What are safe hemoglobin, neutrophil and platelet counts for people with hematological malignancies to participate in exercise and activities of daily living: a scoping review.

Background

There is emerging evidence that exercise in cancer care and during cancer treatment is safe, feasible and provides many health benefits to patients [ 1 ]. In people with hematological malignancies and undergoing stem cell transplantation, exercise has been shown to improve hemoglobin concentration, duration of neutropenia and thrombocytopenia, severity of diarrhoea, pain, length of stay in hospital and quality of life [ 2 ]. The Clinical Oncology Society of Australia (COSA) guidelines advise that all people who have a cancer diagnosis should, if appropriate, complete 150 min/week of moderate-intensity physical activity, with 2 to 3 days/week of resistance training [ 3 ].

The use of the terminology “if appropriate” in the COSA guidelines is a key term and needs to be considered in people with hematological malignancies. This cohort often has abnormal hemoglobin, platelet and neutrophil counts at either diagnosis or during their treatment, due to the nature of hematological cancers affecting patients bone marrow. A low hemoglobin count (i.e. anaemia) is associated with increased fatigue and breathlessness. A low platelet count (i.e. thrombocytopenia) is associated with increased risk of spontaneous bleeding, either externally or as a haematoma. A low neutrophil count (i.e. neutropenia) is associated with increased risk of infection. These symptoms of abnormal blood cell count in people living with hematological malignancies can increase the risk of adverse events and impact their ability to complete activities of daily living (ADLs) and exercise.

It is routine practice for allied health professionals, such as physiotherapists, occupational therapists and exercise physiologists, to prescribe exercises and make recommendations around safe daily functioning. They must carefully balance the risks of engaging in physical activity whilst experiencing low blood counts, against the complications of prolonged bed rest and inactivity including deconditioning, thromboembolic events, pressure injury, fatigue, contracture and risk of pulmonary complications [ 4 ]. It is known that during cancer treatment, the performance and independence with ADLs are negatively affected due to symptoms such as fatigue, muscle weakness and reduced sleep [ 5 ]. In practice, hematological parameters based on the risk of anaemia-related fatigue, serious hemorrhage (thrombocytopenia) or infection (neutropenia) are used to guide therapists in the provision of exercise and ADLs adaptation [ 6 ].

Evidence to support the use of specific blood count parameters for participation in exercise and ADLs in people living with hematological malignancies is limited and has not been thoroughly reviewed. To our knowledge, a systematic or scoping review investigating safe levels of hemoglobin, platelet and neutrophil count for people living with hematological cancers to participate in exercise and ADLs has yet to be published. Such work would be beneficial to provide further clinical reasoning and guidance for therapists working with this cohort. Therefore, the aim of this scoping review was to summarize the extent of the literature in relation to safe levels of platelet, hemoglobin and neutrophil count for people with hematological cancers to participate in exercise or ADLs.

Methods

Protocol and registration

The protocol was prospectively registered in the Open Science Framework (OSF) on the 17 th of December 2021 (OSF registration https://doi.org/10.17605/OSF.IO/9EN2S). The manuscript has been reported according to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) [ 7 ].

Inclusion and exclusion criteria

Original studies, reviews and expert opinion papers were included if they (i) focused on people with active hematological cancer diagnoses (such as lymphoma, leukaemia or myeloma) or those undergoing treatment affecting bone marrow (such as chemotherapy and bone marrow transplantation), and (ii) referenced safe levels of platelet, hemoglobin and neutrophil count for people with hematological cancers to participate in exercise or ADLs. To summarize the most up to date evidence, we included articles published during or after the year 2000.

Articles referencing non-cancerous haematologic disorders (such as haemophilia) were excluded. Studies that used blood count parameters as part of their inclusion criteria, but did not monitor blood counts during their intervention, or provide recommendations for parameters, were also excluded as they did not address the link between blood cell counts and safety in exercises or ADLs. Conference abstracts, protocol papers and articles not available in English were also excluded.

Search strategy

A comprehensive search was completed in July 2024 across five databases: the Cochrane Library, Embase, PEDro, PubMed and OTSeeker. The PubMed search strategy (online resource; Table S 1 ) was developed by three review authors (JLH, KPB and VC). Keywords and MeSH terms related to hematological malignancy and physical activity/exercise were used in the search strategy, which was adapted according to the database. Hand search was also conducted by reviewing reference lists of included studies.

All articles identified in the search were uploaded onto EndNote X9. Duplicate articles were removed using EndNote and subsequently the EndNote database was uploaded into Research Screener [ 8 ], a machine learning Web application used to semi-automate article screening. Two of the authors (JLH and KPB) independently reviewed titles and abstracts through Research Screener, and any disagreement was resolved by either verbal discussion or via consulting a third review author (VC or PMG). Full-text screening was also conducted independently by the review authors (JLH and KPB) and a final database of included articles to be reviewed was achieved. Disagreement was resolved by either verbal discussion or via consulting a third review author (VC or PMG).

