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Purpose: The purpose of this case report is to demonstrate how conditioning exercise for patients with active metastatic neoplasms can improve quality of life (QoL) after a pathological fracture of lumbar vertebrae. Spinal metastasis, in this case from breast cancer, is primarily asymptomatic, and therefore, difficult to detect during early stages. Detection and diagnosis usually occur after initial manifestation of a pathological fracture leading to debilitating effects. Complications with metastatic bone cancer and surgical contraindications may bring patients into outpatient physical therapy to address the pathological fractures and QoL for patients.

Case Description & Methods: The patient is a 44-year old female, diagnosed with breast cancer in Sept 2019. Following a pathological fracture in the L1 vertebrae, she was diagnosed with thoracic and lumbar spine bone cancer in Nov 2019. On evaluation, she had completed a round of radiation therapy, home health physical therapy, and was currently taking Zometa to improve bone health. The patient was unable to receive surgical tumor removal intervention due to location and metastasis. She had an active lifestyle before her diagnosis, but an excessive increase in heart rate was now contraindicated for the patient, contributing to psychosocial factors. She was fearful of sit-to-stand (STS) motion due to her mechanism of injury. Interventions included gentle manual therapy and exercises avoiding end-range motion and a home exercise program consisting of lumbopelvic stability and stretches. Education provided on energy conservation. No mobilizations were performed.

Results: After 6 sessions in 3 weeks of physical therapy consisting of therapeutic exercise, neuromuscular reeducation, and therapeutic activity, the patient showed improvements in strength, decreased neurovascular symptoms into the lower extremity, and increased endurance. The patient was wearing a thoracolumbosacral orthosis (TLSO) less frequently. The patient’s Modified Oswestry Disability Index (ODI) score change from 46% (severe disability) to 38% (moderate disability) is reflective of improved functional capacity. At re-assessment, she was able to perform single-limb balance testing with fair control and 5xSTS in 20.2 seconds. Strength increased half grades in L LE. Flexibility testing revealed 90/90 hamstring length increase from 15° to 0°. The patient had (-) slump test and hyposensitivity to L LE to L1-L2 dermatome compared to the initial evaluation of hyposensitivity in all L LE dermatomes and bilateral (+) slump test; she reported ability to sit without increasing neurovascular symptoms.

Discussion: The current literature has good evidence for low-level functioning patients. This is because more debilitated patients have more to gain compared to their higher functioning counterparts with similar or less severe diagnoses. Psychosocial factors including previous activity level could be appropriate qualitative studies of improved quality of life in patients with cancer. The patient was seen in outpatient, giving her control over her HEP. Her internal motivation and willingness to perform ADLs and walk regardless of physical therapy intervention may have been threats to internal validity and resulted in gains with or without therapeutic interventions or education. Further controlled studies could assist in more quantitative measures and improved validity.

Conclusion: Breast cancer is one the most common cancer in females which can lead to metastasis into other body regions including bone. While therapists are frequently trained to screen out non-musculoskeletal pain, including cancer, it is less common for therapists in the outpatient orthopedic setting to see patients rehabilitating low back pain dues to active cancer. With contraindications to tumor removal, these patients can improve quality of life through medical interventions and physical therapy as indicated. It is important to know the effectiveness of such interventions while following all contraindications and precautions for this population, especially with an unpredictable course of the disease.

Publication Date

Spring 2020

Medical Subject Headings

Physical Therapy; Exercise Therapy; Spinal Neoplasms; Lumbar Vertebrae; Fractures, Spontaneous; Quality of Life; Adult; Female

Disciplines

Oncology | Physical Therapy | Rehabilitation and Therapy

Comments

Poster accepted for the Spring 2020 Campus Research Day on the San Marcos, CA, campus of the University of St. Augustine for Health Sciences.

Case Report: Effects of Therapeutic Exercise on a Patient with Metastatic Osteosarcoma and Pathological Fracture

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