1. Exercise and Multiple Myeloma
Miriam Flatley
Senior Physiotherapist Oncology and Haematology
University Hospital Galway

2. Role of Physiotherapy Education and Support Exercise Prescription
Falls Prevention
Fatigue Management
Relaxation and stress reduction
Chest Physiotherapy
Part of the Multidisciplinary Team

3. Research
Exercise has been shown to be safe and effective during cancer treatment
Exercise can improve Quality of life, fatigue, depression and physical functioning
30 mins of aerobic activity 5-7 times a week
Strength training 2-3 times a week

4. Barriers to Exercise

5. Barriers to exercise
Weakness/Anaemia Bone Involvement – Fractures, Pain Fatigue Peripheral Neuropathy Nausea/Diarrhoea/Constipation

6. Complications of Multiple Myeloma
Myeloma cells activate osteoclast cells, which damage bone, and block osteoblast cells, which normally repair bone.
Bone thinning or osteoporosis
Pain, swelling or collapse of a bone
Higher risk of fracture following minor trauma

7. Bisphosphonates Slow down the bone destruction process
Help prevent further bone damage
Jaw Osteonecrosis- rare side effect of Bisphosphonate use

8. Orthopaedic Surgery (Bone Surgery)
Spine
To repair or prevent fractures and strengthen bone
Physiotherapy for mobility

9. Spinal Cord Compression
Cancer cells put pressure on your spinal cord.
■ Unexplained discomfort or pain in your back or neck
■ Pins and needles or numbness in your fingers or toes
■ Weakness in your limbs
■ Loss of control of your bladder or bowels
Medical Emergency

10. Peripheral Neuropathy
Side effect of chemotherapy
Tingling, numbness or burning sensation in hands or feet
Can lead to an increased risk of falls
Medication and pain relief
Gentle exercises to maintain movement and strengthen muscle groups.

11. Peripheral Neuropathy - Tips
■ Keep your hands and feet warm by wearing gloves and socks.
■ Take regular exercise
■ Eat a well-balanced diet and take vitamin supplements if advised by your
doctor.
■ Get advice from the dietician on how to lose weight if you are overweight.
This can reduce pressure on your nerves endings.
■ Quit smoking, as cigarette smoke narrows the blood vessels to your nerves.
■ Avoid alcohol
■ Treat any cuts or injuries to your feet or hands immediately.
■ Take good care of your feet, especially if you also have diabetes or an
impaired ability to feel pain. Keep feet clean and avoid any tight-fitting
shoes, socks or tights.
■ Test your bath water to make sure it is not too hot.
■ Acupuncture may help, so ask your doctor for advice.

12. Slips and Trips- What's the problem?
1in 3 older people fall every year
2/3rds fall again within six months
50% of over 80 years fall once a year

13. Why is a problem in MM? Minor traumas can cause fractures
Fear of falls can sometimes result in patients not moving
This can result in further muscle wasting, loss of balance reactions and reduced mobility
If you don’t use it, you'll lose it.

14. Falls Prevention Advice
Keep Active - weight-bearing, balance exercises, resistance and flexibility exercises
Have your vision checked
Healthy lifestyle and Nutrition
Choose appropriate footwear
Identify and eliminate risk factors in the home

15. Environmental /Home Risk Factors
Stairs and Steps
Cluttered furniture
Extension Leads
High/ Low shelves
Inappropriate lighting
Rugs/Mats
Bathroom Hazards
Wet Floors/Footpaths
Cold

16. Eliminate Risks at home
Remove obstructions
Remove Rugs
Insert handrails
Fix faulty steps/cracks in footpaths
Ensure adequate lighting
Watch for changes in flooring
Use a non slip mat in the bath or shower
Keep items you use often within easy reach
Clean up spills as they happen
Walk Slowly
Ask for help
Take Action today

17. Weight Bearing exercises
Walking
Climbing Stairs
Dancing
Tai Chi
Gardening
Cross trainer

18. Balance Exercises Used as a strategy to prevent falls
Always carry out safely
Always use a support
Always be guided by your Physiotherapist or Health Care Professional

19. Balance exercises

20. Muscle strengthening Exercises
Resistance exercises
Moving against gravity
Lifting a light weight
Elastic resistance bands
Lifting your own body weight

21. Muscle Strengthening Exercises

22. Exercises to Avoid Avoid Jerking Rapid movement
Avoid bending and Twisting, particularly with a weight
Lifting Heavy Weights
Avoid touching your toes, doing a sit up
Be mindful of golf, tennis and some yoga poses

23. Compression Fractures
When vertebrae's become weak, they can collapse onto one another
Can result in Pain, stooped posture, loss of height, immobility and further fractures
A secondary complication can be loss of appetite and reduced lung capacity

24. Postural/Flexibility Exercises
Help to stretch the muscles gently in the Spine
Help to manage curvature of the spine
Maintain normal range of movement
Maintain mobility

27. Gentle Neck Exercises

28. Shoulder rolls…

29. Tighten your shoulder Blades….

30. Shoulder range of movement

31. Shoulder pulleys

32. And lots more too…….!

33. Log Roll Technique

34. What is Fatigue?

35. Common Features Lack of motivation No energy Feeling impatient
Difficulty making decisions
Difficulty sleeping
Difficulty remembering things
Tearfulness

36. Why are you feeling this way?
Treatments
Pain
Anaemia
Breathlessness and Fluid Retention
Stress and Anxiety

37. Suggestions Keep a diary- activity diary Develop your own programme
Redefine ‘necessary’
Pace yourself
Use best time of day fully

