linda m. tripp, dpt & kim lambert dpt 1 · linda m. tripp, dpt & kim lambert dpt 2 solid...

MN APTA Spring Conference 432015

Linda M Tripp DPT amp Kim Lambert DPT 1

Linda M Tripp DPT Kim Lambert DPT

April 25 2015 MN APTA Spring Conference

1

Recognize clinical presentation of pathologic fractures

Discuss basics of medical management of pathologic fractures

Identify the roles of medical amp therapy team members

Perform effective chart reviewing for impending or completed fractures

Modify therapy interventions appropriately with impending or known fractures

Apply above information to case discussions

2

3

Bony Lesion

Cancer Bone

Metastases

Impending

Fracture

Completed

Fracture

Pathologic fracture occurs in an area with existing bone pathology

Occurs with normal activity or minor trauma

Impending fracture an imminent fracture arising from severe bone destruction

Bony Lesion

Damron TA Bogard JA Blisky M 2014 4

Bone metastases develop in 50 of persons with cancer

80 of those with advanced cancer

9-29 of patients with bone metastases fracture

Highest pathologic fracture rate Multiple myeloma

Lung cancer

Damron TA Bogard JA Blisky M 2014

Goodman 2009 5

Metabolic changes Disease

Osteoporosis

Parathyroidism

Treatment Chemotherapyrarr bone loss

Loss of hormone regulation Prostate breast cancer

Corticosteroids

Unfractionated heparin

Prolonged immobilization Lack of physical activity

Poor nutrition

Benign lesion

Malignant tumor

Primary bone tumor Osteosarcoma

Chondrosarcoma

Metastatic carcinoma Multiple myeloma Lymphoma


National Osteoporosis Foundation

Goodman CC Fuller KS 2009 Vestergaard et al 2009 6



Solid Cancers Lung Breast Prostate Renal Thyroid (uncommon)

Multiple Myeloma Lymphoma Bone may be primary or secondary site of disease

~17-90 of persons with myeloma or solid

cancers have bone metastases


American Cancer Society Cancer Facts amp Figures 2014 7

Osteoblast Bone formation

Osteoblastosis

Balanced by complex signaling pathways hormones

Bone metastases due to dysregulation of this cycle

Osteoclast Bone resorption

Osteolysis

8 Clip Art

Lung Posterior ribs

Breast Pelvis ribs vertebrae proximal femur scapulahumerus

Prostate Pelvis vertebrae

Kidney Vertebrae pelvis

Multiple Myeloma Vertebrae pelvis skull

Goodman CC 2009 9

Indicative of advanced disease process

Average survival 2 yrs or less

bull Breast 24 months post-first bone metastasis

bull Multiple myeloma 176 months post-pathologic fx

bull Other cancers with bone metastasis 6-24 months


Bunting 2001

Goodman CC Fuller KS 2009

Sonmez et al 2008 10

Skeletal-Related Events include Pain

Hypercalcemia

Impaired mobility

Pathologic fracture

Spinal cord or nerve root compression

SRE Incidence 15 to 40 SREsyear in persons with prostate or

breast cancer

bull Occur in a population at risk for poor bone quality

11 Damron TA Bogard JA Blisky M 2014

Abeloff et al 2008

Cormie P et al 2014

Metastatic disease infiltration of bone marrow Pancytopenia ndash infection hemorrhage Osteolysis

Radiotherapy Pancytopenia ndash delay chemotherapy

Chemotherapy Impede osteoblast function

Corticosteroids and endocrine ablation Trigger bone loss impair bone re-growth

Surgical stabilization

Abeloff et al 2008


Cormie P et al 2014 12



13

Pain at fracture site

Point tenderness

May be only symptom for spinal or upper extremity fracture

Abnormality Decreased ROM

Joint instability

Extremity shortening

Loss of bony or limb contour

Soft tissue mass at site

Edema

Ecchymosis

Skin discoloration

Open wound exposed bone

Significant decrease in mobility Decreased ability to weight-

bear

Difficulty walking (LE)

Difficulty using current assistive device (UE)

Radiating symptoms Radiating pain (if nerve

involvement)

Radiculopathy (vertebral compression fracture)

Sensory disturbance of distal extremity

Johnson SK Knobf MT 2008 14

Biologic tumor pain Not mechanical pain amp poorly localized

Suggests bone tumor but not indicative of fracture

Bone pain Deep boring ache or burn with episodes of stabbing pain

Nightearly morning resolves during day

bull Endogenous steroid secretion increased activity improves pain

Causes bull Stretching of periosteum from growing tumor

bull Accelerated angiogenesis amp Cytokine release at tumor

bull Infiltration or compression of nerve roots

bull Reflex muscle spasm


Abeloff et al 2008 15

Sitting or standing (axial load) Thoracic or lumbar spine

Recumbent Thoraco-lumbar junction

Cervical flexionextension Cervical spine


Goodman CC 2009 16

Localized vertebral pain with axial load segmental weakness numbnesstingling Vertebral compression fracture

Red flag person with cancer co back pain with gait ataxia may have neoplastic spinal cord compression

Pain mimics sciatica Pelvis

Suddenly non-ambulatory or difficulty weight-bearing

pain in sitting Femur

UE numbnesstingling loss of function

Scapula Humerus


Goodman CC 2009 17

If access to Medical Record Oncology progress notes

Lab values

Recent imaging

Activity weight-bear orders

If no access to Medical Record Currently being treated for cancer

Hormone therapy

Any bone complications in the past

Recent bone imaging

Ghilchrist 2009

Schwartz 2014 18



Critical lab value if gt 14 mgdL Normal serum Ca++ 85-101 mgdL

Cause Increased resorption of calcium from bone into

blood

Symptoms Nausea vomiting dehydration confusion coma

Affects brain heart kidney bone muscles amp clotting o Cardiac arrhythmias and renal failure -gt death

