Factors that Correlate with an Increase in Fracture Risk in Patients Who Have Been Diagnosed with Bony Metastatic Disease

https://www.iofbonehealth.org/news/whats-your-future-risk-fracture-find-out-frax

Created By: Ashley Lewis, SPT

Background:

My passion for working with patients who have cancer began long before Physical Therapy school when multiple members of my family went through the long and hard process of cancer diagnosis, treatment, and recovery. I have always held a special place in my heart for these individuals as I have seen the negative toil that cancer can have on the body physically, mentally, and emotionally. During one of my previous clinical rotations at UNC Hospital, I had the privilege of working on the oncology and bone marrow transplant unit floors. Throughout this clinical, my passion and interest for working with these patients grew as I was able to see the positive impact I was having on their lives. During this clinical, my Clinical Instructor who is an oncology PT mentioned that they had started working on a project to update a current decision tree for their oncology department on when the PTs/OTs should consult a physician before mobilizing a patient diagnosed with bony metastases. The research they were using was outdated and needed to be updated with the newest evidence. This sparked my interest and led me to working with these oncology PTs/OTs to develop my capstone project on the factors that correlate to an increased fracture risk in patients with bony metastatic disease. I wanted to be able to serve this population and help improve their safety while going through what is already a tumultuous time. This project allowed me to broaden my PT knowledge base, strengthen my clinical reasoning skills, and create valuable educational material for the PTs/OTs. For my project, I created an evidence table with up to date research, and I updated the decision tree to reflect the current research I found. I chose to create an educational PowerPoint presentation for the oncology PTs/OTs and their supervisor discussing the newest research.

Overview/Purpose:

Bone metastatic disease is a common clinical problem with the highest prevalence found in patients who have breast and prostate cancer.¹ These two cancers account for more than 80% of metastatic bone disease cases and cause the greatest morbidity.¹ Bony metastases create a site of increased osteoblast and osteoclast activity, thus leading to an environment that supports tumor growth and bone destruction.² Patients with bony metastases tend to have a shortened overall survival rate and increased risk of serious bone complications, including pathological fractures, pain, and spinal cord compression.² Patients who develop these skeletal related events are at a higher chance of developing more skeletal injuries, having an overall poorer prognosis, and having an impaired quality of life, including ongoing pain.²

Physical therapists play a key role in helping optimize the functional capacity of these patients and helping them stay as independent as possible.³ The main goal of treatment for patients with bone metastases is reducing the incidence of skeletal related injuries and improving their quality of life and mobility.⁴ Exercise interventions have been found to be safe and effective at improving functional outcomes in these patients and helping reduce the chance of complications occurring from the cancer and its treatment.⁵ Balancing the risk of potentially causing a fracture and wanting to increase mobility and independence of these patients with bony metastases is a common source of concern and complex decision-making component for rehab professionals to have to consider when assessing patients and prescribing exercises.³ Having knowledge of red flags indicative of an increased fracture risk and other skeletal related events in these patients is vital in order to provide safe and effective treatment.⁵ By assessing each patient, analyzing their risk factors, and prescribing safe interventions, PTs play a pivotal part in the rehabilitation of these patients with bony metastases.

Statement of Need:

To verify that there was a need for this educational project, I reached out to the oncology PTs and OTs at UNC Hospital. Korre Scott (DPT) and Farrell Wiggins (OTR/L) are both members of my committee that confirmed this research project was needed in the oncology department at UNC Hospital, since many of their patients were delayed in receiving treatment and being able to move until they received physician orders for safe mobilization. They had been trying for a few months to find the research to support which patients with bony metastases need physician orders before mobilizing, however, due to busy schedules this project was put on hold. They wanted to update the current flowsheet that the therapists use to determine which patients need physician orders based on the new research evidence found, which would give the PTs/OTs an easy guide to follow when working with this patient population. The physicians at UNC Hospital also expressed the need for this updated flowsheet in order to reduce the number of unnecessary pages and delayed treatment time. For my Capstone Project, I wanted to create resources that would be useful for all PTs/OTs to use when working with patients with bony metastases using the newest and updated research evidence. I also wanted to create an easy to use flowsheet that physicians can easily reference as well to know which patients they should put orders in for depending on their fracture risk before PT/OT can work with them.

Products:

My Capstone Project included three different products including an evidence table with updated research evidence, an educational PowerPoint presentation for the PTs/OTs at UNC Hospital, and an updated flowsheet for the therapists and physicians to use. The evidence table focused on available newer evidence of factors related to increased fracture risk in patients with bony metastases, including pain with weight bearing and functional activity and androgen deprivation therapy (ADT) for prostate cancer. This evidence, as well as, other information on bony metastases was incorporated into an educational PowerPoint presentation that will be presented to the oncology PTs/OTs and their supervisor at UNC Hospital. The updated flowsheet was created as a clinical resource for the PTs/OTs and physicians to use as an easy reference to know which patients require orders for mobilization depending on their fracture risk. This flowsheet will help reduce delayed treatment time and unnecessary initial restrictions on movement in patients with identified bony metastases that are not at an increased fracture risk.

