Wednesday, February 15, 2017
Spinal metastasis is one of the main causes of morbidity in cancer patients, leading to pain, fracture, mechanical instability, or neurological deficits such as paralysis and bowel and bladder dysfunction. But despite recent studies showing the clear benefits of rehabilitation for these patients, oncology teams often remain unclear on how and when to utilize these services.
Historically, this uncertainty has meant referral for physical therapy happens only after a decline in the patient’s physical or mental function has occurred.
Rehabilitation is a well-established paradigm for enhancing quality of life in the care of patients with traumatic spinal injuries. Recent studies show similarly positive results in cancer-related spinal injuries indicating that rehabilitation can play a complementary role in cancer care. (1)
Bone metastases occur in most tumor types but are most prevalent in cancers of the breast, prostate, and lung. Lesions can cause serious skeletal complications, including spinal cord or spinal nerve root compression, hypercalcemia of malignancy, pathologic fractures, and severe bone pain requiring palliative radiotherapy.
Memorial Sloan Kettering has a multidisciplinary approach to patient care. A physiatrist is an important part of the disease management team (DMT). Our input is essential for the care of patients with spinal involvement. When combined with medical, radiation, and surgical oncology approaches, a physiatrist’s evaluation and recommendations can serve to relieve symptoms, improve quality of life, enhance functional independence, and prevent further complications for patients with cancer-related spinal column and spinal cord involvement. (1)
At MSK, physiatrists lead the rehabilitation team and communicate directly with treating oncologists. We may assist in decision-making impacting treatment by providing input on spinal stability, location of neurological injury, etiology of symptoms, and the impact of non-cancer-related factors on symptoms. These factors include loss of bone density that begins after age 40, increasing the risk for fractures and age-related loss of intervertebral disc integrity, and facet arthropathy, which may result in spinal nerve root or spinal cord compression.
Determining the difference between cancer and non-cancer-related symptoms is paramount because treatment options can differ greatly. For example, some patients’ pain may be alleviated by changes to their posture and physical therapy, as opposed to merely being treated with opioid-based analgesia that can adversely affect bowel function and cause neurological issues.
Pain is reported to be one of the most common symptoms for patients with spinal involvement. Pending the type and etiology of pain, several options are available for treatment including postural bracing, medications (e.g., analgesia, laxatives), physical and/or occupational therapy, and other modalities. Motor weakness and sensory impairments are also common in this population. For patients with neurological impairments, physiatry recommendations include physical and occupational therapy for strengthening exercises, range of motion, sensory reintegration, transfer training, balance, wheelchair mobility, gait training, activities of daily living, and assessment for appropriate assistive devices. If indicated, upper and lower extremity bracing may be recommended to provide functional positioning, joint stability, compensation for weakness, and proprioceptive feedback. (1)
Ms. Smith is a 59-year-old female with a history of multiple myeloma with lytic bone lesions involving the ribs, thoracolumbar spine, ischium, and bilateral iliac bones treated with carfilzomib, lenalidomide, and dexamethasone. She was diagnosed with compression fractures at L3 and L4 in the setting of an acute pain crisis. She is now status post two level kyphoplasty that had improved her pain significantly but not completely. Post-procedure, she continued to experience aching low-back pain requiring opioid use, prompting referral to physiatry. Since her physiatry evaluation, she has been participating in physical therapy and using a spine brace (TLSO-thoracolumbosacral orthosis). At time of follow-up, she noted feeling stronger, with improved posture, and reported she no longer required pain medications.
Bowel and bladder function may also be impaired as a result of spinal nerve root or spinal cord compression. Bladder dysfunction can result in difficulty with urinary drainage and abnormalities in intra-vesicular pressure, increasing risk for infections, renal disease, skin breakdown, and social embarrassment. A thorough neurological examination (including sphincter function and reflexes), voiding diary, and measurement of post-void residual volumes by physiatrists can be used to assess an individual’s bladder pattern and aid in establishment of a bladder program. (1)
Bowel dysfunction can result in social inconvenience, embarrassment, and skin compromise. As with the bladder, a thorough neurological assessment can help establish an individual’s bowel pattern. Stool diaries, stool studies, and abdominal imaging may also be helpful. Once a pattern is established, a bowel program is initiated to allow for control over time and place of bowel movements with desired frequency and without incontinence.
Ms. Jones is a 25-year-old female with a history of sacral chordoma treated with radiation therapy. She presented to physiatry for evaluation of urinary retention and constipation that had been present since diagnosis. Given her history and physical examination findings, her symptoms were felt to be neurogenic in nature, related to injury of the cauda equina from her tumor. A bladder program was initiated, including bethanechol and manual pressure through Crede’s method, and resulted in increased urinary volume, easier initiation of urine, and less frequency. A bowel program including polyethylene glycol and bethanechol was recommended and resulted in two successful bowel movements per day without incontinence. Pelvic floor therapy assisted with sphincter and pelvic floor muscle coordination.
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Preventing Further Complications
Weakness, extradural tumor involvement, hormonal manipulation, and radiation exposure place a patient at risk for fractures and spinal instability. To minimize the load on the spinal column, physiatrists may recommend spinal precautions for activity. Use of bracing and physical therapy for core strengthening and postural training may also be recommended to help prevent instability.
During any course of therapy, physiatrists monitor for medical comorbidities related to cancer and its treatment. These comorbidities include fatigue, cytopenias, electrolyte disturbances, vitamin deficiencies, depression, infection, and deep venous thrombosis. (2) They may require supportive care and modification of the rehabilitation care plan.Back to top
Enhancing Functional Independence and Quality of Life
A physiatric history and examination to determine the neurological level of injury, severity of injury, oncologic prognosis, and patient/caregiver expectations is essential to establishing realistic rehabilitation goals and determining appropriate interventions. Physical and occupational therapy, bracing, and adaptive equipment play a large role in these efforts.
Of course, the goal of all rehabilitation recommendations is to improve quality of life. Studies have shown that rehabilitation efforts in individuals with malignant spinal cord compression improve function, mood, pain levels, quality of life, and survival. (2), (4)Back to top