Most common cancers squamous cell lung breast

renal and multiple myeloma


Goodman CC 2009 19

Complete Blood Count (CBC) darrHemoglobin (anemia)

bull lt 8 gramsdL Fatigue decreased O2 transport

darr White blood cells (leukopenia)

bull lt 1 billion cellsL

darr Platelets (thrombocytopenia) bull lt 50 billionL

Higher risk of bleed avoid straining

Mayo Clinic 2014 20

36yo F hx Breast Cancer

Mets vertebral bodies C4-6

Reason for admit leukopenia nauseavomiting

Chart review anemia PET 6 mos ago with mixed cervical lesions

Activity orders up ad lib

21

Clip Art Proximal humerus fracture

PTOT exam Pain with L arm weight bearing amp joint distraction

during upright activity Decreased L shoulder AROM Decreased L functional grip

PLOF I with ADLrsquos recently needing assist for upper body dressing from mother due to L UE pain and weakness

Pt has up ad lib orders what additional order

would you request

23

Medical history

Physical exam

Overall prognosis amp suitability for operative intervention




Radiographically diagnosed

Bone metastases occur mostly in red marrow regions Skull axial skeleton

bull Rib or vertebrae collapse most common

Medullary portion of appendicular skeleton


Epiphysis Head of bone

Metaphysis Growth plate

Diaphysis Bone shaft

26

Clip Art

Metaphysis

Metaphysis

Cortical Compact bone

Trabecular Cancellous

Spongy

27 Clip Art

Radiography (X-ray)

Cross-sectional Imaging Computed Tomography (CT)

Magnetic Resonance Imaging (MRI)

Entire Skeleton Radionuclide Scintigraphy (Bone Scan)

Positron Emission Tomography (PET)


Ideal imaging type views and contrast

Bone structure amp integrity Lytic blastic or mixed lesion

Type of fracture Impending or completed New or old

Cause of fracture Bone metastases bone sarcoma benign tumor stress

fracture insufficiency fracture bull Extent of disease


Biplanar X-ray of entire bone

Less sensitive than bone scan or PET 10 of fractures not detected by plain X-ray

Use X-ray when lytic metastases Use for multiple myeloma renal cancer




Fracture line Displaced anatomic alignment

Lytic permeative lesion proximal long bone axial skeleton

Blastic sclerotic

Mixed

Vertebral compression fracture endplate collapse

31

Clip Art Lytic Skull Lesions

Common Femur

Most common long bone

bull usually proximal

50 femoral neck

30 subtrochanteric

20 intertrochanteric

Tibia

Humerus

Rare Distal to elbow

Distal to knee

Damron TA Bogard JA Blisky M 2014 32 Clip Art Femur Fracture

X-ray Osteolytic lesion of spine

with compression fractures

MRI Lumbar Spine


Clip Art X-ray Lytic Lesions MRI Lumbar Spine

Computed Tomography (CT)

Estimate prognosis

extent of disease

Assess bone cortex to diagnose pathologic fracture

Use instead of MRI when metastatic disease highly likely


More detailed detect

bone marrow lesions at fracture site

Use if osteosarcoma osteoporosis or spinal cord nerve root compression suspected


Clip Art CT Clip Art MRI

Radionuclide Scintigraphy (Bone Scan) Not effective for detecting small lesions

False negatives with lytic diseases

bull Multiple myeloma renal cancer

Positron Emission Tomography (PET) Detect lytic disease amp little reactive bone formation

Determine if fracture is benign or malignant

Damron TA Bogard JA Blisky M 2014 35 36 Miller R Images and X Rays of Bone Metastases About Cancer [Website]

Clip Art PET

Clip Art Bone Scan of Metastatic Prostate Cancer



Spinal Instability Neoplastic Score (SINS) Location Pain Lytic mixed vs blastic Spinal alignment on X-ray Vertebral body collapse Facet pedicle or costovertebral involvement Score ge 7 (of 0-18) at risk for spinal instability Consult

surgery bull Expert consensus of Spine Oncology Study Group after

systematic review of literature

Assume unstable if pain with movement until proven otherwise

37

Muhhamad UJ Scully SP 2010

Reif et al 2014

Abeloff et al 2008 Damron TA Bogard JA Blisky M 2014

Impending fracture long bone Cortical involvement 50 bone width lysis Lesser trochanter avulsion

fracture Poor sensitivity amp specificity

Mirelrsquos Score Lesion site Lytic vs blastic vs mixed of cortex involved Pain Score 0 -9

0 = more stable 9 = very unstable

Taneichi vertebral body occupied Costovertebral joint

pedicle posterior element involvement

CT-based structural

rigidity analysis Better sensitivity and

specificity for femur fracture

Not available in clinical setting

38


Reif et al 2014

Abeloff et al 2008

Based on of cortical involvement in image

25-50 of cortex ndash PWB

gt50 of cortex - TTWB or NWB

What is long-term plan

Imagine QOL physical fitness amp adherence if NWB on an extremity for gt 8 weeks

Gilchrist et al 2009

Reference Karavatas SG Reicherter A White N Strong A 2006 39

56yo M stage IV prostate cancer ldquowith bony metastasesrdquo

Reason for admit intractable pain Recently discharged following other admit for pain crisis

discharged ambulating with a cane 2 wks later readmitted unable to walk due to L LE pain

Chart Review new PET - Innumerable spinal metastases and L proximal femoral lesion ~50 cortical involvement


40

Exam L LE pain in WB and sitting

Amb 10ft with cane mod A many gait impairments

PLOF 2mos ago working not using gait aid now using cane and unable to work at least set-up required for all ADLrsquos

