How to help cancer patients with bone metastases get the benefits of exercise

An international panel including OHSU’s Kerri Winters-Stone, Ph.D., has published best practice recommendations on exercise for people with cancer that has spread to their bones.

“This consensus guideline is the first of its kind and it addresses a very unique cancer population that can be left out of exercise guidelines due to safety concerns and lack of research,” said Winters-Stone, a professor in the OHSU School of Medicine’s Division of Oncological Sciences, and co-program leader for cancer prevention and control in the Knight Cancer Institute.

Previous systematic reviews have generally concluded that exercise is safe, feasible and beneficial for people with advanced or incurable cancers. But these systematic reviews have not focused specifically on the safety or efficacy of exercise for people with bone metastases. And health professionals have been uncertain about prescribing exercise and promoting physical activity in this population because of concerns about potential complications such as spinal cord compression and bone fractures.

The International Bone Metastases Exercise Working Group came together in 2019, recognizing that people with bone metastases could potentially benefit from exercise but they and their medical providers lack guidance. The group’s process included a modified Delphi survey to work out the practical considerations of implementing exercise for people with bone metastases; a systematic review to assess the safety, feasibility, and efficacy of exercise in controlled trials that included people with bone metastases; a survey of physicians and nurse practitioners to understand attitudes toward exercise for people with bone metastases and components required to promote exercise referral; and engagement with people with bone metastases and with clinician peers to develop best practice recommendations on the basis of existing research evidence, clinical experience, and expert opinion.

The group developed five key recommendations:

  1. Before exercise testing or training, perform a risk assessment to inform the likelihood of a skeletal complication from exercise.
  2. Consultation with the medical team is strongly encouraged before an exercise professional provides structured exercise for a person with bone metastases, to obtain key medical information and establish bidirectional communication for initial assessment and exercise training throughout care.
  3. Exercise professionals best suited to prescribe exercise to people with bone metastases are physical therapists and clinical exercise physiologists (or equivalent), who have additional cancer exercise training and appropriate experience in working with people with a cancer diagnosis.
  4. Professional judgment should be used to consider if exercise testing at baseline and follow-up is necessary by weighing the risks and benefits of including the test or if the testing protocols may need to be modified.
  5. Exercise prescription should follow the standard exercise recommendations as outlined by the International Exercise Guidelines for Cancer Survivors, with greater emphasis on postural alignment, controlled movement, and proper technique, as well as consideration given to the location and presentation of the bone lesion(s). Formal monitoring of exercise response and adjustment of exercise prescription should be ongoing.

The complete consensus guideline is freely accessible online in JCO Oncology PracticeExercise Recommendation for People With Bone Metastases: Expert Consensus for Health Care Providers and Exercise Professionals.