms and side effects of cancer treatments. 

If you only perform aerobic exercise, it is recommended that you aim for 30 to 60 minutes per day, 3 days per week, at a moderate to vigorous intensity. If you perform only strength training, it suggested you engage in this activity 2 to 3 days per week. Ideally, you perform a series of exercises that strengthen your whole body, especially your arms and legs. Each session should include 2 sets of 8 to 15 repetitions of each exercise in a series of exercises. 

For a comprehensive approach, you can consider combining both aerobic exercise and strength training. For strength training, maintain the same frequency (2 to 3 days per week) and same sets and repetitions (2 sets of 8 to 15 repetitions). Ideally, you additionally incorporate aerobic exercise 2 to 3 times per week,  with sessions lasting 20 to 40 minutes at a moderate to vigorous intensity. 

Usually it takes 6 to 12 weeks to start to feel the full physical and mental effects of meeting these physical activity guidelines. But you may start to feel the effects sooner, like within a few weeks. For example, some activities that you do usually in your day may start to feel easier, like climbing a set of stairs. 

It is important to note that these are general guidelines. The overarching goal is to tailor them to your individual preferences and abilities. This might be what you aim to do eventually, but it may not be your starting point. 

There are some other key considerations regarding physical activity if you have bone metastases.  First, listen to your body. It's essential to perform activities that you are comfortable with and do not cause pain. Pay attention to the signals your body gives you. It's a valuable guide in tailoring your activity to your individual needs.  However, keep in mind that some physical activities like strength training may cause muscle discomfort or soreness, especially if they are new to you. 

Second, when being active, it's important to move with correct technique and maintain good posture. This helps to target the right muscles and joints and strengthen those areas while minimizing the risk of injury. Correct technique is also about moving in a way that it optimally engages the muscles and joints. This not only enhances the effectiveness of your exercises, but also safeguards against potential injuries. Exercise professionals can be valuable resources in assisting you with movement techniques. 

Another critical aspect is taking steps to reduce the risk of falls. Start with wearing comfortable shoes that fit well and provide good grip. Proper footwear contributes to stability and can help prevent slips and falls during exercise. Avoid exercising on slippery or uneven surfaces. Opt for stable, even surfaces that reduce the risk of tripping or losing balance. 

Finally, ensure you stay hydrated throughout your activities and avoid performing activities when you are hungry. Being hungry and thirsty may compromise your energy levels, balance and concentration. Certain activities may also increase your risk of injury. These are activities that tend to put extra load on your bones or increase your risk of a fall. These include activities that are high impact, such as running or jumping. You may also want to be mindful of activities that involve twisting quickly or lifting and twisting, such as golf, racket sports, power yoga, or picking up something heavy and twisting (such as your child, grandchild or a heavy household item). 

Lastly, some activities may increase your risk of falling, particularly if you are not experienced performing them, such as ice skating or skiing. 

Overall, the safety of these activities depends on several factors, such as the location of your bone metastases, the severity of the bone metastases, your symptoms like pain and your experience level with the exercise. For example, if you have bone metastases but have been golfing regularly both before and after your cancer diagnosis, and you do not have any symptoms, it may be fine for you to continue golfing. 

But if you don't golf regularly, or you have bone metastases in areas that may be impacted, such as your spine or ribs, it would be best to speak to your healthcare provider before starting. 

There are several steps you can take to be physically active in the safest way possible.  First and foremost, engage in a conversation with your healthcare provider. They are your primary source of information when it comes to understanding any special considerations you should keep in mind while incorporating physical activity into your routine. The type of physical activities that are right for you will depend on the type of bone metastases and where it is in your body, your medical history, any cancer or treatment symptoms you may be experiencing, your current level of physical fitness and your interest in physical activity. 

For more tailored advice, consider consulting a qualified exercise professional such as a physiotherapist or clinical exercise physiologist. Physiotherapists and clinical exercise physiologists are university-trained exercise professionals. There are some who also specialize in working with people with cancer. Qualified exercise professionals can help you to find the best movement options for you based on your preferences and needs. They can also offer guidance about what physical activity might be safest if you have any mobility or balance concerns. If you're seeking a qualified exercise professional like a physiotherapist or clinical exercise physiologist, the Bone Metastases and Exercise Hub (bit.ly/BMEhub) is a valuable resource to find these professionals in your region. 

In addition, to help you to communicate with your healthcare provider and qualified exercise professional, we've created a special health information form for being physically active when you have bone metastases. This health information form is designed to help bridge communication gaps and ensure that everyone involved has a full understanding of your health, including key information about where your bone metastases are located, current treatment you are receiving, and potential implications for physical activity. 

This form allows for a collaborative approach, ensuring your qualified exercise professional and healthcare providers are all on the same page, working together to design a physical activity plan that is safe and tailored for your individual needs. By using the health information form, you also empower yourself to actively participate in the decision-making process to be physically active. Access this resource. You can download the health information form from the Bone Metastases and Exercise Hub. 