Which assistive devices would you recommend

41

Front-wheeled walker Difficulty achieving gt50 off-loading

Axillary or Lofstrand Crutches

Four-wheeled walker

Hemiwalker

Quad cane

Cane max of 25 off-loading

Youdas et al 2005

Clip Art



43

Reduce pain pathologic fracture hypercalcemia amp spinal cord compression

Bisphosphonates

bull End in -ronate

Example Zoledronate Zolendronic Acid (Zometa Aclasta)

Monoclononal antibody

bull Denosumab

Supplemental calcium amp vitamin D


Prescribed by Radiation Oncologist

Radiation to affected area Destroy existing tumor cells to allow for bone

remodeling Decrease spread of bone tumor Pain relief

Radiosensitivity Multiple myeloma is one of the most sensitive Renal cell metastases are one of the most resistant

to radiation


Clip Art Open Reduction and Internal Fixation

Arthroplasty Total Hip Arthroplasty

Hemi-Arthroplasty of hip

Vertebral Augmentation Vertebroplasty

Kyphoplasty

46

Most orthopedic surgeons consider ifhellip

Pain exacerbated by weight bearing and

significantly limits function

If ultimately will require stabilization

47


Reif et al 2014


Most necessitate surgical fixation Impending and completed pathologic fracture


Clip Art External Fixation

Clip Art Dynamic Hip Screw



Intramedullary Nailing Orthopedic surgeon inserts a rod

into medullary cavity of long bone to treat bone shaft fracture

Plate and Screws Orthopedic surgeon uses a plate

and screws to stabilize a bone fracture

Pin

49

Clip Art Tibia Intramedullary Nailing Plate and Screws

Orthopedic surgeon replaces remodels or realigns the articular surface of a joint

Best option for repair of proximal femur fracture

50

Clip Art Total Hip Arthroplasty

both Fix spinal

compression fractures

Neurosurgeon

Interventional Radiologist

51

Insert cement directly into bone with hollow needle

Insert inflate then remove balloon

Insert cement into cavity created by balloon

Restore vertebral body height amp minimize severe kyphotic deformity

Expensive

Kyphoplasty surgery balloons inflated Eorthopod [Website] 2011

Clip Art Kyphoplasty 52

Oncologist Chemotherapy

Osteoclast inhibitors Referrals

Radiologist Interpret imaging

Radiation Oncologist Prescribe radiation

Physiatrist Medical amp Functional

Orthopedic Surgeon Surgical stabilization

Neurosurgeon amp

Interventional Radiologist Spinal fracture

cord compression

53

Stability of bony lesion

Medical treatment plan

Orders Activity ROM weight bearing restrictions bracing with

wear schedule

Extent of MD discussion with patient treatment

options prognosis restrictionshellip Informed consent

When PTOT to initiate activity with patient

Bunting 2001

Cheville 2001 54



Bedrest immobility

Unstable fracture site awaiting stabilization Otherwise bedrest risks outweigh benefits

55

62yo M multiple myeloma mets T8-L1

Reason for admit intractable pain new L2 and L3 pathologic fractures

Chart review Hypercalcemia IV narcotics for pain initial diagnosis 8 mos previous

Activity orders up with assist

56

Exam Max A for rolling

Unable supineltgtsit even with max A due to pain

ldquoI donrsquot care if I ever walk again make the pain go awayrdquo

Wife primary caregiver

PLOF I in gait 4 weeks prior without AD progressive pain limiting gait stretcher transport by EMS to leave his home not ambulated x4 days

What are the precautions

List 3 potential goals

57 58

Perform accurate and thoughtful screening

Maximize safety function amp independence Minimize pain

Teach safe activity within guidelines

Rehab communicate with MD when hellip Pain limits participation in therapy Pt unable to adhere to restrictions

Ghilchrist et al 2009

Cheville 2001 59

Cookbook General Convenient

Clinical Judgment Complexity Individuality

Desired level of Independence

Community involvement

Cognition Caregiver involvement Comorbidities Cultural amp religious

beliefs Finances

60



Radiotherapy side effects Decreased soft tissue mobility or fibrosis Diarrhea Fatigue

Chemotherapy side effects Fatigue Peripheral neuropathy (CIPN) bull Sensation loss dysesthesiaparasethesia bull Weakness

Decreased BMD Pulmonary fibrosis or cardiotoxicity Vestibular andor balance impairments

Other Lymphedema edema

Goodman CC 2009

Ghilchrist 2009 2015 61

Strength balance amp aerobic conditioning Pre-chemotherapy or pre-operative conditioning

Post-operative early mobilization

bull Facilitation vs compensation

Falls risk management 50 of pts with advanced cancer fell in 6mo period

bull Higher likelihood of fall resulting in injury

Fatigue management energy conservation

Chemo brain

Bunting 2001

Cheville 2001 62

Risk appears low

Few reported fractures occurring during

rehab interventions in the literature

Difficult to determine who will fracture amp when ldquoSilentrdquo fracture - no pain or functional compromise Some bony lesions never fracture

Bunting 2001

Bunting et al 1985 63

Protect area of concern via immobilization

MD may order Image affected area

Casting or use of orthosis

Bedrest orders

MD determine diagnosis and treatment plan Monitor for pain exacerbated by active movement

