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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
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Physiotherapy in Bone Tumours
Bone tumours can be benign or malignant. Benign tumours include osteoid osteoma, osteoma, and haemangioma which typically have well-defined borders and do not metastasize. Malignant tumours such as multiple myeloma, Ewing sarcoma and osteosarcoma are poorly defined, invasive and can metastasize. Treatment depends on the type and severity of the tumour and may include surgery, chemotherapy, radiation therapy or palliative care. Physiotherapy can aid in pain relief, improving function and mobility, and maintaining quality of life for patients with bone tumours.
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Physiotherapy in Bone Tumours
- 1. Physiotherapy in Bone Tumours DrSreeraj 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 Benignvs 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 WHOclassification 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 Bonetumours • 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 BenignBone 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 BenignBone 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 BenignBone 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 Benignto 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 Benignto 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 Benignto 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 Benignto 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 Malignantbone 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 Malignantbone 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 Malignantbone 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 Surgicaland 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 Physiotherapeuticmanagement 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 Physiotherapeuticmanagement • 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 Physiotherapyin 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 Physiotherapyin 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 Physiotherapyin 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