Physiotherapy in Multiple Myeloma: An Evidence-Based Guide to Safe Rehabilitation and Exercise
Introduction: When Exercise Becomes a Clinical Decision
Imagine a patient who has recently been diagnosed with multiple myeloma.
Before the diagnosis, she walked every morning, climbed stairs at home, went shopping, and managed most of her daily activities independently.
Now things have changed.
She feels exhausted after a short walk. Her back hurts. She is afraid that exercise might damage her bones. Her legs feel weaker than before, and treatment has left her feeling physically and emotionally drained.
Her family tells her:
"Don't exercise. You have cancer. You need complete rest."
The physiotherapist faces an important question:
Should this patient rest—or should she move?
The answer is more complicated than either "exercise" or "rest."
For a person with multiple myeloma, physical activity may be highly beneficial, but rehabilitation must be individualized according to bone involvement, fracture risk, blood counts, treatment stage, pain, neuropathy, fatigue, cardiovascular status, and overall medical condition.
This makes multiple myeloma one of the situations in which physiotherapy requires particularly careful clinical reasoning.
The goal is not simply to make the patient stronger.
The goal is to help the person move safely, preserve function, reduce inactivity-related decline, maintain independence, and participate in daily life while respecting the medical risks associated with the disease and its treatment.
A physiotherapy clinical practice guideline specifically developed for multiple myeloma recommends that physical therapists consider physiological markers such as hemoglobin and platelet counts together with the patient's overall presentation and stage of medical treatment.
More recent research continues to support exercise as feasible for many people with multiple myeloma, while emphasizing the need for individualized risk assessment and better standardized exercise protocols.
What Is Multiple Myeloma?
Multiple myeloma (MM) is a hematological malignancy involving abnormal plasma cells, a type of immune cell normally involved in antibody production.
These abnormal plasma cells accumulate in the bone marrow and can produce a range of systemic complications.
Clinically important problems can include:
bone lesions
bone pain
pathological fractures
anemia
fatigue
infections
renal complications
peripheral neuropathy
reduced physical capacity
muscle weakness
reduced mobility
deconditioning
Treatment can involve combinations of systemic therapies, corticosteroids, proteasome inhibitors, immunomodulatory drugs, monoclonal antibodies, chemotherapy, stem-cell transplantation, radiation, and supportive treatments.
The disease and its treatment therefore create a complex rehabilitation environment.
Why Is Physiotherapy Important in Multiple Myeloma?
Physiotherapy does not treat the malignant plasma cells themselves.
Instead, physiotherapy addresses the functional consequences of disease and treatment.
These may include:
weakness
fatigue
reduced endurance
reduced balance
gait problems
pain
deconditioning
reduced mobility
fear of movement
neuropathy
functional dependence
reduced participation
A patient may survive the cancer but experience substantial long-term functional limitations.
This is why rehabilitation is increasingly considered an important component of supportive cancer care.
The Major Physiotherapy Problem: The Patient May Need Exercise and Protection at the Same Time
This is one of the most important concepts.
In many patients, exercise is encouraged.
But multiple myeloma can involve bone destruction.
Therefore, the physiotherapist cannot simply prescribe a generic strengthening programme.
For example:
A conventional programme might include:
squats
lunges
loaded spinal exercises
jumping
resistance training
But these exercises may be inappropriate for a patient with unstable vertebral lesions or a high risk of fracture.
Therefore:
The question is not "Can this patient exercise?"
It is:
"What type, intensity, position, load, and duration of exercise are safe for this particular patient today?"
That is the foundation of myeloma rehabilitation.
Physiotherapy Goals in Multiple Myeloma
The goals should be individualized, but commonly include:
1. Maintain mobility
Prevent unnecessary loss of:
walking ability
transfers
joint movement
independence
2. Maintain or improve physical capacity
Address:
strength
aerobic capacity
endurance
balance
3. Manage fatigue
Help patients remain physically active without causing excessive exhaustion.