Abeloff et al 2008

Cheville 2001

Damron 2014 64

Common sites Vertebral bodies

Ribs

Pelvis

Physical exam Spinal cord anterior horn cell peripheral nerve

integrity

Posture

Symptoms during axial loading or flexion

65

Interventions Spinal precautions bull Transfers bed mobility

bull Ergonomics and lifting techniques

Spinal unloading bull Orthosis

bull 90-90 hooklying position

Isometric paraspinal strengthening bull For stable lesions

Avoid Axial loading Trunk flexionextension exercises

66 Rief et al 2014



Logroll Indications osteopenia spinal metastases

Correct lifting technique squat golferrsquos lift

Avoid loaded spinal twisting

Require vs Recommend

67

Common sites Humerus

Scapula

Physical exam considerations Assess AROM within any restrictions

bull No PROM

bull No MMT

Brachial plexus integrity

Functional grip and reach

68

Clip Art

Bunting RW Shea B 2001

Interventions Feeding dressing grooming

Previous gait aid still appropriate

Slings and braces

bull For comfort

bull Encourage adherence to weight bearing status

Scapular stabilization

bull In humerus fracture

Avoid Strengthening with loads distal to humerus

69

Common sites Femoral head neck or shaft

Tibial shaft


ndash No PROM

ndash No MMT

Lumbosacral plexus integrity

Balance deficits

Gait and stair assessment

Bunting RW Shea B 2001 70

Interventions Gait aids off-load affected LE

Gaitstair requirements for the home

Contralateral hip and core stabilization

Avoid High-impact and heavy weight-bearing exercise

Clip Art

71

Limited evidence with mixed results

No established guidelines for ldquoadvancedrdquo or metastatic cancer

Appears safe when modified appropriately

Not shown to increase fatigue

Symptom-based approach to prescription

Shown to improve QOL and some physical performance outcomes

Durstine et al 2009 ACSM

Esser 2001

Goodman 2009 Schwartz 2014

Wyrick Davis 2009 72



Aerobic Improves leg strength (1RM) VO2 max gait speed bone

mineral density of L-spine Reduces fatigue Improved QOL via FACIT SF-36 Higher adherence rates

Resistance Improves leg strength (1RM) bone mineral density at

femoral head Reduces fatigue Improved QOL via FACIT SF-36 Poorer adherence

Beaton et al 2009

Schwartz 2014

Litterini et al 2013 73 Clip Art

Clip Art ACSM Guidelines for cancer patients Aerobic bull 20-60mins

bull 40-60 heart rate reserve

bull 3-5 daysweek

Resistance bull 1-3 sets of 8-12reps

bull 40-60 1RM

bull 2-3 daysweek at least 48hrs between sessions

Use of RPEBORG in literature Target of 10-12

ACSM 2010

Beaton 2009

Litterini et al 2013 74

Esser amp Wruble based upon cortical involvement 0-25 bull Sub-max isometrics bull Aerobics ok

25-50 bull ROM only but avoid end-range bull Likely needs limb off-loading possible PWB orders

gt50 bull Defer exercise to MD team bull May need NWB

Very careful monitoring Subjective pain report before and after

75 Esser C Wruble ER 2001

Avoid for affected area Stretching and end-range ROM

Exercises that increase torque

Isometrics Similar to muscle tension loads induced during ADLs

76 Neumann 2010

Longer duration may yield better results Greater and sustained change in fatigue measure

Sustained bone mineral density amp strength changes

Greater Improvement in QOL than physical performance measures

Beaton 2009

Schwartz 2014

Cormie et al 2014 77

Balance Romberg and Tandem Romberg Dynamic Gait Index

Gait Timed Up And Go (TUG)

Aerobic Capacity 2- or 6-Minute Walk Test

Fatigue FACIT-Fatigue

Quality of Life SF-36 SF-12


Broom et al 2009

Miale Harrington Kendig 2013 78



51yo F newly diagnosed aggressive triple hit lymphoma

Referred for neck pain

Chart review undergoing active chemotherapy CT with increased signaling noted at T4-T6 right pelvis left SI joint

Ambulates independently

79

Exam Cervical ROM mildly limited at end range all planes

Tender to palpation of cervical parapsinals

Neuro exam intact

Subjective chiropractor for bi-monthly adjustments

Yoga and biking

Pt reports MD has not given any activity restrictions based on new imaging

80

Acute or impending fracture No precautionscontraindications E-stim TENS

Cryotherapy

Over acute fracture or trauma Precaution Ultrasound

Contraindication Compression

Over malignancy or tumor Contraindication Ultrasound Superficial heat

Pfalzer 2001 81

Recognition of clinical presentation may lead to earlier diagnosis and proper management

Multi-disciplinary approach to management

Rehab team maximizes function and QOL by educating on precautions and modifying mobility

Exercise shown to be safe and effective when modified appropriately

82

Abeloff MD Armitage JO Niederhuber JE Kastan MB Mckenna WG Abeloffrsquos Clinical Oncology Philadelphia PA Churchill Livingstone 2008

American Cancer Society Cancer facts amp figures 2014 American Cancer Society httpwwwcancerorgresearchcancerfactsstatisticscancerfactsfigures2014 Published 2015 Accessed March 24 2015

American College of Sports Medicine Guidelines for Exercise Testing and Prescription Eigth Edition Baltimore MD Wolters Kluwer Lippincott Williams amp Wilkins 2010

Beaton R Pagdin-Friesen W Robertson C Vigar C Watson H Harris SR Effects of exercise intervention on persons with metastatic cancer a systematic review Physiother Canada 2009 61141-153

Billek-Sawhney B Wells CL Oncology Considerations for the Patient in Acute Care Acute Care Perspectives 20091841-11

Bunting RW Shea B Bone Metastasis and Rehabilitation Cancer 2001921020-1028

Bunting RW Rehabilitation of Cancer Patients with Skeletal Metastases Clinical Orthopaedics and Related Research 1995312197-200

Bunting RW Lamont-Havers W Schweon D Kliman A Pathologic Fracture Risk in Rehabilitation of Patients with Bony Metastases Clinical Orthopaedics and Related Research 1985203282-288

Cavallaro-Goodman C Fuller K Pathology implications for the physical therapist St Louis MO Saunders 2009 363-391 1229-1234

83

Cheng DS OrsquoDell MW Inpatient rehabilitation in persons with multiple myeloma-associated fractures an analysis of 8 consecutive inpatient admissions Amer Acad of Phys Med and Rehab 2010 378-84

Cheville A Rehabilitation of patients with advanced cancer Cancer Supplement 2001 92(4) 1039-1048

