Physiotherapy in Bone Tumours

1. Physiotherapy in
Bone Tumours
Dr Sreeraj S R, Ph.D.

2. Sreeraj S R
Tumours
• A tumour is a
swelling due to
excessive neoplasia
or new growth of a
tissue.
• Tumours are of two
types:
1. Benign
2. Malignant
2
https://www.verywellhealth.com/what-does-malignant-and-benign-mean-514240

3. Sreeraj S R
Benign vs Malignant Tumours
Characteristics Benign Malignant
Onset
Insidious with slow
growth rate
Acute with rapid growth rate
Fever, weight loss,
anorexia
Nil or few
Associated with severe unremitting pain and
disability
Lesion
Well circumscribed and
non-invading
Not well confined and invading
Spread of tumour Do not metastasize Metastasize
Radiographic
lesion
Confined to the involved
bone only
Has ill-defined borders, mottled appearance, the
bony cortex may be broken with pathological
fracture
Prognosis
Generally good with timely
and correct therapy
Generally poor and depends upon the nature and
extent of the tumour; could be fatal
3

4. Sreeraj S R
WHO classification of bone tumors.
4
Tissue Type Benign Malignant
Bone forming
Osteoma, Osteoid osteoma,
Osteoblastoma
Osteosarcoma
Cartilage forming
Chondroma, Osteochondroma
Chondroblastoma
Chondrosarcoma
Fibrous tissue Fibroma, Fibromatosis Fibrosarcoma
Giant-cell tumours Benign osteoclastoma Malignant osteoclastoma
Marrow tumours -- Ewing’s tumour, Myeloma

5. Sreeraj S R
Bone tumours
• Primary bone tumours, when they arise from
the bone itself, and occur mainly in young adults.
• Secondary bone tumours occur as a result of
metastases usually from the carcinoma of breast,
kidney, lung, prostate or thyroid. It may also be
called metastatic bone cancer, bone metastases.
5

6. Sreeraj S R
Benign Bone Tumours
• Osteoid osteoma
• Common Siters:
• Diaphysis of Tibia, and posterior elements of vertebrae.
• Symptoms:
• Localized tenderness, vague intermittent pain worst at night but relieved
completely with salicylates
• Back pain when vertebrae are involved
• Radiographic Investigations
• A zone of sclerosis which is surrounding a radiolucent nucleus – nidus
• Treatment:
• Rest and salicylates
• Excision of the tumour along with nidus
6

7. Sreeraj S R
Benign Bone Tumours
• Osteoma
• Common sites:
• Flat bones Face or skull
• Symptoms:
• Pain-free bony lump near the end of long bones
• Bony deformity may occur
• Radiographic Investigations:
• Medulla and the cortex of outgrown tumour are in continuity with the parent
bone
• Treatment:
• Excision of osteoma if the size is bigger and causes hindrance or for cosmetic
reasons
7

8. Sreeraj S R
Benign Bone Tumours
• Haemangioma
• More common in young adults. Vascular or haemangiomatous in origin
• Common Sites:
• Skull
• Vertebrae
• Clinical Features:
• May be asymptomatic or develop persistent pain
• Vertebral involvement may result in cord compression
• Radiographic Investigations:
• There is loss of horizontal striations with appearance of vertical striations
• Treatment:
• Radiotherapy
8

9. Sreeraj S R
Benign to Malignancy
• Enchondroma
• Origin: Cartilaginous
• Site: Metaphysis of short & long bones, e.g., Phalanges, Metacarpals, Rarely humerus, pelvis
• Clinical Features:
• Small-sized. slow progressing swelling with or without pain
• Lobulated enlargement at the tumour site
• Thin and expanded cortex
• Radiographic and Laboratory Investigations:
• Cystic lobulated tumour could be contained in bone (enchondroma), or perforating the
bony outline (eccondroma).
• Stippling or calcification may be seen
• Treatment:
• Single small tumour – curettage
• Large tumour – excision with removal of capsule
• When the long bones are involved – radical resection with bone grafting
9

10. Sreeraj S R
Benign to Malignancy
• Osteoclastoma (giant cell tumour)
• Origin: Bone
• Site:
• Epiphysis of long bones
• Lower end femur
• Upper end tibia
• Lower end radius
• Clinical Features:
• Pain, tenderness, brownish swelling
containing blood-filled cavities.
• May have ‘egg shell crackling’ due to
fragile cortex
• pathological fractures
• Radiographic and Laboratory
Investigations:
• Cystic lesion with trabeculae which
appear like ‘soap bubbles’
• Erosion of epiphyseal line appears
with the development of malignancy
• Histopathology– multinucleated giant
cells in fibrous stroma
• Spindle cells
• Treatment
• Curettage and bone grafting
• Excision with reconstruction
• Arthrodesis
• Amputation preceded by radiotherapy
10