Before and after taking part in physical activity, consider asking yourself a few important questions. These questions can serve as checkpoints to gauge your well-being and ensure that the chosen activities align with your current health status. 

Questions to consider: Do you notice any change in pain? Do you have neurological symptoms such as numbness or weakness? Are there any changes in your ability to move or perform certain activities, such as getting in and out of bed? 

If at any point you notice pain, symptoms or your ability to move has changed, it's important for you to take proactive steps. Reach out to your healthcare provider, and communicate any changes you've observed. They can offer insights, adjustments or guidance based on your individual health considerations. 

Additionally, seek guidance from a qualified exercise professional. They are equipped to provide personalized advice and adjust your physical activity routine, ensuring it aligns with your health needs overall. Proactively monitoring how you feel before and after activity enhances your ability to make informed choices about your physical activity routine. 

Next, we're going to hear from a patient partner about her experience being physically active while living with bone metastases. 

Patient partner: My name is Lucia. I'm a mom of 2 kids. I have elderly parents that live with me. I was originally diagnosed in 2019 with breast cancer. I went through a double mastectomy and radiation. After that, I was on hormone therapy. Things seemed like they were going well until 2022, when I discovered that it actually had metastasized to my bones. 

My cancer was hormone dependent. When you decrease the hormones, it increases the possibility of osteoporosis. So I wanted to load up with exercises. It makes you feel better, like you go and you go out for a run. Nice day or ugly day, it doesn't matter. You come home, you feel like you've accomplished something. To me, it was do it for my health, but also because it made my mind and my whole outlook on life a lot better. 

So, you know, I just started moving as much as I could. I did a lot of exercises for obviously for my shoulders and all that stuff so I can gain back my mobility after the surgery. My daughter's into volleyball. I want her to do well. So, I try to practise with her, like little things. That kind of was part of our family life, to keep myself, you know, as if nothing happened really. I think that exercise is a great part because it just kept me mobile and moving so that I could participate and do all those things. 

I do have, like, achy joints. And I again, I don't know if that's because of the drug or because of bone metastasis, I'm not sure. But it's one of those things where you move your body and maybe see endorphins or whatever make you feel better and you forget about it and you keep moving on. I think that for every person it is different, their symptoms and things that they go through.

I'm not concentrated on my diagnosis now. It's come back and what will be the effects on my future be? Will I be there for my children? All these negative things that may cross your mind, I'm not really focused on that because every day I do something, I feel good, I feel better. And there's a combination of those things. And eventually your whole outlook is a lot more positive. 

So I would say: Go out there, exercise, enjoy yourself. And the positivity will, like, it will come in and it'll help you in this particular situation. 

Dr Kristin Campbell: We encourage you to embrace variety in your activities to keep things interesting. Most importantly, choose activities that you enjoy. We've heard from Lucia that she enjoys playing volleyball with her daughter. This was just one example of what physical activity can look like for someone, but there are plenty of options to choose from. 

The best physical activity is the activity you are most likely to do. Choosing activities you enjoy doing means that you'll be more likely to actually do those activities. Finally, remember to celebrate every achievement, no matter how small. Whether it's going for the first walk around the block or booking an appointment to speak to a qualified exercise professional. Finding ways to incorporate physical activity into your everyday life is a statement of your resilience and determination. 

Finally, remember you are not in this alone and resources like the Bone Metastases and Exercise Hub are here to support you. The Bone Metastases and Exercise Hub includes additional resources that can be downloaded and can help connect you with qualified exercise professionals to assist you with your physical activity. There's also a lot of excellent information available at cancer.ca and an online community that you can connect with at CancerConnection.ca. 

Thank you so much for tuning into this talk. 

CCS host: Thank you so much to our speakers, Dr Nadler and Dr Campbell for sharing valuable information about physical activity if you have bone metastases. We appreciate your time and your expertise. 

The Canadian Cancer Society is dedicated to supporting people affected by cancer at all stages of the cancer experience. The Canadian Cancer Society offers free information and support services that you can access online or over the phone from the comfort of your home. These services are confidential, and many are available in multiple languages. 

Our Cancer Information Helpline can answer your questions about diagnostic tests, treatments, side effects, clinical trials, coping with cancer resources, and many other related topics. Call 1-888-939-3333 or email info@cancer.ca. 

Our online community CancerConnection.ca helps people who have cancer, cancer survivors and caregivers share their experiences and build supportive relationships. For any other cancer-related information, please visit our website cancer.ca. You can also live chat with one of our information specialists who can answer your questions and connect you with additional resources. 

Thank you again to our speakers for joining us today and sharing their expertise. This now concludes today's presentation and on behalf of the Canadian Cancer Society, we wish you well.