Clarke MJ Mendel E Vrionis FD Primary spine tumors Diagnosis and treatment Cancer Control 2014 21(2) 114-123

Clarke MJ Vrionis FD Spinal tumor surgery Management and the avoidance of complications Cancer Control 2014 21(2) 124-132

Coleman RE Bisphosphonates and denosumab in patietents with metastatic cancer UpToDate Gralow JR (Ed) UpToDate 2014

Cormie P Galvao DA Spry N Joseph D Taaffe DR Newton RU Functional benefits are sustained after a program of supervised rsistance exercise in cancer patients with bone metastases longitudinal results of a pilot study Support Care Cancer 2014 221537-1548 doi 101007s00520-013-2103-1

Damron TA Bogart JA Bilsky M Evaluation and management of complete and impending pathologic fractures in patients with metastatic bone disease multiple myeloma and lymphoma UpToDate Rose BD (Ed) UpToDate Waltham MA 2014

DeVita VT Hellman S Rosenberg SA Cancer Principles amp practice of Oncology 7th ed Philadelphia PA JB Lippincott Co 2011

Dijkstra PDS Oudkerk M Wiggers T Prediction of pathological subtrochanteric fractures due to mestastic lesions Archives of Orthopaedic and Trauma Surgery 1997 116(4) 221-224 httplinkspringercomarticle1010072FBF00393714

Dustrine JL Moore GE Painter PL Roberts SO ACSMrsquos Exercise Management for Persons wih Chronic Diseases and Disabilities 3rd Edition 2009 American College of Sports Medicine Champaign IL

84



Filis AK Aghayev KV Doulgeris JJ Gonzalez-Blohm SA Vrionis FD Spinal neoplastic instability Biomechanics and current management options Cancer Control 2014 21(2) 144-150

Esser C Wruble ER A literature review of solid bone cancers occurring during adulthood and the implications for physical therapy Acute Perspect 10(1 2)30-35 2001

Ghilchrist LA Galantino ML Wampler M et al A framework for assessment in oncology rehabilitation Phys Ther 2009 89296-306

Gonnerman J Bone Metastases [PowerPoint] Minneapolis MN UMMC Fairview 2011

Guise TA Mohammad KS Clines G et al Basic Mechanisms Responsible for Osteolytic and Osteoblastic Bone Metastases Clinical Cancer Research 2006126213s-6216s

Jawad MU Scully SP Clin Orthop Relat Res 2010 4682825-2827

Johnson SK Knobf MT Surgical interventions for cancer patients with impending or actual pathologic fractures Orthop Nurs 200827160 doi10109701NOR000032054390115d5

Kaloostian PE Zadnik PL Etame AB Vrionis FD Gokaslan ZL Sciubba DM Surgical management of primary and metastatic spinal tumors Cancer Control 2014 21(2) 133-139

Kaloostian PE Yurter A Etame AB Vrionis FD Sciubba DM Gokaslan ZL Palliative strategies for the management of primary and metastatic spinal tumors Cancer Control 2014 21(2) 140-143

85

Kanis JA FRAX WHO Fracture Risk Assessment Tool World Health Organization Collaborating Centre for Metabolic Bone Diseases University of Sheffield Available at httpwwwshefacukFRAXtoolaspxcountry=9 Accessed May 10 2014

Litterini AJ Fieler VK Cavanaugh JT Lee JQ Different effects of cardiovascular and resistance exercise on functional mobility in individuals with advanced cancer a randomized trial Arch Phys Med and Rehab 2013942329-35

Malignant Lymphoma Medscape Web site httpemedicinemedscapecomarticle1256034-overview Updated December 5 2013 Accessed January 1 2015

Miale S Harrington S Kendig T Oncology Section Task Force on Breast Cancer Outcomes Clinical Measures of Upper Extremity Function Rehabilitation Oncology 2013 30(4) 27-34

Mirels H Clinical Orthopaedics and Related Research 1985249256-264

Morris GS Anderson K Exercise Guidelines for Oncology Patients [PowerPoint] Minneapolis MN UMMC Fairview 2014

Moussazadeh N Laufer I Yamada Y Bilsky MH Separation surgery for spinal metastases Effect of spinal radiosurgery on surgical treatment goals Cancer Control 2014 21(2) 168-174

National Osteoporosis Foundation American Bone Health The State of Osteoporosis and Low

Bone Mass to our Nation 2014

Neumann DA Kinesiology of the musculoskeletal system foundations for rehabilitation Mosby Elsevier 2010 12-20

86

Papanastassiou ID Filis AK Gerochristou MA Vrionis FD Controversial issues in kyphoplasty ad vertebroplasty in malignant vertebral fractures Cancer Control 2014 21(2) 151-157

Pazdur Richard Lawrence D Wagman Kevin A Camphausen and William J Hoskins Cancer Management A Multidisciplinary Approach 12th ed Np CMPMedica 2010 Print

Pfalzer L Physical AgentsModalities for Survivors of Cancer Rehabilitation Oncology 19 (2) 2001

Reif H Omlor G Akbar M et alndash first results of a randomized pilot trail Feasibility of isometric spinal muscle training in patients with bone metastases under radtion therapy BMC Cancer 2014 1467

Reuter N Medical Oncologist MD FACP (Fellow of American College of Physicians) [Jan 2015]

Schwartz A Cancer Rehabilitation [PowerPoint] Minneapolis MN Medbridge Education 2014

Setzer M Robinson LA Vrionis FD Management of locally advanced pancoast (superior sulcus) tumors with spine involvement Cancer Control 2014 21(2) 158-167

Somnez M Akagun T Topbas M et al Effect of pathologic fractures on survival in multiple myeloma patients a case control study J Exp Clin Can Res 2008 27(11)

Stone CA et al J Clin Oncol 20120 30(21) 2128-2133

Tatu B Physical Therapy Intervention with Oncological Emergencies Rehabilitation Oncology 20052314-6