Data extraction/items

Data extraction was completed for each included study using a standardized extraction form. Data were collected on characteristics of the paper (i.e. year published, author name, country paper type/study design, sample size), characteristics of participants (i.e. age and hematological cancer diagnoses), blood cells (types of cells, cut-off for safe levels and whether physical activity was modified or contraindicated when below the cut-off level), details of intervention(s) (if any) and results (including adverse events). Other relevant information or clinical reasoning (in relation to safe exercise or ADL engagement) was also included. Two review authors (JLH and KPB) extracted data independently and consultation occurred to ensure there was agreement on the data extracted.

Synthesis of findings

A narrative summary of the characteristics of the included articles as well as their reported safe levels of platelet, hemoglobin and neutrophil count for people with hematological cancers to participate in exercise or ADLs is presented. The units of measure for hemoglobin, platelet and neutrophil count have been standardized across all the studies to allow for easier comparison of results.

Results

A total of 3113 papers were identified via database search with an additional study identified via hand search. After screening and exclusion using the pre-determined criteria, 47 papers were included in the review (Fig. 1 ). One of the papers [ 10 ] did not provide the unit of measure for blood cell count. As the authors did not reply to several contact attempts, the paper was not included in the narrative synthesis of the current review. Fig. 1 PRISMA flow diagram [ 9 ]