4. Manage pain
Use appropriate:
positioning
movement strategies
exercise
education
assistive devices
5. Reduce fall risk
Especially important in patients with:
neuropathy
weakness
balance impairment
bone fragility
6. Prevent complications of inactivity
Prolonged inactivity can contribute to:
muscle loss
reduced cardiovascular capacity
stiffness
constipation
reduced independence
worsening deconditioning
7. Support participation
The ultimate objective may be:
walking independently
returning home
performing self-care
returning to work
participating in family activities
maintaining social life
Initial Physiotherapy Assessment
A patient with multiple myeloma should not be treated using a routine musculoskeletal assessment alone.
The physiotherapist needs a broader assessment.
1. Medical History
Important information includes:
diagnosis and disease status
current treatment
previous treatments
stem-cell transplantation
chemotherapy
radiation therapy
medications
corticosteroid use
bone-targeted treatment
recent surgery
recent hospitalization
infections
comorbidities
The physiotherapist should communicate with the oncology/hematology team when relevant.
2. Bone Involvement
This is one of the most important considerations.
The therapist should determine whether the patient has:
lytic bone lesions
vertebral lesions
pathological fractures
previous fractures
spinal instability
severe focal bone pain
recent orthopedic intervention
Exercise selection should be modified accordingly.
A patient with significant skeletal involvement cannot automatically be placed into a standard resistance-training programme.
3. Pain Assessment
Pain should be assessed carefully.
Ask:
Where is the pain?
Is it new?
Has it changed recently?
Is it constant?
Is it mechanical?
Is it associated with movement?
Is it severe at rest?
Is there night pain?
Is there new neurological weakness?
New or unexplained severe pain may require medical assessment rather than simply being treated as routine musculoskeletal pain.
4. Neurological Assessment
Multiple myeloma and its treatment can be associated with neurological problems.
Assess:
sensation
proprioception
strength
reflexes where appropriate
balance
gait
coordination
neuropathic symptoms
Peripheral neuropathy can increase fall risk and affect exercise selection.
5. Hematological Parameters
This is particularly important in oncology rehabilitation.
The physiotherapist may need to review:
hemoglobin
platelet count
white blood cell count
neutrophil count
The clinical practice guideline specifically incorporates physiological markers, including hemoglobin and platelet count, into physical therapy decision-making for patients with multiple myeloma.
Why does this matter?
Low hemoglobin
Anemia can contribute to:
fatigue
breathlessness
reduced exercise tolerance
dizziness
tachycardia
Exercise intensity may therefore need to be reduced.
Low platelets
Thrombocytopenia increases bleeding risk.
This can influence:
exercise intensity
resistance training
fall-risk management
manual techniques
activities with injury potential
Low white-cell/neutrophil counts
These may increase infection risk.
The physiotherapist may need to consider:
infection-control procedures
exercise location
contact with other patients
equipment hygiene
current medical advice
Laboratory values should never be interpreted in isolation.
The patient's medical team and the specific clinical context matter.
6. Cardiovascular Assessment
Assess:
resting heart rate
blood pressure
oxygen saturation when indicated
symptoms
exercise tolerance
cardiovascular history
Some patients may have cardiovascular complications or treatment-related limitations.
A recent review emphasizes that multiple myeloma rehabilitation may need to account for complications such as cardiac amyloidosis, peripheral neuropathy, cytopenias, and unstable bone lesions.
7. Fatigue Assessment
Cancer-related fatigue is different from ordinary tiredness.
It may not disappear simply because the patient rests.
Ask:
How long does fatigue last?
What activities trigger it?
Is fatigue worse after treatment?
Does it interfere with walking?
Does it affect sleep?
Does it affect self-care?
A fatigue diary or patient-reported outcome measure can sometimes help monitor changes.
8. Functional Assessment
Assess meaningful activities such as:
bed mobility
sit-to-stand
transfers
walking
stair climbing
balance
endurance
activities of daily living
Depending on the patient, standardized tests may include:
Timed Up and Go
6-Minute Walk Test
2-Minute Walk Test
5 Times Sit-to-Stand
gait-speed assessment
balance tests
However, testing should be modified or avoided when it creates unnecessary risk.
