Physical wellbeing

Physical Wellbeing Pie Chart

A multidisciplinary approach to care: Top tips for the management of patients with multiple myeloma (MM) undergoing autologous stem cell transplant (ASCT)

Ms Alexandra Clay and Professor Diana Greenfield

Physical wellbeing throughout autologous stem cell transplantation (ASCT)

Written by Ms Alexandra Clay, Clinical Specialist Physiotherapist in Oncology and Palliative Care, Sheffield Teaching Hospital NHS Foundation Trust

Please note: Some recommendations provided are based on the personal experience of the author and should not be used in place of official guidance.

INTRODUCTION

Physical activity is known to improve physical and psychological outcomes of transplant in patients with cancer.1 In patients with multiple myeloma (MM), research has shown that it is beneficial and feasible before, during and after transplant to remain physically active.2,3 However, physical activity can be challenging in these patients and is further complicated by their variable physical abilities, comorbidities and recovery time. All members of the multidisciplinary team can help to encourage patients to remain active, identify barriers to physical activity and make referrals to appropriate professionals (e.g. physiotherapists). Early identification of barriers to activity such as pain, fatigue and deconditioning is key to optimising outcomes. Creating opportunities to discuss a patient’s physical health and ‘make every contact count’ is also crucial to improve physical wellbeing. This article outlines some key recommendations to support physical activity in patients undergoing ASCT.

Key considerations to guide management through ASCT
  • What are the patient’s existing physical abilities, personal motivations and attitude towards ASCT?
  • Does the patient have any comorbidities that may impact their ability to exercise?
  • What are the patient’s expectations of physical activity during and after ASCT?
1

PRE-TRANSPLANT

ASSESSMENT

Recognise barriers to physical activity and seek advice from specialists where necessary

  • Recognise pre-existing limitations that could make it challenging for patients to benefit from maintaining/improving their levels of physical activity and fitness
  • Ascertain any do’s or don’ts for physical activity from the consultant and physiotherapist, particularly in patients at risk of fracture due to bone disease4,5
  • Gauge a patient’s attitude and confidence towards physical activity; highlight the value of exercise to patients, and how it can optimise outcomes following ASCT1,2
MANAGEMENT

Encourage patients to be physically active and support in the development and implementation of physical activity programmes

  • Refer appropriate patients (e.g. those without an established exercise routine) to a physiotherapist or a prehabilitation scheme, if available
  • Emphasise that physical activity can support recovery following ASCT, and is a routine part of an ASCT treatment plan
MONITORING

Monitor bone pain, and be aware of different attitudes toward physical activity

  • Monitor new or worsening bone pain as this may be indicative of bone lesion development, which can impact physical wellbeing and fitness
2

DURING TRANSPLANT

ASSESSMENT

Recognise signs of physical decline, and identify patients who may need to be referred to rehabilitation services

  • Monitor and recognise signs of deconditioning or decline in activity, including:
    • Decrease in activity levels or mobility (for example, becoming sedentary or bed-bound)
    • Decrease in balance or exercise tolerance
    • Negative attitudes or anxiety towards physical activity, e.g. fear of injury
    • Decline in mental wellbeing*
MANAGEMENT

Help keep patients physically active, and utilise rehabilitation services

  • Be aware that patients might need to adapt the type and intensity of physical activity depending on specific needs and side effects of treatment
  • For those patients that become acutely unwell, all HCPs can prevent further deconditioning by encouraging:
    • Regular position change or sitting in a chair, if able
    • Regular mobilisation, if able
  • For patients who are in isolation during ASCT, prevent inactivity and use individualised training programmes in order to maintain strength and cardiovascular fitness
  • Utilise inpatient rehabilitation or community care and therapy services to support patients during ASCT, particularly for those who have a significant decline in physical fitness
  • Support patients who are less mobile (e.g. assist with washing and eating); however, encourage independence where possible
MONITORING

Monitor side effects, including reduced mobility and proximal myopathy

  • Monitor patients with compromised strength or mobility as they may have an increased risk of falls
  • Be aware of reduced balance or mobility, which may be indicative of peripheral neuropathy caused by neurotoxic drugs.6* Utilise referral pathways:
    • Physiotherapy to optimise strength and mobility
    • Orthotics to provide specialist insoles or footwear
  • Chemotherapy and high-dose steroids can cause proximal myopathy** (muscle weakness, inflammation in the upper or lower limbs). Referrals (e.g. to consultants and physiotherapists) should be made if patients have:7
    • Difficulty standing up, managing stairs and lifting arms
    • Falls
    • Weakness and fatigue
3