Characteristics of included papers

The characteristics of the 47 included papers are presented in Table 1 . Thirty-four were prospective studies, four were retrospective studies, five were reviews and four were expert opinion papers. The number of papers that referenced each type of blood count are as follows: (i) platelet count = 44 (94%) [ 4 , 5 , 11 – 17 , 19 – 21 , 23 – 54 ]; (ii) hemoglobin count = 36 (77%) [ 2 , 11 – 17 , 19 , 20 , 22 – 24 , 26 , 27 , 29 , 30 , 32 , 33 , 35 – 40 , 43 – 47 , 49 – 54 ]; and (iii) neutrophil count = 17 papers (36%) [ 13 – 15 , 18 , 19 , 26 , 32 , 33 , 36 , 40 , 43 – 45 , 49 , 50 , 52 , 53 ]. Two of the papers reviewed had the same authors and utilized the same parameters [ 14 , 15 ]; however, both were included as they tested these parameters on different participants. Table 1 Characteristics of the included papers ( n = 47), cut-off values used for blood cells and adverse events reported Author, year and study design Sample size and characteristics Blood cells cut-off values used for exercise or ADLs Platelet count (×10 9 /L) Hemoglobin count (g/L) Neutrophil count (×10 9 /L) Adverse events Alibhai et al. 2012 [ 11 ] Non-randomized pilot trial N = 35 (two groups; < 60 years, N = 18; > 60 years, N = 17) Age: < 60 years group: 47 ± 10 > 60 years group: 67 ± 6 Patient cohort: acute myeloid leukaemia Platelet < 10: exercised post transfusion 10–20: use of resistance tubing rather than dumbbells to avoid risk of bruising and bleeding Hemoglobin: < 80: discuss with patient and nurse regarding contraindications to exercise (e.g. light-headedness). If so, exercise post transfusion One possible grade II musculoskeletal event in 600 patient days Bartels et al. 2015 [ 12 ] Longitudinal single arm intervention study N = 25 at discharge, 22 at 8/52 post discharge Age: 56 ± 13 years (23–70) Patient cohort: multiple myeloma, lymphoma, amyloidosis Platelet: < 15: contraindication for physical testing and participation in the training program Hemoglobin: < 80: contraindication for physical testing One patient had a hematoma in groin from aerobic training, two with muscle soreness. None discontinued the exercise program due to this. Battaglini et al. 2009 [ 13 ] Single arm intervention study N = 10 Age: 36 ± 9 years (18–55) Patient cohort: acute myeloid leukaemia Platelet: < 20: exercise cancelled Hemoglobin: no parameters Neutrophil: nil parameters. However, if febrile, contraindicated activity Nil adverse events reported in paper Baumann et al. 2010 [ 14 ] Randomized controlled, pilot trial N = 64 (EG = 32; CG = 32) Age: EG: 45 ± 12 years CG: 44 ± 14 years Patient cohort: multiple myeloma, lymphoma, leukaemia Platelet: <10: contraindication with acute bleeding, thrombocytes 10–20: depending on individual inclination to bleeding Hemoglobin: <80: contraindication Neutrophil: nil number to contraindicate. However, fever and severe infection contraindications Nil adverse events during exercise intervention. 15 deceased; 14 transplant related mortality and 1 disease progression Baumann et al. 2011 [ 15 ] Randomized controlled trial N = 33 (EG = 17; CG = 16) Age: EG: 41 ± 12 years CG: 43 ± 14 years Patient cohort: multiple myeloma, chronic myelomonocytic leukaemia, myelodysplastic syndromes, myeloproliferative syndromes, chronic myelogenous leukaemia, chronic lymphocytic leukaemia, acute lymphocytic leukaemia, acute myeloid leukaemia Platelet: Exercise therapy interrupted or not performed <10: with acute bleeding, thrombocytes 10–20: depending on individual inclination to bleeding Hemoglobin: < 80: contraindication Neutrophil: nil number to contraindicate. Contraindication with fever and severe infection Nil adverse events with exercise 7 deceased during admission Bühl et al. 2019 [ 16 ] Case report N = 1 Age = 22 years Diagnosis: acute lymphocytic leukaemia A relaxation technique named autogenic training was carried out instead of cycling if: Platelet: < 10 Hemoglobin: < 70 No serious adverse events occurred, even when exercising immediately after infusion of chemotherapy Camacho Pérez et al. 2023 [ 17 ] Clinical program evaluation N = 45, 31 at discharge from hospital and 9 at 100 days post Age: 56 ± 13 years Patient cohort: Acute myeloid leukaemia, myelodysplastic syndromes, acute lymphocytic leukaemia, chronic myelogenous leukaemia, myelofibrosis, B-cell lymphoma, mast cell leukaemia, chronic lymphocytic leukaemia Platelet: < 10: cancelled testing and assessments < 15: participants were not offered participation in classes Hemoglobin: < 70: participants were not offered participation in classes, testing and assessments were cancelled at this level No adverse events were reported, two participants returned to their room early due to fatigue Chamorro-Viña et al. 2010 [ 18 ] Controlled trial using historical control group N = 20 (EG = 7; CG = 13) Age: EG: 8 ± 4 years (5–16) CG: 7 ± 3 years (4–16) Patient cohort: acute myeloid leukaemia, B-cell acute lymphocytic leukaemia, T cell acute lymphocytic leukaemia, neuroblastoma, Rhabdomyosarcoma Neutrophil: No cut-off value for neutrophils, all training completed in neutropenic