Mobilization Guidelines for Multiple Myeloma

Multiple myeloma, an aggressive cancer affecting plasma cells in the bone marrow primarily targeting the elderly population, is estimated to affect over 24,000 individuals annually. Five-year survival rates remain around 30-50% ¹ despite improved treatment options associated with the advent of autologous stem cell transplantation and immunomodulatory and proteasome inhibitor medications. In the throes of the disease however, patients still suffer from reduced functional performance, alongside anemia, fractures, and bony lesions, compromising their energy levels and mobility. As such, physical therapy and patient mobilization, for which carefully honed guidelines have been developed, form an integral part of rehabilitation programs for multiple myeloma.

In general, studies have found – excluding patients at high risk for pathological fractures – that exercise is safe and well-adhered to by patients ^2,3. In addition, reports generally show that aerobic exercise improves fatigue and depression ⁴.

However, mobilization guidelines come with specific stipulations as certain limitations and contraindications need to be carefully taken into account in order to ensure their safety and efficacy ⁵. In particular, clinical features for which physical therapy is contraindicated, besides skeletal considerations, include hypercalcemia and monoclonal gammopathy – both of which complicate clinical management. In addition, while patients may receive physical therapy during red blood cell transfusion, which has been shown not to incur any adverse side effects ⁶, physical therapy is generally contraindicated in patients with low hemoglobin values, under 8 g/dL ⁷. Also, while chemotherapy may reduce platelet counts, warranting bed rest, this should be balanced with the functional decline associated with multiple days of bed rest. Furthermore, to prevent bleeding from heightened blood pressure, gentle range of motion and strength-training exercises without resistance or strain are recommended for patients with platelet levels between 10,000-20,000/μL, exercises with light resistance for patients with platelet levels between 20,000-40,000/μL, and gentle aerobic activity for patients with platelets in excess of 40,000/μL. To minimize the risk of bone fracture, exercises should be modified and additional precautions; enhancing circulation by physical modalities at tumor sites should also be avoided ⁸. Finally, patients with multiple myeloma with neutropenia or leukopenia are immunocompromised, and the use of face masks, frequent hand cleaning, and equipment sanitization should be implemented to reduce the risk of infection.

Most recently, following a thoroughly developed research plan, a Canadian Physiotherapy Association study sought to develop guidelines aimed at clinically informing physical therapists on how implement mobilization strategies for patients with multiple myeloma ⁹. Anchored in a thorough review of the literature, thirty action statements were put forth reflecting physical therapy recommendations based on patient physiological features, including hemoglobin and platelet levels, clinical presentation, and the stage of medical treatment ¹⁰. Judiciously carried out within a strictly well-defined context, the proper mobilization of patients with multiple myeloma has the potential to reduce fatigue and muscle wasting, increase quality of life and sleep, and improve overall strength. Given their clear benefits, these guidelines are thus slated to be updated in 2025 based on feedback from physical therapists and their patients ¹⁰. In the meantime, the existing framework for patient mobilization should be assiduously studied and adhered to in order to maximize patient well-being and recovery.

References

1.        Kazandjian D. Multiple myeloma epidemiology and survival: A unique malignancy. Semin Oncol. 2016. doi:10.1053/j.seminoncol.2016.11.004

2.        Smith L, McCourt O, Henrich M, et al. Multiple myeloma and physical activity: a scoping review. BMJ Open. 2015. doi:10.1136/bmjopen-2015-009576

3.        Gan JH, Sim CYL, Santorelli LA. The effectiveness of exercise programmes in patients with multiple myeloma: A literature review. Crit Rev Oncol Hematol. 2016. doi:10.1016/j.critrevonc.2015.11.005

4.        Knips L, Bergenthal N, Streckmann F, Monsef I, Elter T, Skoetz N. Aerobic physical exercise for adult patients with haematological malignancies. Cochrane Database Syst Rev. 2019. doi:10.1002/14651858.CD009075.pub3

5.        Keilani M, Kainberger F, Pataraia A, et al. Typical aspects in the rehabilitation of cancer patients suffering from metastatic bone disease or multiple myeloma. Wien Klin Wochenschr. 2019. doi:10.1007/s00508-019-1524-3

6.        Stiller K, Phillips A. Safety aspects of mobilising acutely ill inpatients. Physiother Theory Pract. 2003. doi:10.1080/09593980390246751

7.        Peterson ML. The Impact of Low Hemoglobin on the Percentage of Adverse Events During Physical Therapy in the Acute Care Setting. J Acute Care Phys Ther. 2015. doi:10.1097/jat.0000000000000010

8.        Crevenna R, Kainberger F, Wiltschke C, et al. Cancer rehabilitation: current trends and practices within an Austrian University Hospital Center. Disabil Rehabil. 2020. doi:10.1080/09638288.2018.1514665

9.        Jeevanantham D, Rajendran V, Tremblay L, Larivière C, Knight A. Evidence-based guidelines for physiotherapy management of patients with multiple myeloma: Study protocol. Syst Rev. 2018. doi:10.1186/s13643-018-0785-7

10.      Jeevanantham D, Rajendran V, McGillis Z, Tremblay L, Larivière C, Knight A. Mobilization and Exercise Intervention for Patients with Multiple Myeloma: Clinical Practice Guidelines Endorsed by the Canadian Physiotherapy Association. Phys Ther. 2021. doi:10.1093/ptj/pzaa180