Review
The effectiveness of exercise programmes in patients with multiple myeloma: A literature review

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Abstract

A limited number of clinical studies have investigated the effectiveness of participation in exercise training programmes for patients with multiple myeloma (MM), exploring the different biomedical, physical, psychological and quality of life. The aim of this literature review is to evaluate current quantitative and qualitative evidence concerning the effectiveness of participation in exercise programmes for patients with MM in improving physiological and/or psychological status. A literature search encompassing studies published between January 1998 and July 2013 was conducted through ten electronic databases. This search was further expanded through citation chaining, manual grey literature searches, and peer review consultation. In total, seven interventional studies were identified and appraised using Critical Appraisal Skill Programme (CASP) or Centre for Evidence-Based Management of Amsterdam (CEBMa). Though the majority of the studies presented encouraging data, however, three studies that implemented individualized exercise interventions for patients at different stages of MM and myeloablative treatment showed mixed results. In conclusion, the effectiveness of participation in exercise programmes remains unclear for patients with MM, as the studies reviewed were flawed by relatively weak methodological approaches.

Introduction

Multiple myeloma (MM) is an incurable cancer with an incidence rate that accounts for 1% of all cancers, and 15% of all haematological cancers in the United Kingdom (Cancer Research UK, 2014, Westlake, 2008). Unfortunately, it is a vicious malignant disease with a median survival rate of 3–5 years, provided intensive regimens of myeloablative therapy are given (Booker et al., 2009, Durie et al., 2003). The detrimental nature of this disease and its related medical treatments can have debilitative physical effects, which includes muscle atrophy, fatigue, immobility, and decline in activities of daily living (ADL) (Anderson et al., 2000). These incapacities may lead to poor quality of life (QOL) within the shortened life expectancy of individuals with MM (Durie et al., 2003). Since physical rehabilitation has increasingly been integrated into oncology care management (Courneya et al., 2003, Dimeo et al., 1999, Mock et al., 1997a, Segal et al., 2003), physical exercise is now considered an essential part of a comprehensive treatment to improve the quality of survival (Mock et al., 2001). Most studies investigating rehabilitation services in oncology management, focused on patients with solid tumours or a different collective type of cancer (Courneya et al., 2003, Dimeo et al., 1999, Hoffman et al., 2012, Mello et al., 2003, Mock et al., 1997b, Schwartz, 2000, Segal et al., 2001, Segar et al., 1998). Available evidence shows that exercise capacity and fitness level are reduced in survivors with MM, resulting in a low percentage of these survivors being able to exercise at recommended levels (Jones et al., 2004).

A cancer rehabilitation programme has to be tailored individually, based on the disease stage, degree of bone lesions, severity of fatigue and deconditioning, level of adverse effects experienced, and according to other special rehabilitation guidelines in myeloablative treatment (Blaney et al., 2010, Berger et al., 2010). The American College of Sports Medicine (ACSM) advises that exercise parameters should be based on the pre-treatment aerobic fitness level, medical co-morbidities, treatment response, and the immediate or persistent adverse effects of treatment that are experienced at any point along the cancer care continuum (Schmitz et al., 2010).

The key to generating a high quality literature review is to identify a relevant and focused research question (Aveyard, 2007). In this literature review we focus on the available studies to evaluate the “effectiveness of participation in an exercise programme for patients with MM in improving physiological and/or psychological status” (Schmitz et al., 2010, Aveyard, 2007, Sackett et al., 2000).

The preliminary literature review we conducted did not reveal any current systematic reviews specific to this research question. There is, however, a study by Strong et al. (2006) that attempted to develop an exercise protocol for reducing fatigue and muscle wasting issues in patients with MM. The exercise protocol used in this study was based on those used in previous selected studies (published up to the year 2005) which included any cases with cancers that cause osteolytic bone lesions, primarily breast cancer and mixed haematological cancer (Strong et al., 2006). Additionally, there is another similar systematic review (of studies published up to the year 2007) that investigated haematological cancers that involved both the children and adults population (Liu et al., 2009). The findings might not be generalizable to the MM population because MM is a cancer affecting older adults rather than children (Kyle et al., 2007). Hence, the available systematic reviews were not able to address the current evidence for the effectiveness of exercise intervention in patients with MM comprehensively and specifically. These limitations signal the need for a more comprehensive review of those data specific to patients with MM in an effort to better understand the possible effects of participation in exercise training and its related impact on the co-morbidities and/or complication of MM.

The objective of this work was to systematically review existing literatures to examine the effects of formal exercise programmes in patients with MM, as well as to evaluate the methodological quality of the selected research studies.

Section snippets

Electronic search strategy and selection criteria

To find the relevant studies published from January 1998 to June 2013, we searched through 10 electronic databases: AMED, ASSIA, British Nursing Index with full text, CINAHL, Cochrane database of systematic review, Medline, PubMed, PsyINFO, Web of Science via Web of Knowledge, and CIRRIE. Due to the variety of exercise interventions and the variables in the research question, we looked for separate search terms based on ‘Population/Patient’, ‘Intervention/Issue’, ‘Comparison’ and ‘Outcome’

Electronic search results

We retrieved seven studies following the removal of duplicates, and exclusion of irrelevant records from a total of 536 records reviewed (Fig. 1).

Combined search results

The combined search results from both electronic and manual searches resulted in a total of seven studies that meet the selection criteria (Table 7).

Summary of findings from critical appraisal

We have illustrated the summary of the six quantitative studies and one qualitative study in Table 5, Table 6. Methodological qualities of the studies were appraised by the critical appraisal tools

Exercise intervention in MM prevention phase

We have presented the outcomes of the different exercise programmes based on myeloablative treatment stages to obtain clinically meaningful information. Despite the small sample sizes from the studies involving asymptomatic or smoldering MM phase, these long-term case studies utilized high technology assessment methods, which are uncommon and costly (Boullosa et al., 2010, Boullosa et al., 2013). Knight et al. (2004) argued that it is often necessary to conduct small scale studies to

Conclusions

After having examined the relevant literature, we recommend that patients with MM participate in a partially supervised, long-term exercise training programme as it represents a safe and feasible intervention, which counters the negative impact of myeloablative treatment and adverse symptoms of MM. The possible benefits of exercise therapy for MM patients include improvement in physiological, psychological, QOL, physical, and exercise performance outcomes. However, in view of the wide variety

Ethical considerations

In this study, ethical approval was not needed because the literature review has no direct involvement of the participants. We only used published studies for this manuscript. All the studies selected were ensured to have received ethical approval from the appropriate institutional review board.

Funding

This study was conducted as part of the requirements for Master's degree in Musculoskeletal Rehabilitation by the corresponding author (J.H. Gan), and received no funding.

Conflict of interest

The authors have no conflicts of interest associated with this publication.

Acknowledgements

We would like to thank the reviewers for their helpful feedback, the librarians involved in Oxford, and the involved research and clinical network in supporting the data retrieving process.

Jia Hui Gan (MSc Musculoskeletal Rehabilitation, Oxford Brookes University, United Kingdom) is an experienced physiotherapist in Parkway East Hospital of Singapore. She worked in clinical environment for several years mainly in the orthopaedic and cancer areas. Her aim is to expand the evidence based physiotherapy service in the niche oncology rehabilitation area.

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    Jia Hui Gan (MSc Musculoskeletal Rehabilitation, Oxford Brookes University, United Kingdom) is an experienced physiotherapist in Parkway East Hospital of Singapore. She worked in clinical environment for several years mainly in the orthopaedic and cancer areas. Her aim is to expand the evidence based physiotherapy service in the niche oncology rehabilitation area.

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