phase (< 0.5 × 10 9 L) Precautions during neutropenic phase included: No group training Individual supervised exercise Train equipment sterilized before session; instructor wore face mask during session No major adverse event or health problem induced by exercise during or after the training sessions Cox et al. 2021 [ 19 ] Non-randomized longitudinal control trial N = 30 (EG = 16; CG = 14) Age: EG: 65 years (34–77) CG: 63 years (29–80) Patient cohort: Hodgkin's lymphoma, non-Hodgkin's lymphoma Exercise sessions suspended if Platelet: < 50 Hemoglobin: < 100 EG: Lumbar compression fracture in two female participants, third patient underwent intervention for existing inguinal hernia. CG: Lumbar fracture and two patients admitted to hospital for sepsis and pneumonia. All 3 fractures had osteoporosis history de Almeida et al. 2019 [ 20 ] Randomized, controlled, feasibility trial N = 31 (EG = 15; CG = 16) Age: EG: 44 ± 15 years (35–52) CG: 47 ± 13 years (40–54) Patient cohort: multiple myeloma, Hodgkin's lymphoma, non-Hodgkin's lymphoma, acute myeloid leukaemia, aplastic anaemia, renal amyloidosis Platelet: > 20: stretching, strengthening, coordination, balance exercises, aerobic exercise with resistive load, IMT 10–20: stretching, strengthening, coordination, balance exercises, aerobic exercise with resistive load, breathing exercises. < 10: breathing exercises and encouragement of activities of daily living Hemoglobin: < 70: breathing exercises and encouragement of activities of daily living Two adverse events, nausea and oxygen desaturation during inspiratory muscle training. Dimeo et al. 2003 [ 21 ] Single arm intervention study N = 66 Age: 48 ± 15 years (20–73) Patient cohort: acute myeloid leukaemia, acute lymphocytic leukaemia, chronic myelogenous leukaemia, chronic lymphocytic leukaemia, Hodgkin's lymphoma, multiple myeloma Platelet: < 20 or bleeding: training stopped and resumed when symptoms resolved or platelet count increased 2 patients experienced sepsis, rest completed the study Duregon et al. 2019 [ 22 ] Non-randomized, controlled, feasibility study N = 25 (EG = 15; CG = 10) EG: 49 ± 14 years CG: 51 ± 13 years Patient cohort: acute myeloid leukaemia, non-Hodgkin's lymphoma, Hodgkin’s lymphoma, multiple myeloma, acute lymphocytic leukaemia Hemoglobin: < 80 Exercise paused Nil adverse events reported in paper Elter et al. 2009 [ 23 ] Single arm intervention, pilot study N = 12 Age = 44 years (median) (25–66) Patient cohort: acute myeloid leukaemia, acute lymphocytic leukaemia, non-Hodgkin’s lymphoma Platelet: < 20: without sign of haemorrhage: patients proceeded with program with BP monitoring < 170/100 < 10: received transfusion prior to training Hemoglobin: < 80: transfusion prior to training No patients with thrombocytes below < 10 suffered bleeding Two patients with severe infections, one calf and one sepsis requiring intensive care Fioritto et al. 2021 [ 24 ] Single arm intervention feasibility study N = 26 Age: 40 ± 15 years Patient cohort: Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, leukaemia, multiple myeloma, medullary aplasia Platelet < 10 with hemoglobin < 70: breathing exercises in bed and rest. If hemoglobin > 70 and clinically stable: breathing exercises and ADLs. 10–40 with hemoglobin > 70: in hospital training program moderate intensity without training load. Platelet > 50 and hemoglobin > 70: in hospital training program moderate-intensity aerobic training with load. No adverse events were reported during the training program Hacker et al. 2011 [ 25 ] Single arm intervention, pilot study. N = 10 Age: 62 ± 8 years (48–71) Patient cohort: hematopoietic stem cell transplant for a variety of hematologic malignancies Platelet: Exercise completed if > 50 Nil adverse events documented in paper Jarden et al. 2009 [ 26 ] Randomized controlled trial N = 42 (EG = 21; CG = 21) Age: EG: 41 ± 13 years (18–60) CG: 37 ± 11 years (18–55) Patient cohort: chronic myelogenous leukaemia, acute myeloid leukaemia, acute lymphocytic leukaemia, aplastic anaemia, myelodysplastic syndromes, myelofibrosis, waldenstrom macroglobulinemia, paroxysmal nocturnal hemoglobinuria Testing postponed or patient disqualified if: Platelet: < 20 Hemoglobin: <5 0 Neutrophil: < 0.05 No adverse reactions or injuries were observed as a direct result of the testing or intervention Jarden et al. 2013 [ 27 ] Single arm intervention, pilot study N = 17 Age: 49 ± 18 years (18–68) Patient cohort: acute myeloid leukaemia, acute lymphocytic leukaemia Patients transfused (as such exercise postponed or modified) at: Platelet: < 15 Hemoglobin : < 90 No adverse reactions or injuries were observed as a result of exercise intervention. Two falls occurred in baseline testing during 6MWD and sit-to-stand test. Jarden et al. 2016 [ 28 ] Letter to editor based on randomized controlled trial N = 70 (EG = 34; CG = 36) Age: 53 years Patient cohort: acute leukaemia Platelet: Participation allowed if ≥ 15 Eight EG patients experienced non-serious adverse events Kabak et al. 2019 [ 54 ] Non-randomized control trial N = 26 (EG = 15; CG = 11) Age: EG: 9 ± 3 years CG: 7 ± 3 