Bone Lesions: The Most Important Safety Issue
Multiple myeloma frequently affects bone.
The disease can cause osteolytic lesions and weaken the skeleton.
Commonly affected regions include:
spine
pelvis
ribs
skull
long bones
This creates a major physiotherapy concern:
Mechanical loading must be matched to skeletal stability.
What Does a Bone Lesion Mean for Exercise?
A bone lesion does not automatically mean:
"No exercise."
Instead, it means:
"Exercise must be appropriately modified."
The therapist needs to understand:
lesion location
lesion size and characteristics when known
fracture history
pain
spinal stability
current treatment
medical/orthopedic recommendations
When fracture risk is significant, high-impact activities and inappropriate loading may need to be avoided.
The International Myeloma Foundation currently advises medical discussion before exercise in people with active bone lesions, recent fractures, severe anemia, severe fatigue, uncontrolled pain, recent surgery, balance problems, or significant neuropathy.
Exercise Selection in Multiple Myeloma
Exercise is generally individualized into several categories.
1. Aerobic Exercise
Potential options include:
walking
stationary cycling
recumbent cycling
low-impact aerobic exercise
aquatic exercise when medically appropriate
The choice depends heavily on:
bone status
balance
fatigue
neuropathy
cardiovascular capacity
2. Resistance Exercise
Resistance training may help preserve or improve:
muscle strength
functional capacity
independence
But resistance should be carefully selected.
Possible options include:
resistance bands
light weights
controlled functional strengthening
seated resistance exercises
machine-based exercise where appropriate
The programme should avoid excessive loading of vulnerable skeletal regions.
3. Balance Training
Important particularly for patients with:
peripheral neuropathy
weakness
deconditioning
previous falls
Training may include:
supported standing
weight shifting
controlled stepping
gait training
functional reaching
Safety and environmental support are essential.
4. Flexibility and Mobility
Gentle mobility may help maintain:
joint movement
functional range
comfort
independence
But aggressive stretching or loading across unstable or painful skeletal lesions should be avoided.
5. Functional Training
Functional rehabilitation is particularly valuable.
Examples:
sit-to-stand
bed mobility
transfers
walking
stair training
dressing-related movements
bathroom mobility
The therapist should connect exercise to the patient's actual goals.
Exercise Prescription: The FITT Principle
Exercise can be structured using:
F — Frequency
How often?
I — Intensity
How hard?
T — Time
How long?
T — Type
What activity?
The International Myeloma Foundation also recommends considering FITT when developing activity plans while first assessing individual safety.
However, FITT should not be treated as a rigid formula in multiple myeloma.
The prescription must change according to:
treatment cycle
blood counts
fatigue
pain
bone involvement
infection
neuropathy
cardiovascular status
Treatment Phases Matter
A patient with newly diagnosed multiple myeloma may have different rehabilitation needs from someone in long-term remission.
Similarly, a patient receiving intensive treatment may have very different exercise tolerance from a stable outpatient.
Therefore, rehabilitation should be dynamic.
During Active Treatment
The priority may be:
maintaining mobility
preventing severe deconditioning
managing fatigue
preserving independence
safe transfers
gentle aerobic activity
carefully selected strengthening
The goal may not be to maximize fitness.
It may simply be:
Keep the patient moving safely through treatment.
During Stem-Cell Transplantation
Patients may experience substantial:
fatigue
weakness
reduced endurance
treatment-related symptoms
hospitalization-related deconditioning
Physiotherapy may focus on:
bed mobility
transfers
walking
breathing exercises where indicated
low-intensity activity
maintaining independence
Exercise intensity may need frequent adjustment.
After Treatment / Survivorship
As medical stability improves, rehabilitation may gradually focus on:
strength
aerobic capacity
balance
return to work
community mobility
recreational activity
long-term physical activity
The objective shifts from simply preventing decline toward rebuilding capacity.