Evidence Table

Capstone PPT presentation

Finalized Physician/Therapist Decision Tree

Evaluation:

To evaluate the components of my capstone, I utilized feedback from my committee members throughout the process of creating this project to incorporate suggested revisions and edits. At the midterm and final, I sent my committee members all of my products and made corrections based on their suggestions. I met with all of my committee members multiple times in person to discuss the goals of my project, intended audience, their requirements/expectations for this project, and adequate synthesis of evidence. Feedback forms were sent to all of the committee members to review the final project components, and revisions were made based on their responses.

Additionally, my PowerPoint presentation will be delivered as a lunch and learn to the PTs/OTs and their supervisor at UNC Hospital in a few weeks. I have created a survey to give the attendees following the inservice that will assess what they thought of the presentation and if it was useful to them. This survey will also include areas that need improvement and questions related to presentation delivery. This survey will help determine whether the presentation objectives were met and if I effectively organized and presented the information in a useful way.

PowerPoint Evaluation Form

Self-Reflection:

Working on this capstone with the oncology PTs/OTs has provided me with many opportunities to network with experienced therapists in a setting that I am very interested in working in when I graduate. It has also helped me gain more knowledge on working with this patient population with cancer, which aligns with my future career goals of being an oncology certified PT. I feel better prepared to serve these individuals in the future and incorporate this new knowledge on providing safe and effective care to these patients. This project has given me the confidence to identify patients in the future that are at an increased fracture risk that need physicians’ orders before mobilizing. This capstone project also helped me contribute to our profession by helping the PTs/OTs at UNC Hospital and myself stay up to date on the most recent research in order to strengthen our quality of care when treating these patients. I was able to grow stronger in my professional development skills by continuing to be a lifelong learner and taking the opportunity to broaden my PT knowledge base. From this project, I have also learned the importance of communication and teamwork, especially between professions. Communication with my committee members has been vital to the success of this project and has given me an appreciation for the mentorship and encouragement that my committee has provided. By working with multiple professions on this project, I was able to address the needs of each group and incorporate their knowledge into my project to make it stronger and more applicable.

Overall, I am very pleased with the final result of my capstone project and think it will be very useful for the oncology PTs/OTs in the future. I am grateful for the personal learning and growth that has occurred throughout this semester while working on this project. This project further expanded my skills in creating and giving effective, engaging presentations, which will also be valuable to have as a future clinician. Working on this project challenged me to use the skills I learned in Evidence Based Practice courses of the curriculum to independently find and implement the research evidence on this topic. I was able to achieve all of my stated learning objectives that related to the creation of my products, including finding, appraising, and summarizing relevant and updated evidence-based research on this topic. I hope that the products I have created will continue to be beneficial and used for years to come in order to help provide the highest quality of care for this patient population.

Acknowledgements:

I would like to take the time to express my gratitude and appreciation to all of those with whom I had the pleasure to work with throughout this entire process. This project would not have been possible without your ongoing help, commitment, and support, which I am forever grateful for. I would personally like to thank Korre Scott, DPT, and Farrell Wiggins, OTR/L, for serving on my committee and letting me work on this project with them. Thank you for the time and effort that you both put in to giving me feedback and helping me develop this into a successful project. I also thank you for your drive and passion to serve this patient population and your commitment to provide the highest quality of care to all of your patients. I also would like to thank the PT/OT supervisor at UNC Hospital for allowing me to work on this project with Korre and Farrell. In addition, I would also like to thank my capstone advisor, Prue Plummer, PhD, PT, for her professional guidance and assistance throughout this semester, which was key to the completion of this project. I really appreciate you taking the time to always answer my questions and help me develop my ideas to create this final project.

References:

1. Coleman RE. Metastatic bone disease: clinical features, pathophysiology and treatment strategies. Cancer Treat Rev 2001;27(3):165-176. doi:10.1053/ctrv.2000.0210.
2. Hernandez RK, Wade SW, Reich A, Pirolli M, Liede A, Lyman GH. Incidence of bone metastases in patients with solid tumors: analysis of oncology electronic medical records in the United States. BMC Cancer 2018;18(1):44. doi:10.1186/s12885-017-3922-0.
3. Bunting RW, Shea B. Bone metastasis and rehabilitation. Cancer 2001;92(4 Suppl):1020-1028. doi:10.1002/1097-0142(20010815)92:4+<1020::AID-CNCR1415>3.0.CO;2-I.
4. Sheill G, Guinan EM, Peat N, Hussey J. Considerations for exercise prescription in patients with bone metastases: A comprehensive narrative review. PM R 2018;10(8):843-864. doi:10.1016/j.pmrj.2018.02.006.
5. Maltser S, Cristian A, Silver JK, Morris GS, Stout NL. A focused review of safety considerations in cancer rehabilitation. PM R 2017;9(9S2):S415-S428. doi:10.1016/j.pmrj.2017.08.403.