years Patient cohort: leukaemia, thalassemia major, immune deficiency, aplastic anaemia Contraindication to exercise Platelet: < 20 Hemoglobin: < 70 No adverse events related to the exercise program during exercise sessions Keser et al. 2014 [ 2 ] Single arm intervention study N = 26 Age: 48 years (19–64) Patient cohort: Hodgkin's lymphoma, non-Hodgkin's lymphoma, leukaemia, multiple myeloma, acute myeloid leukaemia Eligibility criteria for exercise program: Hemoglobin : < 70 Patients not meeting inclusion criteria skipped exercise program that day. Exercised continued post transfusion. Nil major adverse events reported some participants complained of fever, fatigue and dyspnoea however participants could complete exercise program without distress. Kuehl et al. 2023 [ 30 ] Multicentre, single arm intervention study N = 14 (completed study) Age: 55.3 ± 10.8 (28–69) Patient cohort: Myelodysplastic syndromes, Hodgkin's lymphoma, acute lymphocytic leukaemia, acute myeloid leukaemia, aplastic anaemia Platelet: < 15: exercise was contraindicated < 20: exercise intensity was reduced to 60% peak power output assessed via CPET and for resistance exercise to 40% 1RM. < 30: exclusion criteria at commencement of study Hemoglobin: < 80: exercise contraindicated at this level, exclusion criteria at commencement of study No adverse events were reported with exercise. Complaints of dyspnoea, nausea, infections and bleeding signs were not related to exercise Lindman et al. 2023 [ 31 ] Single arm longitudinal and feasibility study N = 30, 18 completed program including 12-month follow-up Age: 64.1 ± 6.5 Patient cohort: acute myeloid leukaemia, acute lymphocytic leukaemia, myelodysplastic syndromes, B-cell lymphoma, chronic myelomonocytic leukaemia, chronic lymphocytic leukaemia Platelet: < 50: VO2 max testing sessions were delayed or cancelled No patients experienced any accidental or adverse events, caused by elements of or participation in the program Møller et al. 2010 [ 29 ] Single arm review and evaluation of an outpatient treatment program N = 60 Age: Men: 49 years (18–74) Women: 44 years (23–62) Patient cohort: acute lymphocytic leukaemia, acute promyelocytic leukaemia, acute myeloid leukaemia without and without preceding myelodysplastic syndromes No exercise/ADL-related cut-off value Platelet: < 15 transfusion given. Hemoglobin: transfusions given according to individual limits, on basis of symptoms and co-morbidities Neutrophil: if < 0.5, told to avoid persons carrying infection or who had a fever, could leave their homes for daily walking however not allowed to go to supermarkets, cinemas, restaurants, buses, where many people gathered. Strict food prep precautions. Two readmissions due to bleeding. One minor, one severe gastrointestinal bleed. Morishita et al. 2012 [ 29 ] Observational, longitudinal study N = 385 (EG = 227; CG = 158) Age: EG: 45 ± 14 years CG: 42 ± 13 years Patient cohort: acute leukaemia, myelodysplastic syndromes, chronic myelogenous leukaemia, chronic lymphocytic leukaemia, myelofibrosis, plasmacytoma, aplastic anaemia Platelet: nil criteria for suspending physical therapy Hemoglobin: no criteria for suspending physical therapy Neutrophil: < 0.5: patient to remain in single room, physical therapists wore masks, aprons and plastic gloves. 14 complications in EG group, 10 in CG. Nil statistically significant difference between groups No patient experienced bleeding, dizziness or tachycardia during critical cytopenia phase. Oeschsle et al. 2014 [ 32 ] Randomized control trial N = 48 (EG = 24; CG = 24) Age: EG: 52 ± 13 years CG: 53 ± 15 years Patient cohort: acute myeloid leukaemia, non-Hodgkin's lymphoma, multiple myeloma, relapsed germ cell tumour Training suspended if: Platelet: < 20 Hemoglobin: < 80 Neutrophil: nil cut-off to suspend training without fever. Training suspended if fever arose. One death due to intracranial bleed not related to exercise intervention Rexer et al. 2016 [ 33 ] Single arm intervention study N = 28 (completed study) Age: 55 ± 11 years Patient cohort: multiple myeloma, lymphoma Platelet: Included in study if platelet count > 50 at baseline. Nil set platelet count as contraindication to exercise. Thrombocytopenia defined as platelets < 20. Significant thrombocytopenia defined as platelets < 10 Participants did not report any adverse events whilst performing the exercise program. No reported bleeding events. Rupnik et al. 2020 [ 34 ] Single arm intervention, pilot study N = 28 Age: 59 ± 8 years Patient cohort: multiple myeloma, acute myeloid leukaemia, acute lymphocytic leukaemia, amyloidosis, mantle cell lymphoma, myelodysplastic syndromes Training discontinued if: Platelet: < 30 Hemoglobin: < 80 Neutrophil: < 0.5 No serious adverse events due to exercise. Two cases of transient muscle soreness, one case of fluoroquinolone-associated tendinopathy. Safran et al. 2022 [ 35 ] Randomized controlled trial N = 43 (EG = 21; CG = 22) (Completed study EG = 16; CG = 15) Age: EG: 38 ± 12.48 (23–63) CG: 40.47 ± 9.77 (24–58) Patient cohort: acute myeloid leukaemia, B acute lymphoblastic leukaemia, T-acute lymphoblastic