Physiotherapy for Cancer-Related Fatigue
Fatigue is one of the most important symptoms in cancer rehabilitation.
It can create a vicious cycle:
Fatigue → less activity → deconditioning → greater effort required for activity → more fatigue
Appropriately prescribed activity can help break this cycle.
But the solution is not:
"Exercise harder."
It may instead involve:
short activity periods
frequent movement
pacing
rest intervals
gradual progression
energy conservation
individualized aerobic exercise
resistance training where safe
The 2025 scoping review found that exercise programmes studied in multiple myeloma commonly included aerobic exercise, resistance training, and Nordic walking, often around 3–5 sessions per week for 30–60 minutes, although protocols varied substantially and evidence quality was limited.
These research frequencies should not be interpreted as a universal prescription for every patient.
Physiotherapy and Peripheral Neuropathy
Peripheral neuropathy may occur because of the disease or its treatment.
Symptoms may include:
numbness
tingling
burning
altered sensation
weakness
impaired balance
This can create a major fall risk.
Physiotherapy may address:
balance
gait
lower-limb strengthening
footwear
walking aids
home safety
sensory compensation strategies
Patients with significant sensory loss may require additional environmental precautions.
Fall Prevention
Fall prevention is particularly important because falls can have more serious consequences when bones are fragile.
A fall-prevention programme may include:
Strength
Improve lower-limb capacity where safe.
Balance
Improve postural control.
Gait
Optimize walking pattern and assistive devices.
Environment
Remove:
loose rugs
clutter
poor lighting
unnecessary obstacles
Footwear
Use stable, appropriate footwear.
Assistive devices
Use canes, walkers, or other aids when indicated.
Respiratory Physiotherapy
Respiratory rehabilitation is not required for every patient with multiple myeloma.
However, selected patients may develop:
reduced activity tolerance
respiratory weakness
postoperative respiratory complications
prolonged hospitalization-related deconditioning
Respiratory assessment and treatment should therefore be based on the patient's actual presentation.
Physiotherapy After Orthopedic Surgery or Fracture
Some patients with myeloma may require orthopedic management because of:
pathological fractures
spinal instability
vertebral compression
impending fracture risk
After surgical stabilization or fracture management, physiotherapy may become essential for:
safe mobility
transfers
gait
strengthening
assistive devices
functional independence
The rehabilitation programme must respect the surgeon's restrictions and the stability of the repair.
What Physiotherapy Should Avoid?
There is no single list that applies to every patient.
However, caution is particularly important with:
high-impact exercise
jumping
running in high-risk skeletal disease
heavy spinal loading
aggressive manual techniques over affected bones
excessive resistance
exercises that reproduce significant bone pain
activities with substantial fall risk
unsupervised exercise in medically unstable patients
The specific restriction depends on the individual's skeletal and medical status.
Contraindications and Precautions
Rather than using a simplistic "contraindicated for everyone" list, it is more clinically useful to distinguish situations requiring medical review, modification, or temporary withholding of exercise.
Major Concerns
Active or unstable bone lesions
Particularly when fracture risk is significant.
Recent fracture
Exercise must follow medical/orthopedic guidance.
Severe uncontrolled pain
Especially new focal bone or spinal pain.
Severe anemia
Exercise tolerance may be substantially reduced.
Significant thrombocytopenia
Bleeding risk must be considered.
Significant neutropenia or active infection
Exercise environment and intensity may require modification.
Recent surgery
Follow surgical precautions.
Significant peripheral neuropathy
Fall and injury risk may increase.
Severe fatigue
The programme may need to be reduced or modified.
Cardiovascular instability
Medical assessment may be necessary before exercise.
New neurological symptoms
For example:
new weakness
new sensory loss
changes in bladder/bowel function
severe new spinal symptoms
These require urgent medical evaluation rather than routine exercise progression.