Van der Linden YM Dijkstra PDS Kroon HM Comparative analysis of risk factors for pathological fracture with femoral metastases results based on a randomised trial of radiotherapy J Bone Joint Surg [Br] 200486-B566-73

Vestergaard P Rejnmark L Mosekilde L Fracture risk in patients with different types of cancer Acta Oncologiza 2009 48 105-115

Wyrick K1 Davis A Exercise for the management of cancer-related fatigue Am Fam Physician 2009 Oct 180(7)689

Youdas JW Kotajarvi BJ Pudgett DJ Kaufman KR Partial weight-bearing gait using conventional assistive devices Arch Phys Med Rehabil 2005 89 394-398

87

American Cancer Society

wwwcancerorg

Cancer Care

wwwcancercareorg

National Cancer Institute

wwwcancergov

National Institutes of Health

wwwnihgov

National Comprehensive Cancer Network

wwwnccnorg

Association of Community Cancer Centers

wwwaccc-cancerorg

Association of Cancer Online Resources

wwwacororg

88

Gildarsquos Club (Twin Cities) httpwwwgildasclubtwincitiesorg

Susan G Komen httpww5komenorgbreastcancersupporthtml

Leukemia amp Lymphoma Family Support Groups

httpwwwllsorgaboutllschaptersmnpatientsupportprogramsFSG

American Cancer Society Support Groups for all Cancer Types httpwwwcancerorgtreatmentsupportprogramsservicesindex

Minnesota Cancer Resource Directory httpwwwhealthstatemnusdivshpcdccsscreeningsagematerialsCancerResourceDirectorypdf

89

Bisphosphonates

Nitrogenous bull Zoledronate Zolendronic Acid (Zometa Aclasta)

bull Pamidronate (PAD Aredia) bull Neridronate (Nerixia)

bull Olpadronate

bull Alendronate (Fosamax)

bull Ibandronate (Boniva) bull Risendronate (Actonel)

Non-Nitrogenous

bull Etidronate (Didronel)

bull Clodronate (Bonefos Loron)

bull Tiludronate (Skelid)


Denosumab




Solid Cancers Lung Breast Prostate Renal Thyroid (uncommon)

Multiple Myeloma Lymphoma Bone may be primary or secondary site of disease

~17-90 of persons with myeloma or solid

cancers have bone metastases


American Cancer Society Cancer Facts amp Figures 2014 7

Osteoblast Bone formation

Osteoblastosis

Balanced by complex signaling pathways hormones

Bone metastases due to dysregulation of this cycle

Osteoclast Bone resorption

Osteolysis

8 Clip Art

Lung Posterior ribs

Breast Pelvis ribs vertebrae proximal femur scapulahumerus

Prostate Pelvis vertebrae

Kidney Vertebrae pelvis

Multiple Myeloma Vertebrae pelvis skull

Goodman CC 2009 9

Indicative of advanced disease process

Average survival 2 yrs or less

bull Breast 24 months post-first bone metastasis

bull Multiple myeloma 176 months post-pathologic fx

bull Other cancers with bone metastasis 6-24 months


Bunting 2001

Goodman CC Fuller KS 2009

Sonmez et al 2008 10

Skeletal-Related Events include Pain

Hypercalcemia

Impaired mobility

Pathologic fracture

Spinal cord or nerve root compression

SRE Incidence 15 to 40 SREsyear in persons with prostate or

breast cancer

bull Occur in a population at risk for poor bone quality

11 Damron TA Bogard JA Blisky M 2014

Abeloff et al 2008

Cormie P et al 2014

Metastatic disease infiltration of bone marrow Pancytopenia ndash infection hemorrhage Osteolysis

Radiotherapy Pancytopenia ndash delay chemotherapy

Chemotherapy Impede osteoblast function

Corticosteroids and endocrine ablation Trigger bone loss impair bone re-growth

Surgical stabilization

Abeloff et al 2008


Cormie P et al 2014 12



13


Point tenderness



Joint instability




Edema

Ecchymosis

Skin discoloration



bear




involvement)



















Goodman CC 2009 16







Scapula Humerus


Goodman CC 2009 17


Lab values

Recent imaging



Hormone therapy


Recent bone imaging

Ghilchrist 2009

Schwartz 2014 18





blood






Goodman CC 2009 19







Mayo Clinic 2014 20






21






would you request

23

Medical history

Physical exam













26

Clip Art

Metaphysis

Metaphysis



Spongy

27 Clip Art

Radiography (X-ray)




















Blastic sclerotic

Mixed


31


Common Femur



50 femoral neck

30 subtrochanteric


Tibia

Humerus


Distal to knee




MRI Lumbar Spine




Estimate prognosis

extent of disease















Clip Art PET








37


Reif et al 2014








CT-based structural




38


Reif et al 2014

Abeloff et al 2008













40





41



Four-wheeled walker

Hemiwalker

Quad cane


Youdas et al 2005

Clip Art



43


Bisphosphonates

bull End in -ronate



bull Denosumab







to radiation






Kyphoplasty

46





47


Reif et al 2014












Pin

49




50


both Fix spinal


Neurosurgeon


51





Expensive









Neurosurgeon amp


cord compression

53




wear schedule




Bunting 2001

Cheville 2001 54



Bedrest immobility


55





56








57 58






Cheville 2001 59






beliefs Finances

60







Goodman CC 2009








Chemo brain

Bunting 2001

Cheville 2001 62

Risk appears low




Bunting 2001





Bedrest orders


Abeloff et al 2008

Cheville 2001

Damron 2014 64


Ribs

Pelvis


integrity

Posture


65







66 Rief et al 2014







67


Scapula


bull No PROM

bull No MMT



68

Clip Art




Slings and braces

bull For comfort





69


Tibial shaft


ndash No PROM

ndash No MMT


Balance deficits







Clip Art

71








Esser 2001









Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab




13


Point tenderness



Joint instability




Edema

Ecchymosis

Skin discoloration



bear




involvement)



