leukaemia, myelodysplastic syndromes, non-Hodgkin lymphoma, myelofibrosis Platelet: < 20: could continue exercise program if appropriate after blood support Hemoglobin: < 80: could continue exercise program if appropriate after blood support No recorded adverse events directly related to resistance exercise training and neuromuscular electrical stimulation treatment programs in the study San Juan et al. 2007 [ 36 ] Single arm intervention study N = 7 Age= 5 ± 1 years (4–7) Patient cohort: acute lymphocytic leukaemia Contraindication to exercise Platelet: < 50 Hemoglobin: < 80 Neutrophil: ≤ 0.5 No major adverse events during training and detraining period Schuler et al. 2016 [ 53 ] Single arm intervention, pilot study N = 16 Age: 65 years (60–70) Patient cohort: acute myeloid leukaemia, secondary acute myeloid leukaemia, myelodysplastic syndromes, non-Hodgkin’s lymphoma, chronic lymphocytic leukaemia Contraindication for daily training: Platelet: ≤ 10 Hemoglobin: < 80 No adverse events due to the exercise program were reported. No falls, fractures or bleeding episodes. Vermaete et al. 2013 [ 37 ] Observational, longitudinal study N = 29 Age: 56 ± 15 years Patient cohort: lymphoma Exclusion criteria: Platelet: < 50 Hemoglobin: < 70 No strict cut-off values within the trial for activity One participant stopped 6-min walk test after 3 min due to knee pain, one unable to perform maximal inspiratory and expiratory assessment due to fatigue. Wehrle et al. 2019 [ 38 ] Randomized control pilot study N = 29 (10 Endurance Group, 9 Resistance Group, 10 Control Group) Age: Endurance Group: 48 years (22–63) Resistance Group: 47 years (41–62) Control Group: 51 years (35–58) Patient cohort: acute leukaemia Platelet: < 10: acute petechiae or bleeding or physicians advice to avoid exercise. 10–20: intensity reduction in resistance exercise. Hemoglobin: < 80: exercise omitted No adverse events associated with exercise intervention. Wilson et al. 2005 [ 39 ] Single arm intervention, pilot study N = 13 completed study Age: 49 ± 10 years Patient cohort: multiple myeloma, breast cancer, acute lymphocytic leukaemia, large B-cell lymphoma Excluded from study if: Platelet: < 30 Hemoglobin: < 100 Neutrophil: < 1.0 No adverse reactions or events attributed to exercise were noted. Wiskemann et al. 2010 [ 40 ] Multicentre, randomized controlled trial N = 105 (EG = 52; CG = 53) Age: EG: 48 years (18–70) CG: 50 years (20–71) Patient cohort: acute myeloid leukaemia, acute lymphocytic leukaemia, chronic myelogenous leukaemia, chronic lymphocytic leukaemia, myelodysplastic syndromes due to acute myeloid leukaemia, myeloproliferative syndromes, multiple myeloma, lymphomas, aplastic anaemia Platelet : < 10: contraindication 10–20: needing doctors’ approval Hemoglobin: < 80: exercise contraindicated Nil adverse events reported in paper Fu et al. 2018 [ 4 ] Retrospective study N = 135 Age: 67 years (23–91) Patient cohort: leukaemia and pre-leukaemic syndromes, lymphoma, multiple myeloma Platelet: Institutional guidelines for physical activity precautions for platelets: > 20: no additional restrictions. 10–20: no resistive exercise. If a high fall risk, avoid standing or ambulating. 5–10: no resistive exercises and minimal activity (limit the exercises to in bed or chair). < 5: discuss with medical team or consider deferring treatment. 97 total bleeding events in 77/135 patients. 4/135 attributable to exercise. Only one of these four experienced a high severity event. Grencheski et al. 2021 [ 41 ] Retrospective study N = 77 Age (median): 54 years (39–66) Patient cohort: leukaemia and pre-leukaemic syndromes, lymphoma, multiple myeloma Platelet: Nil restrictions 49 bleeding events in the study, six attributable to physical exercise Four: platelets < 10, One: platelets 10–20 One: platelets 30–40 Low bleeding frequency in PT, no high severity bleeding events attributable to physical activity Ibanez et al. 2018 [ 5 ] Retrospective study N = 63 Age: 8 years (0–18) Patient cohort: leukaemia, myelodysplastic syndromes, non-Hodgkin’s lymphoma, non-malignant heme conditions Platelet: Clinical notes reviewed and documentation which demonstrated platelets < 50 were included in the study. Severely thrombocytopenic defined as platelets < 50 Results: 6–18 years Platelet 0–10: bleeding complications 0/7 11–20: bleeding complications 1/39 21–30: 0/57 31–50: 4/150 All episodes minor bleeding (small emesis with “bloody streaks”, 1 boy: 2 epistaxis received platelets prior to therapy moderate session 1 girl: 2 epistaxis platelet pre therapy intensive session Platelet: 0 bleeding complications 0–5 years Complications based on intensity: Very light: 0/11 Light 0/67 Moderate: 1/67 Intensive: 4/108 Rosenfeldt and Covert 2017 [ 42 ] Case report N = 1 Age = 47 years Diagnosis: myelodysplastic syndrome Platelet: < 10: typically receive prophylactic platelet transfusion Nil formal manual muscle testing due to low platelet, assessed functionally Platelet 3 when fell in shower, nil intracranial haemorrhage Platelet maximum 6 during intervention sessions Fell in shower resulting in laceration, no bleeding