Red Flags for the Physiotherapist
A physiotherapist should be particularly cautious when a patient develops:
sudden severe bone pain
new severe back pain
sudden inability to bear weight
suspected fracture
new neurological deficit
rapidly worsening weakness
new bladder or bowel dysfunction
severe dizziness
chest pain
unexplained severe breathlessness
fever or signs of infection
unusual bleeding
These findings may require immediate medical assessment.
Manual Therapy in Multiple Myeloma
Manual therapy requires careful clinical judgment.
Direct, aggressive techniques over:
known lytic lesions
unstable vertebrae
fracture sites
painful skeletal regions
may be inappropriate.
The presence of cancer does not automatically mean that every form of hands-on treatment is forbidden.
But the therapist must understand:
disease distribution
tissue status
fracture risk
platelet count
pain
medical treatment
When in doubt, coordinate with the oncology team.
Can a Patient With Multiple Myeloma Lift Weights?
Potentially, yes.
But the answer depends on the patient.
Resistance training may be useful for maintaining muscle strength and physical function.
However:
Heavy lifting is not automatically safe simply because the patient feels capable of doing it.
The therapist must consider:
bone lesions
fracture risk
pain
spinal involvement
blood counts
previous fractures
technique
treatment phase
A controlled resistance programme may be appropriate while maximal or high-risk loading is not.
Can Patients Walk?
In many cases, yes.
Walking is often a practical form of physical activity.
But walking prescription depends on:
skeletal stability
pain
balance
neuropathy
endurance
assistive-device needs
For some patients, walking may begin with only a few minutes at a time.
For others, longer walking may be appropriate.
The principle is:
Start from the patient's current capacity and progress safely.
Can Patients Swim?
Aquatic exercise may be useful because water can reduce mechanical loading.
However, it is not automatically appropriate.
Consider:
infection risk
skin integrity
wounds
catheter/line considerations
fatigue
balance
medical clearance
pool accessibility
The specific clinical situation determines whether aquatic therapy is appropriate.
Physiotherapy During Chemotherapy
Treatment cycles can cause fluctuating symptoms.
A patient may tolerate exercise well one week and poorly the next.
Therefore:
The exercise programme should not be fixed permanently.
The therapist should reassess:
fatigue
pain
blood counts
dizziness
neuropathy
infection
treatment effects
and adjust accordingly.
Physiotherapy During Corticosteroid Treatment
Corticosteroids can contribute to:
muscle weakness
changes in glucose metabolism
osteoporosis
fatigue
altered body composition
This makes carefully selected strengthening and functional activity potentially important, while skeletal risks still need consideration.
The Role of Patient Education
Education is a major part of physiotherapy.
Patients should understand:
why movement matters
how to exercise safely
when to stop
how to pace activity
how to prevent falls
how to use assistive devices
why pain should not simply be ignored
when to contact the medical team
Education can also reduce fear.
A patient who understands:
"I don't need to avoid all movement; I need to move safely"
may be more confident participating in rehabilitation.
A Sample Physiotherapy Session
The exact session must be individualized, but a stable patient might have a structure such as:
1. Pre-session check
Assess:
symptoms
fatigue
pain
dizziness
recent medical events
treatment status
2. Gentle warm-up
Examples:
breathing
gentle active movement
low-intensity mobility
3. Aerobic activity
Potentially:
walking
stationary cycling
at a tolerable intensity.
4. Strengthening
Selected exercises targeting:
lower limbs
upper limbs
trunk
while respecting skeletal restrictions.
5. Balance
Supported balance activities where appropriate.
6. Functional training
For example:
sit-to-stand
transfers
gait
7. Cool-down
Gentle movement and recovery.
8. Education
Review:
home programme
fatigue management
fall prevention
warning signs
Home Exercise Programme
A home programme should be:
simple
safe
realistic
individualized
progressive when appropriate
For example:
Daily movement
Short walks or movement sessions as tolerated.
Strength
Selected low-load exercises.
Mobility
Gentle range-of-motion exercises where appropriate.
Balance
Only when safe and with adequate support.
Functional practice
Sit-to-stand or walking practice when clinically appropriate.