11. Sreeraj S R
Benign to Malignancy
• Osteochondroma
• Origin: Cartilage
• Site:
• Metaphysis of long bones, Shoulder, Elbow, Hip, knee, ankle
• Clinical Features:
• Pain and swelling
• May compress on bursae, neurovascular structures, or result in stiff joints
• Radiographic and Laboratory Investigations:
• Pedunculated outgrowth of bone in continuation with cortex and medullary
portions, with cartilaginous cap
• Tumour grows in an opposite direction to the growing end of the bone
• Treatment:
• Surgical excision of the tumour
11

12. Sreeraj S R
Benign to Malignancy
• Chodroblastoma
• Origin: cartilaginous
• Site:
• Long bones Epiphysis close to the growth plate. Femur, around knee is
commonly involved
• Clinical Features:
• Pain, swelling and joint effusion
• Tumour is positioned eccentrically to bone
• Radiographic and Laboratory Investigations:
• Thinning of cortex, Lytic lesion surrounded by sclerosis, Multiple areas of
calcification within the tumour with mottled appearance
• Treatment
• Small tumour – curettage + bone grafting
• Large tumour – excision + bone grafting
12

13. Sreeraj S R
Malignant bone tumours
• Multiple myeloma (40–60 years)
• Origin:
• Plasma cells in bone marrow
• Site:
• Flat bones of Skull, Ribs, Lumbar spine,
Sacrum, Pelvis
• Clinical Features:
• Early phase– asymptomatic
• Later – bouts of sharp pain, swelling at the
site.
• Bone marrow is replaced by plasma cells
causing anaemia, haemorrhages
• Late signs of renal failure due to blockade
by protein casts (myeloma – kidney)
• Radiographic and Laboratory Investigations:
• Skull – punctuated out lytic lesions
• Vertebrae – wedge collapse
• Pathological fractures
• Ectopic bone formation – kidneys, lungs;
• Histopathology: ↓Hb,↑ESR, total proteins,
serum calcium;
• Bone biopsy – gamma globulin
• Treatment:
• Preventive measures for pathological
fractures
• Chemotherapy
• Surgery (suitable)
• Decompressive laminectomy
• IM fixation for pathological fracture
• Palliative – radiotherapy when the tumour is
widely spread and is nonoperative
13

14. Sreeraj S R
Malignant bone tumours
• Ewing sarcoma affecting 4– 25 years
• Origin: Bone, Reticulum cells lining the
marrow spaces
• Site: Diaphysis of longbones
• Clinical Features:
• Intermittent vague pain worst at night
• Redness of skin, dilated veins
• Tumour spreads to medullary cavity
• Metastasis to skull, vertebrae through
the blood, lymphatics
• Periods of exacerbations and
remissions
• Radiographic and Laboratory
Investigations:
• Rarefaction, lytic lesions in medullary
region
• Bone destruction and subperiosteal
new bone formation
• Expansion of tumour raises
periosteum which appears like ‘onion
peel’.
• Histopathology: sheets of round cells
• Treatment:
• Chemo + radiotherapy
• Debulking of tumour by surgery
• Irradiation followed by resection or
amputation
14

15. Sreeraj S R
Malignant bone tumours
• Primary osteosarcoma (10–25 years)
• Origin: Bone tissue from multipotent
mesenchymal cells
• Site:
• Long bones
• Lower ends of femur
• Upper end of tibia or humerus or
lower end of radius
• Clinical Features:
• Intermittent night pain, tenderness
and swelling
• Egg shell cracking may be present
• Dilated veins
• Fatigue, anaemic
• Radiographic and Laboratory
Investigations:
• sclerotic lesion
• Laying down of bone along the blood
vessels gives an appearance of ‘sun
rays’
• Codman’s triangle is present
• Pathological fractures may occur
• Treatment:
• Chemotherapy
• Radiotherapy
• Immunotherapy – allogenic sarcoma
tumour cell vaccine
• BCG vaccine can be used
• Early Radiofrequency Ablation (RFA)
15

16. Sreeraj S R
Surgical and Nonsurgical Methods
• Surgical Methods
• Curettage
• Excision
• Excision with reconstruction
• Limb salvage procedures: remove a tumor without
amputation.
• Resection arthrodesis
• Turn-o-plasty: After excision of the tumour, other
intact bone is split into two halves and the bone
required to bridge the gap is turned upside down
and fixed to the remaining stump of the bone
• Rotationplasty: The affected bone is resected and
the tibia is rotated 180 degrees to form a functional
knee joint.
• Joint arthroplasty – either by allograft or metallic
prosthesis
• Amputation
• Nonsurgical Methods
• Chemotherapy. Chemotherapy uses drugs to kill
cancer cells throughout the body.
• Hormone therapy. For cancers sensitive to
hormones, certain treatments can stop hormone
production in your body or block the effect of
hormones.
• Radiation therapy. Radiation therapy uses high-
powered energy beams, such as X-rays or protons,
to kill cancer cells. It can be given internally or
externally.
• Immunotherapy. Immunotherapy works with your
body's immune system to fight off any remaining
cancer cells by stimulating your body's own
defenses or supplementing them.
• Targeted therapy. Targeted therapy is designed to
alter specific abnormalities present within cancer
cells.
16