events during therapy Gillis and Donovan 2001 [ 43 ] Expert opinion Patient cohort: hematological malignancies Platelet: Prophylactic platelet cut-off typically 20 have been lowered to 5 in some facilities. In the absence of fever and falling counts, patients should be allowed active participation in therapy tailored to their own physical limitations. Hemoglobin: Mild anaemia ≤ 80, but less than normal fixed criteria for participation in rehab unwarranted, monitor symptomatology Neutrophil: Neutropenia and/or infection do not preclude active participation in therapy If in isolation, defer gym, 1:1 therapy maintaining gown, glove and/or mask If febrile and malaise restricted to functional mobility activities and ADLs N/A Granger 2023 [ 44 ] Literature review and expert opinion Patient cohort: hematological malignancies Platelet: <10: essential ambulation only, assistance/supervision and gentle range of motion 10–20: exercise without resistance and without strain, exercise in standing or mobilization only if ambulates independently with no signs of bleeding 20–40: light resistance without strain if no evidence of bleeding, gentle aerobic exercise > 40: low-intensity (gentle) aerobic exercise including stationary cycling permitted < 50: avoid high-intensity exercise Hemoglobin: < 80: exercise training generally contraindicated, consult with Physician prior to commencement, mobilization with caution and monitor closely for vital signs Neutrophils: Recommendations: wear face mask when walking outside room and wash hands properly before and after sessions. Therapy should be in the patients room with equipment cleaned before and after use N/A Jeevanantham et al. 2021 [ 45 ] Systematic review and expert consensus Therapists: 10 Patients: 10 17 critically appraised articles Patient cohort: multiple myeloma Platelet: < 10: platelet transfusion, essential ambulation only, assistance/supervision and gentle range of motion 10–20: exercise without resistance and without strain, monitor BP, ambulate if steady 20–40: light resistance without strain, monitor BP > 40: gentle aerobic activity, including stationary cycling < 50: avoid vigorous activity and equipment to prevent bleeding from trauma Hemoglobin: < 80: monitor vital signs and adverse events < 70: withhold mobilization Neutrophil: Recommendations: wear face mask when walking in hallways and wash hands properly before and after sessions. Regular cleaning of equipment and assistive devices before and after use. Therapy should be in the patients room. N/A Keilani et al. 2019 [ 46 ] Narrative review Patient cohort: multiple myeloma and metastatic bone disease Contraindications of exercise: Platelet: < 20 Hemoglobin: < 80 N/A Mohammed et al. 2019 [ 47 ] Literature review and expert opinion Patient cohort: hematopoietic stem cell transplant Platelet: < 5: very light intensity exercise 5–20: light to moderate 21–30: moderate 31–50: moderate to vigorous Hemoglobin: < 80: should not receive physiotherapy management, consider case by case if benefits of physiotherapy outweigh risks. In some patients, blood transfusions would be recommended before training if hemoglobin levels are below the cut-off. N/A Morishita et al. 2020 [ 48 ] Systematic review with expert opinion N = 27 studies included Patient cohort: lymphoma, leukaemia, hematopoietic stem cell transplant Platelet: < 10: limit activity. Patients may require transfusion before exercise 10–20: exercise gently, without resistance. Sitting or standing exercise, gentle stretching and walking may be allowed 20–50: resistance equip such as weight, elastic tubing or TheraBand may be used. The patients may be allowed to walk more briskly and practice step-ups or stairs 50–80: activities such as stationary cycling and golfing are acceptable > 80: the patient can perform vigorous resistance exercises and aerobic exercises such as biking or jogging. However, an appropriate use of protective gear should be used and precautions must be taken to avoid accidental injury N/A Paul 2011 [ 49 ] Expert opinion Patient cohort: multiple myeloma, hematologic malignancies Platelet: No set parameters to contradict or adapt exercise, transfusion < 20 Hemoglobin: No set cut-off to contradict or adapt exercise. Rate of decrease important as opposed to insidious drop Neutrophil: Should not preclude active participation, unless acute medical instability exists. N/A Rome et al. 2011 [ 50 ] Expert opinion Patient cohort: multiple myeloma Delay exercise other than ADLs until condition improves or approved by Physician: Platelet: < 50 Hemoglobin: < 80 Neutrophil: < 1.0 should avoid gyms and other public places until white blood cell counts return to normal levels N/A Wiskemann J and Huber G 2008 [ 51 ] Literature review N = 15 studies (609 patients) Age: 41 years (14–74) Patient cohort: hematological Malignancies Contraindication to exercise criteria: Platelet: < 20 Hemoglobin: < 80 N/A Data presented as mean ± standard deviation or median (interquartile range), unless otherwise stated Abbreviations: ADLs , activities of daily living; CG , control group; EG , experimental group