The programme should be modified around treatment cycles and changing symptoms.
Research Evidence: What Do We Actually Know?
This is where the subject becomes particularly interesting.
The evidence is increasingly supportive of physical activity in multiple myeloma, but it is not strong enough to justify a single universal exercise prescription.
Evidence 1: Physiotherapy Clinical Practice Guideline
A dedicated clinical practice guideline for mobilization and exercise in multiple myeloma was developed through systematic review and expert/patient consensus.
The guideline identified 30 action statements and specifically incorporated:
hemoglobin
platelet count
patient presentation
treatment stage
into physiotherapy decision-making.
It was endorsed by the Canadian Physiotherapy Association.
Clinical meaning
This is important because it confirms that rehabilitation should be based on medical and physiological status, not merely on the diagnosis of multiple myeloma.
Evidence 2: 2022 Systematic Review
A systematic review evaluated the safety, feasibility, and efficacy of exercise interventions in people with multiple myeloma.
Seven studies involving 563 participants were included.
The review found that exercise interventions appeared safe and well attended, with no serious adverse events attributed to exercise testing or training across the included studies.
However, the evidence for improvements in fatigue, anxiety, depression, body composition, quality of life, and sleep was inconsistent.
Some studies showed improvements in:
lower-limb strength
peak oxygen uptake
physical activity
but the overall evidence remained limited.
Important lesson
Safety and feasibility are better established than the magnitude of clinical benefit.
Evidence 3: 2025 Scoping Review
A 2025 scoping review identified 17 studies, including:
10 randomized controlled trials
4 single-arm studies
1 retrospective cohort
2 quasi-experimental studies
Exercise interventions included:
aerobic exercise
resistance training
Nordic walking
The studies commonly used exercise around 3–5 times per week for 30–60 minutes, but protocols varied substantially.
The review reported potential improvements in:
fatigue
functional capacity
quality of life
psychological well-being
while emphasizing inconsistencies in intervention design and limitations in evidence quality.
Evidence 4: 2026 Systematic Review and Meta-Analysis
A particularly important recent study was published in 2026.
The review included:
20 studies
1,032 participants in qualitative synthesis
9 studies
576 participants in quantitative synthesis
Exercise interventions lasted an average of approximately 14.4 weeks and were performed around 3.3 times per week, with combined aerobic and resistance training commonly used.
The pooled results showed generally small and statistically non-significant effects across outcomes including:
aerobic capacity
quality of life
fatigue
upper-limb strength
lower-limb strength
pain
The authors concluded that exercise appears feasible, but the true magnitude of benefit remains uncertain because of limited studies, small samples, and methodological heterogeneity.
What Does This Mean for Clinical Practice?
This is an important distinction.
The evidence does not mean:
"Exercise doesn't work."
Nor does it mean:
"Exercise definitely produces large improvements in every patient."
A more accurate interpretation is:
Exercise appears feasible and generally tolerable for appropriately selected patients with multiple myeloma, but the size and consistency of clinical benefits remain uncertain, and exercise prescription must be individualized.
That is a much more evidence-based conclusion.
Why Is the Evidence Difficult to Interpret?
Multiple myeloma is a complex disease.
Studies may differ in:
disease stage
treatment
bone involvement
age
baseline fitness
exercise type
exercise intensity
supervision
duration
outcome measures
A patient with stable disease and no major skeletal limitations is not equivalent to a patient with multiple painful vertebral lesions undergoing intensive treatment.
Therefore, "exercise for multiple myeloma" is not one intervention.
It is a large family of different interventions applied to different patients.
Evidence-Based Practice Analysis
What appears reasonably supported?
Maintaining physical activity
Avoiding unnecessary inactivity is generally important.
Aerobic exercise
Appropriately selected aerobic exercise can be feasible.
Resistance training
Controlled resistance exercise can be incorporated in suitable patients.
Functional training
Walking, transfers, balance, and independence are important rehabilitation targets.
Individualization
This is perhaps the strongest practical principle.