38. At Home
Pace yourself
Sit down
Prioritise
Get Help
Plan visitors

39. Everyday Activities Plan ahead- Make lists, freeze dinners, shopping
Sit down- to make the dinner, to do ironing, to shower
Grab rails
Comfortable shoes

40. Going to Sleep Regulate Bedtimes Have routine to wind down
Remember room temperature
Don’t go to bed hungry
If you cant sleep- get up
Avoid stimulants before bedtime, such as alcohol, coffee, tea, coke or chocolate

41. Waking up
Don’t lie in bed
Regulate getting up times

42. Naps
Find out how the effect you
30-40 minutes recommended

43. Exercise and Managing Cancer Related Fatigue ( CRF)
One way of gaining control over fatigue
Moving around can be effective
Aerobic exercise
Large muscle groups
Walking/Running/Cycling
Pace yourself
Individualised Exercise Plan/Activity diary

44. Benefits of exercise Help Fight Fatigue and Nausea
Helps fight low mood
Improves how you feel
Feel like you have more energy
Improves sleep
Reduces body fat
Increases muscle mass
Improves working of the heart

45. Benefits of exercise
Aerobic exercise programmes have been shown to increase the red blood cell count, which has a positive effect on managing fatigue in cancer patients undergoing treatment
The better condition you can maintain you body, the better you will tolerate the side effects of chemotherapy, radiation and other invasive treatments
10 mins of walking is as effective at treating mild to moderate depression as antidepressants

46. When to exercise
Often its hard to exercise because we don’t feel like it
Those are often the times we need to exercise and move
Sometimes its not a good idea
Important to know the difference

47. AVOID exercise Haemoglobin below 8.0 g/dl
Platelet count less than 20,000
Hours before lab tests/investigations
Until day after IV Chemotherapy
Fever
New onset of pain- needs to be reported

48. STOP Exercising Dizziness Difficulty catching your breath
Chest pain/discomfort
Nausea
Irregular Pulse/Heart Rate
If you experience any of these symptoms, stop, rest, report it!

49. Stress Management
Relaxation- Make time for activities that relax you, stress uses up energy and makes you tired. Stress can increase with hospital admissions/start of new treatment. Research has shown that relaxation during the course of cancer treatment makes the experience less stressful and aids in reducing side effects of stress.
Support- talk to others, Support Groups
Distraction- do things you enjoy
Light exercise- gentle exercise decreases stress hormones and increases the feel good hormones. Promotes a positive sense of well being.
Avoid anxious situations
Complimentary therapies-aromatherapy, reflexology NB always discuss this with your cancer specialist before commencing any of these treatments
Feel good hormones endorphines

50. Stress Management
Gentle Massage-provides physical and psychological health benefits, increases relaxation and decreases blood pressure and anxiety and can promote a more natural sleep.
Expressive writing- time spent acknowledging and writing down thoughts, feelings and emotions related to their cancer has been shown to improve Quality of life by changing attitudes towards the illness

51. Specific Relaxation Techniques
Cancer and its treatment can be stressful for the patient, family members and caregivers
Relaxation techniques can help calm your mind and increase your ability to cope
This is hugely important in conserving energy levels and managing fatigue

52. Relaxation Exercises Can be divided into physical and Mental exercises
Physical exercises relieve tension in the muscles eg tai chi, yoga, gentle exercises
Mental exercises help relax the mind e.g. breathing exercises, muscle relaxation, body awareness, visualisation, imagery, relaxation tapes

53. Deep Breathing exercises
Anxiety and stress can make us take short shallow breaths, this shallow breathing, which does not allow us to take enough Oxygen into the body, can cause us to feel more anxious and fatigued.

54. Deep Breathing Exercises
Can be done anywhere, anytime, any position
Place your hand on your lower tummy
Take a long slow deep breath in through your nose as able
Feel your tummy rise as you complete this
Hold for a couple of seconds
Now Slowly exhale, letting your tummy muscles relax
Repeat this 4/5 times
You can close your eyes to focus
Focus on your breathing and the experience of being calm
Practice when you are not stressed for maximum benefit

55. Deep Breathing Exercises

56. Breathlessness Can happen gradually or suddenly Respiratory Infections
Secondary to Chemotherapy/Radiotherapy
Fluid around your lungs
Lung clots
Panic/stress/anxiety
Lack of physical Fitness
Overweight
Smoking

57. Treatment of Breathlessness
Oxygen
Breathing exercises
Positions of ease
Quitting smoking
Hand held fans
Specific treatments
Special Treatments for individual lung conditions eg Pleural fluid aspiraton etc

58. Positions of ease for Breathlessness

59. Exercise Guidelines Start slowly Gradually increase
Monitor Progress - Set Goals
Listen to your body
Avoid lifting heavy weights
Avoid Breath holding
Avoid uneven ground, risk of falling esp. with altered sensation in feet e.g. peripheral neuropathy
Avoid public gyms/pools if you are at risk of infection

60. Something for everyone!
Bed/Chair based exercise Programme
Indoor and Outdoor Programmes
Group Vs Individual
What do you enjoy?
What is available to you?

61. Role of the Multidisciplinary Team
Dietician- meal plans, bone strengthening
Social worker- discharge planning, respite care, grants, pendant alarms, home help applications
Podiatrist- footwear, nail care, falls prevention
Occupational Therapist- aids and appliances, home assessment, energy conservation techniques

62. Take Home Message You can Start Exercising today!
Build up to 30 minutes 5-7 times weekly
Include some strengthening exercises
Be aware of falls Risks in your environment
Try take some control of Cancer Related Fatigue
Listen to your own body- recognise limitations
If in doubt- seek advice from a Chartered Physiotherapist

63. Questions?