Goodman CC 2009 16







Scapula Humerus


Goodman CC 2009 17


Lab values

Recent imaging



Hormone therapy


Recent bone imaging

Ghilchrist 2009

Schwartz 2014 18





blood






Goodman CC 2009 19







Mayo Clinic 2014 20






21






would you request

23

Medical history

Physical exam













26

Clip Art

Metaphysis

Metaphysis



Spongy

27 Clip Art

Radiography (X-ray)




















Blastic sclerotic

Mixed


31


Common Femur



50 femoral neck

30 subtrochanteric


Tibia

Humerus


Distal to knee




MRI Lumbar Spine




Estimate prognosis

extent of disease















Clip Art PET








37


Reif et al 2014








CT-based structural




38


Reif et al 2014

Abeloff et al 2008













40





41



Four-wheeled walker

Hemiwalker

Quad cane


Youdas et al 2005

Clip Art



43


Bisphosphonates

bull End in -ronate



bull Denosumab







to radiation






Kyphoplasty

46





47


Reif et al 2014












Pin

49




50


both Fix spinal


Neurosurgeon


51





Expensive









Neurosurgeon amp


cord compression

53




wear schedule




Bunting 2001

Cheville 2001 54



Bedrest immobility


55





56








57 58






Cheville 2001 59






beliefs Finances

60







Goodman CC 2009








Chemo brain

Bunting 2001

Cheville 2001 62

Risk appears low




Bunting 2001





Bedrest orders


Abeloff et al 2008

Cheville 2001

Damron 2014 64


Ribs

Pelvis


integrity

Posture


65







66 Rief et al 2014







67


Scapula


bull No PROM

bull No MMT



68

Clip Art




Slings and braces

bull For comfort





69


Tibial shaft


ndash No PROM

ndash No MMT


Balance deficits







Clip Art

71








Esser 2001









Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab






blood






Goodman CC 2009 19







Mayo Clinic 2014 20






21






would you request

23

Medical history

Physical exam













26

Clip Art

Metaphysis

Metaphysis



Spongy

27 Clip Art

Radiography (X-ray)




















Blastic sclerotic

Mixed


31


Common Femur



50 femoral neck

30 subtrochanteric


Tibia

Humerus


Distal to knee




MRI Lumbar Spine




Estimate prognosis

extent of disease















Clip Art PET








37


Reif et al 2014








CT-based structural




38


Reif et al 2014

Abeloff et al 2008













40





41



Four-wheeled walker

Hemiwalker

Quad cane


Youdas et al 2005

Clip Art



43


Bisphosphonates

bull End in -ronate



bull Denosumab







to radiation






Kyphoplasty

46





47


Reif et al 2014












Pin

49




50


both Fix spinal


Neurosurgeon


51





Expensive









Neurosurgeon amp


cord compression

53




wear schedule




Bunting 2001

Cheville 2001 54



Bedrest immobility


55





56








57 58






Cheville 2001 59






beliefs Finances

60







Goodman CC 2009








Chemo brain

Bunting 2001

Cheville 2001 62

Risk appears low




Bunting 2001





Bedrest orders


Abeloff et al 2008

Cheville 2001

Damron 2014 64


Ribs

Pelvis


integrity

Posture


65







66 Rief et al 2014







67


Scapula


bull No PROM

bull No MMT



68

Clip Art




Slings and braces

bull For comfort





69


Tibial shaft


ndash No PROM

ndash No MMT


Balance deficits







Clip Art

71








Esser 2001









Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab












26

Clip Art

Metaphysis

Metaphysis



Spongy

27 Clip Art

Radiography (X-ray)




















