The principal finding of this study is that a tailored EP is safe and feasible in treated MM patients. Patient participating in the study demonstrated improvements in QOL measures, particularly fatigue, and in muscle strength, suggesting possible benefits of such an EP. Our study is the first to systematically explore the feasibility and benefits of a tailored EP in the rehabilitation of treated MM patients. The high rate of uptake (80% of eligible patients) compares favourably with a RCT in lymphoma patients (26%, ref.14) and attests to the keenness of these patients to engage in an EP, despite the perceived frailty of their bones. The attrition rate (24%) was similar to that reported for exercise programmes in other cancer patient populations
[27, 28], and compares favourably with one of the few reported studies in MM patients (42%, Coleman et al.). Importantly, all patients who started on the EP completed their planned 3, or 6 months. This, together with the high attendance rates in the gym classes (87% in first 3 months, 100% in second 3 months), indicates the acceptability of the EP. Adherence was only assessable in patients who returned their logbooks (71-86%), but levels were acceptable (72% and 86%), and many patients testified that they performed the EP at home, despite not filling in the log books. We also confirmed that a tailored mixed EP is safe, in that there were no AR’s.
In this era of MM therapy where new and effective treatments are increasing remission rates and extending survival
, it is vital to focus on non-drug strategies that will help to maximise wellbeing and QOL for survivors. The inclusion of EP in rehabilitation is a novel approach because hitherto, few clinicians have advised their patients to engage in exercise, for fear of further bone damage. On the other hand, their bone pathology and skeletal complications mean that MM patients have much to gain from exercising. Exercise improves bone health, as shown by studies in women at risk of osteoporosis where weight bearing exercise increased bone density
. Resistance exercise, by improving muscle mass, improves strength and balance, reducing the rate of falls which is a major risk factor for fractures
. Previous studies in this patient group have excluded subjects with lytic bone disease, thus to the best of our knowledge, this is the first study to demonstrate that MM patients with significant bone disease are able to exercise safely. Our results will make an important contribution to the development of rehabilitation programmes for these patients.
Due to their bone disease and generally older age, (median age of MM survivors is 70 years) many MM patients may not be suited to even moderately intensive aerobic programmes, hence the inclusion of resistance exercises is an important feature of the EP. Resistance exercises can reduce fatigue, improve QOL and muscle strength, and produce longer term improvements compared with aerobic exercises
. Because of their bone disease, patients were given individually tailored programmes, and attended supervised weekly exercise sessions, factors that are likely to contribute to the safety of the EP. Testimonies from the focus groups indicated that patients found the supervised sessions reassuring, gaining confidence to undertake new physical activities. Because we found that some patients were unable to perform the single stage submaximal treadmill walking test, we used an alternative method of estimating VO2max; future studies should standardise the test for cardiorespiratory fitness. To improve on the logbook return rate, patients may be offered incentives, and given positive reinforcement in the form of follow-up telephone calls from the physiotherapist.
Our study was designed as a single arm pilot study, which clearly presents limitations when interpreting the results. In particular, because subjects are compared only to themselves previously, this design does not allow us to conclude that the improvements in patient reported and objective outcomes are necessarily due to the intervention. It is possible that patients would have experienced improvements in these parameters over time. A comparator group of patients, in a randomized study, is required to answer this question. Some insights however, may be derived from the focus groups. A focus group is a more natural situation than an interview as the participants share and compare experiences and opinions. The results thus provide a powerful insight into experiences, beliefs and attitudes
[32, 33]. Patients reported benefits from meeting other MM sufferers, such as increased confidence and hope for the future, and thus patients may gain from engaging in physical activity together. In an RCT of a group-based exercise programme in breast cancer patients Mutrie and co-workers concluded that some of the benefits observed derived from the group experience
A potentially important finding is the improvement in fatigue levels following the EP. Because of the limitations of a single arm study, we cannot conclude that this is due to the EP, however, these findings warrant further investigation. Fatigue is a prominent symptom in cancer patients
, and one of the widely reported benefits of exercise training is a reduction in fatigue, however not all studies have shown statistically significant effects
[8, 34, 36, 37], and much of the evidence derives from patients undergoing treatment. There is less information in patients who have completed therapy, however a single arm study reported that 32 cancer patients, after a 3-week programme of endurance and resistance exercise, had improved physical performance and reduced fatigue levels
. The mechanisms whereby exercise lessens fatigue are not completely understood, but may relate in part to improved sleep patterns
[39, 40]. Future work could explore this mechanism by including a measure of sleep. Reduced fatigue would particularly benefit this older, more frail cancer group with bone morbidity as it would lead to increased activity and functionality, with attendant benefits on wellbeing and social functioning.