17. Sreeraj S R
Physiotherapeutic management
1. Keep up the morale of patients who are highly depressed
• Counselling Emphasizing moving unaffected body parts (ability) and maximizing
functional activities.
• Diversion procedures as per aptitude (e.g., reading and playing cards)
2. Reduction of pain
• Pain-free relaxed rhythmic movements
• Cryotherapy
• Medications
3. Improvement in swelling, circulation, muscle function and joint flexibility
• Intermittent compression
• Gentle effleurage
4. Improvement in muscle function and joint flexibility
• Simple full ROM or maximum ROM exercise, progressing (PRE) in a graduated manner
5. Improving / restoring function in complicated cases involving limbs or major
surgical procedures
• Early initiation of assistive functional activities, to provide optimal functional
independence
• Guidance and training in the use of orthosis or prosthesis for functional self-sufficiency
17

18. Sreeraj S R
Physiotherapeutic management
• If surgery is performed, depending upon the type
and the extent of surgery, all postsurgical
physiotherapeutic techniques should be employed.
• The procedures to improve strength and
endurance should be started.
• Low intensity, brief sessions of cardiorespiratory
conditioning to provide multiple physical and
mental benefits, especially in young adults.
18

19. Sreeraj S R
Physiotherapy in Palliative Care
• The primary goal of
physiotherapy in palliative care is
to achieve the best possible QoL
for both the patient and their
families.
• Other common goals of
physiotherapy are:
1. Minimise symptoms
2. Optimise functioning ability
3. Maintain or regain physical
independence
4. Preserve the patient's autonomy
19
https://www.physio-pedia.com/Physiotherapy_in_Palliative_Care#cite_note-Emma_19-22

20. Sreeraj S R
Physiotherapy in Palliative Care
• Pain Relief: TENS, heat, massage, lymphedema treatment and
acupuncture are common forms of pain relief. Pain relief is often
employed where rehabilitation is not appropriate.
• Physical Activity: This may have a positive effect on depression and is
currently emerging as a major aspect of the treatment of patients in
palliative care.
• Soft Tissue/Therapeutic Massage: Soft tissue massage and/or
therapeutic massage is used to relieve muscle tension can often aid in
easing the symptoms of anxiety.
• Passive Movements: These are often used in bed bound patients.
20

21. Sreeraj S R
Physiotherapy in Palliative Care
• Relaxation Exercises: Teach the patient on how the relaxation can be
carried out and the patients can handle this program by themselves in
order to reduce tensions of the muscles which have occurred due to pain.
• Positioning (rest/comfort): Teach useful sitting/lying positions for
relaxation, especially where breathing exercises is too tiring. Different
resting positions can facilitate breathing and lessen dyspnoea and
anxiety, create calmness, comfort and well-being for the patient
• Advice (family/relatives): Providing advice or education to patient and
family/carers, enabling them to adjust and adapt to consequences of the
illness
21

22. Sreeraj S R
References
1. Joshi J, Kotwal P. Chapter 23. Bone tumours. In: Essentials of Orthopaedics and
Applied Physiotherapy. 3rd ed. New Delhi: RELX India Pvt. Ltd.; 2017.
2. Aston W, Briggs T, Solomon L. Chapter 9, Tumours. In: Apley’s System of Orthopaedics
and fractures. 9th ed. FL: Taylor & Francis Group; 2010.
3. Bone Tumours - TeachMeSurgery [Internet]. TeachMeSurgery. 2020 [cited 2021 Jun
18]. Available from: https://teachmesurgery.com/orthopaedic/principles/bone-tumours/
4. Physiotherapy in Palliative Care [Internet]. Physiopedia. 2013 [cited 2021 Jun 19].
Available from: https://www.physio-
pedia.com/Physiotherapy_in_Palliative_Care#cite_note-Emma_19-22
5. Frymark U, Hallgren L, Reisberg A-C. Physiotherapy in palliative care - a clinical
handbook Physiotherapy in palliative care -a clinical handbook [Internet]. ; Available
from: https://physionewstz.files.wordpress.com/2013/05/physiotherapy-in-palliative-
care-a-clinical-handbook.pdf
22