What Remains Uncertain?
The optimal:
intensity
frequency
duration
resistance
progression
timing relative to treatment
has not been firmly established for all patients.
The 2026 meta-analysis specifically highlighted limited evidence and substantial methodological variation.
The Most Important Clinical Principle
The physiotherapist should not ask:
"What is the standard multiple myeloma exercise programme?"
Instead ask:
1. What can this patient safely do?
2. What does this patient need to do?
3. What does the patient want to be able to do?
4. What medical restrictions exist?
5. How can exercise be progressed safely?
This creates individualized rehabilitation.
Common Myths
Myth 1: "Cancer patients should stay in bed."
Not necessarily.
Unnecessary inactivity can contribute to deconditioning and loss of function.
Myth 2: "Exercise will spread the cancer."
Exercise is not considered a treatment that causes multiple myeloma to spread.
The concern is primarily safety and disease-related complications, particularly skeletal and systemic risks.
Myth 3: "If the patient has bone lesions, exercise is completely forbidden."
Not necessarily.
Exercise may still be possible, but the programme may require substantial modification and medical coordination.
Myth 4: "More exercise is always better."
No.
Overtraining may worsen fatigue or increase risk.
The appropriate dose depends on the patient.
Myth 5: "Pain should always be pushed through."
Definitely not.
New or significant focal bone pain can represent an important warning sign.
Myth 6: "Physiotherapy is only needed after treatment."
No.
Rehabilitation may be relevant:
during active treatment
during hospitalization
around transplantation
after treatment
during survivorship
during palliative stages when the goal is comfort and function
Physiotherapy in Advanced or Palliative Multiple Myeloma
Physiotherapy remains relevant even when cure is not the goal.
The priorities may change toward:
comfort
safe mobility
positioning
breathing comfort
transfers
maintaining independence
caregiver education
energy conservation
reducing unnecessary suffering
The rehabilitation goal may become:
Help the person do what matters most to them with the least possible burden.
That is still meaningful physiotherapy.
Communication With the Oncology Team
Good myeloma rehabilitation is rarely isolated.
The physiotherapist may communicate with:
hematologist
oncologist
rehabilitation physician
orthopedic surgeon
nurse
occupational therapist
dietitian
psychologist
prosthetist/orthotist
palliative-care team
Important information to clarify may include:
skeletal lesions
fracture risk
activity restrictions
blood counts
treatment phase
surgery
neurological concerns
weight-bearing status
A Practical Physiotherapy Decision-Making Framework
Before prescribing exercise, think:
STEP 1 — MEDICAL STABILITY
Is the patient medically stable enough for activity?
STEP 2 — SKELETAL SAFETY
Are there lesions, fractures, or spinal concerns?
STEP 3 — BLOOD COUNTS
Are anemia, thrombocytopenia, or neutropenia relevant?
STEP 4 — SYMPTOMS
What are the current levels of:
pain
fatigue
neuropathy
dizziness
breathlessness?
STEP 5 — FUNCTION
What can the patient currently do?
STEP 6 — GOALS
What does the patient want to accomplish?
STEP 7 — PRESCRIPTION
Choose:
type
intensity
duration
frequency
STEP 8 — MONITOR
Observe response during and after exercise.
STEP 9 — PROGRESS OR MODIFY
Progress only when clinically appropriate.
Example of Clinical Reasoning
Imagine two patients with the same diagnosis.
Patient A
stable disease
no unstable bone lesions
mild fatigue
good balance
independent walking
adequate blood counts
This patient may potentially participate in a structured aerobic and resistance programme with gradual progression.
Patient B
painful vertebral lesions
recent fracture
severe fatigue
significant neuropathy
thrombocytopenia
difficulty walking
This patient requires a very different rehabilitation approach.
The diagnosis is identical.
The rehabilitation prescription is not.
This is why patient-specific assessment is essential.