Blastic sclerotic

Mixed


31


Common Femur



50 femoral neck

30 subtrochanteric


Tibia

Humerus


Distal to knee




MRI Lumbar Spine




Estimate prognosis

extent of disease















Clip Art PET








37


Reif et al 2014








CT-based structural




38


Reif et al 2014

Abeloff et al 2008













40





41



Four-wheeled walker

Hemiwalker

Quad cane


Youdas et al 2005

Clip Art



43


Bisphosphonates

bull End in -ronate



bull Denosumab







to radiation






Kyphoplasty

46





47


Reif et al 2014












Pin

49




50


both Fix spinal


Neurosurgeon


51





Expensive









Neurosurgeon amp


cord compression

53




wear schedule




Bunting 2001

Cheville 2001 54



Bedrest immobility


55





56








57 58






Cheville 2001 59






beliefs Finances

60







Goodman CC 2009








Chemo brain

Bunting 2001

Cheville 2001 62

Risk appears low




Bunting 2001





Bedrest orders


Abeloff et al 2008

Cheville 2001

Damron 2014 64


Ribs

Pelvis


integrity

Posture


65







66 Rief et al 2014







67


Scapula


bull No PROM

bull No MMT



68

Clip Art




Slings and braces

bull For comfort





69


Tibial shaft


ndash No PROM

ndash No MMT


Balance deficits







Clip Art

71








Esser 2001









Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab






Blastic sclerotic

Mixed


31


Common Femur



50 femoral neck

30 subtrochanteric


Tibia

Humerus


Distal to knee




MRI Lumbar Spine




Estimate prognosis

extent of disease















Clip Art PET








37


Reif et al 2014








CT-based structural




38


Reif et al 2014

Abeloff et al 2008













40





41



Four-wheeled walker

Hemiwalker

Quad cane


Youdas et al 2005

Clip Art



43


Bisphosphonates

bull End in -ronate



bull Denosumab







to radiation






Kyphoplasty

46





47


Reif et al 2014












Pin

49




50


both Fix spinal


Neurosurgeon


51





Expensive









Neurosurgeon amp


cord compression

53




wear schedule




Bunting 2001

Cheville 2001 54



Bedrest immobility


55





56








57 58






Cheville 2001 59






beliefs Finances

60







Goodman CC 2009








Chemo brain

Bunting 2001

Cheville 2001 62

Risk appears low




Bunting 2001





Bedrest orders


Abeloff et al 2008

Cheville 2001

Damron 2014 64


Ribs

Pelvis


integrity

Posture


65







66 Rief et al 2014







67


Scapula


bull No PROM

bull No MMT



68

Clip Art




Slings and braces

bull For comfort





69


Tibial shaft


ndash No PROM

ndash No MMT


Balance deficits







Clip Art

71








Esser 2001









Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab








37


Reif et al 2014








CT-based structural




38


Reif et al 2014

Abeloff et al 2008













40





41



Four-wheeled walker

Hemiwalker

Quad cane


Youdas et al 2005

Clip Art



43


Bisphosphonates

bull End in -ronate



bull Denosumab







to radiation






Kyphoplasty

46





47


Reif et al 2014












Pin

49




50


both Fix spinal


Neurosurgeon


51





Expensive









Neurosurgeon amp


cord compression

53




wear schedule




Bunting 2001

Cheville 2001 54



Bedrest immobility


55





56








57 58






Cheville 2001 59






beliefs Finances

60







Goodman CC 2009








Chemo brain

Bunting 2001

Cheville 2001 62

Risk appears low




Bunting 2001





Bedrest orders


Abeloff et al 2008

Cheville 2001

Damron 2014 64


Ribs

Pelvis


integrity

Posture


65







66 Rief et al 2014







67


Scapula


bull No PROM

bull No MMT



68

Clip Art




Slings and braces

bull For comfort





69


Tibial shaft


ndash No PROM

ndash No MMT


Balance deficits







Clip Art

71








Esser 2001









Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab




43


Bisphosphonates

bull End in -ronate



bull Denosumab







to radiation






Kyphoplasty

46





47


Reif et al 2014












Pin

49




50


both Fix spinal


Neurosurgeon


51





Expensive









Neurosurgeon amp


cord compression

53




wear schedule




Bunting 2001

Cheville 2001 54



Bedrest immobility


55





56








57 58






Cheville 2001 59






beliefs Finances

60







Goodman CC 2009








Chemo brain

Bunting 2001

Cheville 2001 62

Risk appears low




Bunting 2001





Bedrest orders


Abeloff et al 2008

Cheville 2001

Damron 2014 64


Ribs

Pelvis


integrity

Posture


65







66 Rief et al 2014







67


Scapula


bull No PROM

bull No MMT



68

Clip Art




Slings and braces

bull For comfort





69


Tibial shaft


ndash No PROM

ndash No MMT


Balance deficits







Clip Art

71








Esser 2001









Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab








Pin

49




50


both Fix spinal


Neurosurgeon


51





Expensive









Neurosurgeon amp


cord compression

53




wear schedule




Bunting 2001

Cheville 2001 54



Bedrest immobility


55





56








57 58






Cheville 2001 59






beliefs Finances

60







Goodman CC 2009








Chemo brain

Bunting 2001

Cheville 2001 62

Risk appears low




Bunting 2001





Bedrest orders


Abeloff et al 2008

Cheville 2001

Damron 2014 64


Ribs

Pelvis


integrity

Posture


65







66 Rief et al 2014







67


Scapula


bull No PROM

bull No MMT



68

Clip Art




Slings and braces

bull For comfort





69


Tibial shaft


ndash No PROM

ndash No MMT


Balance deficits







Clip Art

71








Esser 2001









Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab




Bedrest immobility


55





56








57 58






Cheville 2001 59






beliefs Finances

60







Goodman CC 2009








Chemo brain

Bunting 2001

Cheville 2001 62

Risk appears low




Bunting 2001





Bedrest orders


Abeloff et al 2008

Cheville 2001

Damron 2014 64


Ribs

Pelvis


integrity

Posture


65







66 Rief et al 2014







67


Scapula


bull No PROM

bull No MMT



68

Clip Art




Slings and braces

bull For comfort





69


Tibial shaft


ndash No PROM

ndash No MMT


Balance deficits







Clip Art

71








Esser 2001









Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab








Goodman CC 2009








Chemo brain

Bunting 2001

Cheville 2001 62

Risk appears low




Bunting 2001





Bedrest orders


Abeloff et al 2008

Cheville 2001

Damron 2014 64


Ribs

Pelvis


integrity

Posture


65







66 Rief et al 2014







67


Scapula


bull No PROM

bull No MMT



68

Clip Art




Slings and braces

bull For comfort





69


Tibial shaft


ndash No PROM

ndash No MMT


Balance deficits







Clip Art

71








Esser 2001









Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab








67


Scapula


bull No PROM

bull No MMT



68

Clip Art




Slings and braces

bull For comfort





69


Tibial shaft


ndash No PROM

ndash No MMT


Balance deficits







Clip Art

71








Esser 2001









Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab








Beaton et al 2009

Schwartz 2014




bull 3-5 daysweek


bull 40-60 1RM



ACSM 2010

Beaton 2009










76 Neumann 2010




Beaton 2009

Schwartz 2014








Broom et al 2009








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab








79



Neuro exam intact


Yoga and biking


80


Cryotherapy




Pfalzer 2001 81





82










83











84












85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab













85











86















87


wwwcancerorg

Cancer Care

wwwcancercareorg


wwwcancergov


wwwnihgov


wwwnccnorg


wwwaccc-cancerorg


wwwacororg

88







89

Bisphosphonates



bull Olpadronate



Non-Nitrogenous





Denosumab


linda m. tripp, dpt & kim lambert dpt 1 · linda m. tripp, dpt & kim lambert dpt 2 solid...

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