POST-TRANSPLANT

ASSESSMENT

Assess signs of decline in fitness

  • Recognise patients who:
    • Show signs of limited recovery or are not returning to their normal lifestyle within the first weeks or months following ASCT
    • Do not return to their normal exercise routine due to physical symptoms
    • Lack confidence or experience low mood*
MANAGEMENT

Encourage patients to reintroduce physical activity into their daily routine

  • Emphasise to patients the need for continued physical activity, and provide advice on how this may be incorporated into their daily routine
  • Be aware of referral schemes that may help to rebuild patients’ fitness levels
  • Remind patients of the UK’s fitness guidelines, and encourage them to work towards:8
    • At least 150 minutes of moderate intensity activity and 75 minutes vigorous activity per week, or a mixture of both
    • Strengthening activities on 2 days per week and reducing extended periods of sitting
  • Encourage patients to set realistic physical aspiration goals, aiming to integrate physical activity into daily routines
  • Advise patients that physical activity can help with fatigue and consider giving patients information about fatigue management and refer patients to appropriate services
MONITORING

Continue to monitor side effects, including reduced mobility and proximal myopathy

  • Patient physical wellbeing should continue to be monitored. Please refer to the recommendations listed in the ‘During Transplant’ section above

*Please refer to the ‘Psychological Wellbeing’ piece for further information on ASCT and mental wellbeing.

**Please refer to the relevant NICE guidelines or Summary of Product Characteristics for guidance on the management of treatment-related symptoms.

Abbreviations

ASCT, autologous stem cell transplantation; HCP, healthcare professional; MDT, multi-disciplinary team; MM, multiple myeloma; NICE, National Institute for Health and Care Excellence.

Ms Alexandra Clay

Clinical Specialist Physiotherapist in Oncology and Palliative Care, Sheffield Teaching Hospital NHS Foundation Trust

Alexandra Clay has a BSc in Physiotherapy and is currently a clinical specialist physiotherapist in Oncology and Palliative Care at Sheffield Teaching Hospital NHS Foundation Trust. She provides clinical leadership to a therapy team in specialised medicine across 13 different wards, including haematology and oncology. Ms Clay has had a continued interest in haematological malignancies throughout her career and has worked in haematology wards and rehabilitation groups.

In addition to working with patients with various types of cancer, Ms Clay currently works extensively with patients with multiple myeloma in the acute ward setting. She plays a crucial role during various stages of patients’ treatment including during chemotherapy, stem cell transplantation, radiotherapy and during treatment for infections. Additionally, Ms Clay works with patients with multiple myeloma in the outpatient clinic during a goal-orientated 12-week exercise programme. She is committed to improving patients’ lives through optimising their treatment and recovery at all stages of the cancer pathway, through building their activity levels, strength and fitness.

Alex Clay

Professor Diana Greenfield

Consultant Nurse, Multidisciplinary Team Lead & NIHR Senior Nurse Research Leader, Sheffield Teaching Hospitals NHS

Professor Diana Greenfield is a consultant nurse in late effects at Sheffield Teaching Hospitals NHS Foundation Trust, the first post of its kind in the UK. Professor Greenfield also holds a faculty position of honorary professor in cancer survivorship in the Department of Clinical Oncology and Metabolism at the University of Sheffield since 2015. Professor Greenfield is also the first practicing clinical nurse to be conferred Honorary Professor at Sheffield Teaching Hospitals. These reflect her research and collegiate activities at local, regional, national and international level. Additionally, Professor Greenfield is a senior nurse research leader for the National Institute for Health Research.

As an NHS consultant nurse and honorary professor, Professor Greenfield’s key roles and responsibilities include expert clinical practice and leadership, learning and development, research, audit and collegiate activities, and service innovation and improvement. These responsibilities are all focused in the relatively new clinical field of long-term and late consequences of cancer and its treatment.

Diana Greenfield

References:
1. Wiskemann J & Huber G. Bone Marrow Transplant 2008;41:321–329; 2. Jafari H et al. J Res Med Sci 2017;22:13; 3. Wiskemann J. Eur Rev Aging Phys Act 2013;10:15–18; 4. Drake MT. Oncology (Williston Park) 2009;23:28–32; 5. Terpos E et al. Blood Cancer J 2018;12:7; 6. NHS. Peripheral Neuropathy Symptoms. Available at: https://www.nhs.uk/conditions/peripheral-neuropathy/symptoms/ (accessed December 2019); 7. Faiman B et al. Clin J Oncol Nurs 2008;12(3 Suppl):53–63; 8. Gov.uk. Physical activity: applying All our Health. Available at: https://www.gov.uk/government/publications/physical-activity-applying-all-our-health/physical-activity-applying-all-our-health (accessed December 2019).

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