Benefits of Physiotherapy in Multiple Myeloma
Potential goals and benefits include:
maintaining mobility
preserving strength
reducing deconditioning
improving physical capacity
supporting independence
improving balance
reducing fall risk
supporting daily activities
improving confidence with movement
helping manage fatigue
supporting quality of life
However, the magnitude of these effects varies between individuals, and current research does not establish large, consistent benefits across every outcome.
Limitations of Physiotherapy
Physiotherapy cannot:
eliminate myeloma
replace anticancer treatment
repair every skeletal lesion
eliminate treatment-related fatigue in every patient
guarantee prevention of fractures
Its role is supportive and rehabilitative.
The physiotherapist works alongside, rather than instead of, hematological and oncological treatment.
Patient Education: What Should We Tell Patients?
A simple message is:
"Movement is usually important, but the right movement depends on your bones, blood counts, treatment, symptoms, and overall health."
Patients should know that they should contact their medical team when they develop concerning symptoms rather than simply pushing through them.
They should also understand that rehabilitation can change from week to week.
A programme that was appropriate last month may need modification today.
Evidence-Based Takeaway
Physiotherapy has an important role in the multidisciplinary management of people with multiple myeloma.
The strongest practical principles are:
Assess before prescribing exercise.
Consider bone lesions and fracture risk.
Review relevant blood counts and medical status.
Consider neuropathy and fall risk.
Monitor pain and fatigue.
Use individualized aerobic, resistance, balance, mobility, and functional training when appropriate.
Coordinate with the oncology/hematology team.
Progress gradually rather than automatically.
Avoid unnecessary inactivity while respecting medical restrictions.
Make rehabilitation goals meaningful to the patient's life.
Current research supports the feasibility of exercise for many appropriately selected patients, but the evidence for large and consistent improvements remains uncertain. The 2026 systematic review and meta-analysis found generally small, non-significant pooled effects across several major outcomes, while earlier reviews and guidelines support individualized, monitored exercise and rehabilitation.
Conclusion
Multiple myeloma creates a unique rehabilitation challenge.
The patient may need to move—but may also have fragile bones.
They may need strengthening—but may have severe fatigue.
They may need walking practice—but may have neuropathy.
They may benefit from exercise—but their blood counts or treatment status may require modification.
This is why physiotherapy in multiple myeloma cannot be based on a generic exercise sheet.
It requires assessment, communication, clinical reasoning, monitoring, and individualized progression.
The physiotherapist's role is not to tell every patient:
"Exercise more."
It is to determine:
"What movement is safe, meaningful, and appropriate for this person today—and how can we help them maintain as much independence and quality of life as possible?"
That is the heart of evidence-based physiotherapy in multiple myeloma.
Selected References
Mobilization and Exercise Intervention for Patients With Multiple Myeloma: Clinical Practice Guidelines Endorsed by the Canadian Physiotherapy Association. Physical Therapy. PMID: 32975563.
Safety, Feasibility, and Efficacy of Exercise Interventions for People With Multiple Myeloma: A Systematic Review. PMID: 36450625.
Exercise interventions in patients with multiple myeloma: a scoping review. BMC Sports Science, Medicine and Rehabilitation. 2025. PMID: 40490782.
Efficacy of exercise interventions in multiple myeloma: a systematic review and meta-analysis. Journal of Cancer Survivorship. 2026. PMID: 42337137.
Risk Stratification Strategies and Implementation of Exercise Training in Patients with Multiple Myeloma. Current Oncology Reports. 2025. PMID: 41182654.
Treatment of Multiple Myeloma: ASCO Living Guideline, Version 2026.1.1. Journal of Clinical Oncology. 2026. PMID: 42160714.
Multiple Myeloma: EHA-ESMO Clinical Practice Guidelines for Diagnosis, Treatment and Follow-up. HemaSphere. PMID: 33554050.
NCCN Guidelines Insights: Multiple Myeloma, Version 1.2025. Journal of the National Comprehensive Cancer Network. PMID: 40340857.
International Myeloma Foundation. Physical activity and exercise guidance for people with multiple myeloma. Updated 2026.
