Customized Exercise Programming for Multiple Myeloma Patient

Tom received a referral for a client with stage II Multiple Myeloma (MM). He’s been a Cancer Exercise Specialist for a little over two years, but has not had any experience with MM. He asked if he could hire me to help him with custom exercise programming and teach him how to put together John’s exercise program. He completed his initial assessment and health history and shared the following information with me:

• John is 56 years old and in relatively good health prior to his cancer diagnosis
• John is 6’0 and 180 lbs. He has 15% bodyfat.
• He has been exercising his entire life. Typically walking an hour a day 3-4 times per week, swimming once a week, and lifting weights. He has not exercised in 3 months and is anxious to get back to his routine.
• He was diagnosed with MM in January 2019
• He completed chemotherapy in May 2019
• He underwent radiation to his left hip and finished treatment in April 2019. He has stage one lymphedema in his left pelvis and upper leg.
• He currently is taking Prednisone (corticosteroid), Aredia (bone loss) and Prozac (anti-depressant)
• He is suffering from fatigue
• His BP is 120/70 and his RHR is 78.

Postural Assessment:

• Upper-crossed syndrome
• Right shoulder slightly elevated
• Moderate winged scapula on both sides
• Right hip slightly elevated
• Moderate anterior pelvic tilt
• Both knees laterally rotated

Limited shoulder ROM on left side. Had rotator cuff surgery 10 years ago and only has 110 degrees of abduction and 130 of flexion.

He has difficult moving his left leg when the lymphedema is bad

During squat test his arms fall forward and out to the sides and his knees “bow” out.

Balance is too unstable to test and Tom was afraid of John falling. These are the only tests that were done for fear of causing injury to John.

Tom told me that he was hesitant to work with John because he was afraid that John would fracture something and that it was too much of a risk for him. I told him what a critical role he could play in helping John to get his life back and that together we would make sure that everything was done methodically and safely to ensure the best results for John.

I started by compiling my own notes and breaking everything down for Tom one step at a time.

1. Because John has MM, he will be extremely prone to fracture. The most concerning Lyctic Lesions are in his Left hip. Tom must make sure that there is virtually no risk of John tripping, or falling during his sessions with Tom. He will need to work on core strength and balance, but must do so in the safest way possible.
2. Because he underwent chemotherapy he is still struggling with fatigue (compounded by the radiation) and will need to start with shorter workouts. He will begin with 20-30 min. 3-4 times per week at a very low intensity. Because his immune system is compromised, Tom will need to use antibacterial wipes on mats and equipment, have John bring his own water bottle and clean towel, and make sure that if he is feeling sick, he cancels the appointment so he does not take a chance of getting John sick. The long-term side-effects of chemotherapy include damage to the heart and lungs, diabetes, and osteoporosis, therefore, the exercise program must include both cardio and strength training to minimize or prevent those particular co-morbidities.
3. Because he has lymphedema in his Left leg, John will begin and end his exercise sessions with lower-extremity lymph drainage exercises and be encouraged to do them as often as possible. It would be a good idea to take baseline measurements of his legs to be able to monitor swelling and see if it gets better or worse with the prescribed exercise program.
4. John has occasional dizziness from the Prednisone. On days when he is struggling with dizziness, he should be advised to stay home, or simply come in to do gentle stretching and breathing exercises. The Prednisone causes difficulties sleeping which is adding to his fatigue and depression. Sometimes he has bone pain and headaches from the Aredia. 
5. Because of the upper-crossed syndrome and the squat test results, John needs to stretch both his pecs and lats while strengthening the scapular stabilizers to help correct round shoulder syndrome and the winged scapula. He should avoid pushing exercises like push-ups and chest press and focus on shoulder retraction/depression, rowing, and maybe reverse flys.  He should do shoulder protraction exercises like ceiling punches or wall push-ups for his winged scapula. Performing the lymph drainage exercises includes neck stretches that will help to open up lymphatic pathways as well as stretch the tight SCM and Levator muscles on his right side. 
6. Tom believes that John’s right hip elevation is caused by a tight Quadratus muscle. It is probably working overtime to stabilize his hip and spine. John will need to stretch his QL, TFL, and Gluteus Minimus on the left side and strengthen the Adductors and Gluteus Medius on the right side.
7. After Tom completed the Modified Thomas Test on John he was able to determine  that his anterior tilt was due in part to extremely tight hip flexors. Therefore, he would need to focus on hip extension and avoid hip flexion-type exercises.
8. Because both knees are laterally rotated, Tom will want to have John avoid exercises that will encourage hip abduction, and focus on exercises that will strengthen his hip adductors.
9. Because John only has 110 degrees ROM in shoulder abduction and 110 degrees in flexion (left side), John should not begin strength training exercises in either of those planes until he reaches 135 degrees in both flexion and abduction (they are both viewed separately). He can, however, do strength training exercises in the other planes if there is a logical reason to do so.
10. Balance exercises in a controlled environment are essential.