A range of exercise interventions were assessed across the prospective studies (online resource; Table S 2 ). Of the 34 prospective studies, 28 [ 2 , 11 – 20 , 22 , 24 , 26 – 37 , 39 , 53 , 54 ] used a multimodal intervention method. Twenty-nine of the 34 prospective studies included aerobic exercise [ 2 , 11 – 21 , 23 – 31 , 33 , 34 , 36 , 37 , 39 , 40 , 53 , 54 ] and 24 of the prospective studies included resistance training [ 11 – 13 , 17 – 20 , 22 , 24 – 26 , 28 – 37 , 39 , 53 , 54 ]. With regard to delivery method, 24 of the 34 (71%) prospective studies delivered a supervised intervention [ 2 , 11 – 21 , 23 , 24 , 26 – 30 , 32 , 33 , 35 , 39 , 53 ] and a further six of the 34 (18%) delivered a partly supervised intervention, which included supervised sessions and unsupervised home based exercise (Fig. 2 ) [ 22 , 25 , 31 , 36 , 37 , 54 ]. Fig. 2 Types of exercise training modalities across the 34 prospective studies. Abbreviations: ADL, activities of daily living; NMES, neuromuscular electrical stimulation

Summary of papers that included platelet count cut-off values

Of the 47 papers included in this review, 44 referenced cut-off values for platelet count either as an exclusion for exercise or to adapt the exercise program. Of the 44, 31 were prospective studies, four were retrospective review papers, five were reviews and four were expert opinion papers. Table 2 provides a graphical representation of such cut-off values. Table 2 Platelet count cut-off values (× 10 9 /L) at which activity is indicated *Participants in this study had no standardized parameters to activity; however, activity was retrospectively rated to be very light, light, moderate and intensive + Assessment of maximal oxygen uptake (VO 2 max) delayed or cancelled below this level Colour code: Nil restrictions; activity modified; activity contraindicated; authors unable to determine as cut-off related to participation in study or outcome testing and did not specify platelet cut-off related to exercise/ADLs during the study

Of the 44 papers that referenced cut-off values for platelet count either as an exclusion for exercise or to adapt the exercise program, 31 were prospective studies. Four (13%) of the 31 prospective studies which referenced platelets [ 29 , 31 , 33 , 52 ] did not use any platelet cut-off value for participating in an exercise intervention or did not report criteria for suspending exercise [ 52 ]. One study reported a platelet transfusion was required if participants platelet value were < 15 × 10 9 /L; however, exercise and activity were not withheld awaiting this [ 29 ]. One study suspended the assessment of maximal oxygen uptake (VO 2 max) if platelet count was < 50 × 10 9 /L; however, there was nil comment on adaption to the exercise program during the study [ 31 ]. There are a range of recommendations within the prospective studies regarding adaptation or cessation of exercise based on platelet counts (see online resource , section “Extended results”).

Two of the five reviews indicated contraindications for exercise with platelet count < 20 × 10 9 /L [ 46 , 51 ]. The other three provided very specific parameters for platelet cut-off values and participation in exercise/ADLs [ 45 , 47 , 48 ]. Mohammed et al. [ 47 ] recommended patients with platelet < 5 × 10 9 /L participate in very light activity, which includes essential ADLs in a bed or chair, and bed mobility [ 47 ]. Jeevanantham et al. [ 45 ] and Morishita et al. [ 48 ] recommended that, for individuals with platelet count < 10 × 10 9 /L, activity is limited to essential ambulation only [ 45 ] or that transfusion should occur before exercise participation [ 48 ]. These two reviews are also consistent with their recommendations of platelet count between 10 and 20 × 10 9 /L for exercise without resistance [ 45 ] and ambulation if the participant is steady [ 45 , 48 ]. Across the three reviews, essential activities of daily living and no weight training or resistance were recommended for platelet count < 20 × 10 9 /L [ 45 , 47 , 48 ]. Where platelet count was > 20 × 10 9 /L, recommendations included light resistance and gentle cycling for platelet count < 40 × 10 9 /L [ 45 ], stationary cycling if between 50 and 80 × 10 9 /L [ 48 ] and moderately intensity activity including a jumping obstacle course and climbing at a platelet count between 31 and 50 × 10 9 /L [ 47 ].

Of the four expert opinion papers [ 43 , 44 , 49 , 50 ], one recommended delaying activity where platelet count is < 50 × 10 9 /L, unless approved to participate by a physician [ 50 ]. Two specified that a transfusion is required when platelet count is < 20 × 10 9 /L [ 43 , 49 ]. It was further reported that, in the absence of fever and falling platelet count, patients should be allowed to participate in therapy tailored to their own physical limitations [ 43 ]. One expert opinion paper [ 44 ] based their recommendations off another article mentioned in the previous paragraph [ 45 ].

Summary of papers that included hemoglobin count cut-off values

In total, 36 of the papers referenced hemoglobin counts in relation to exercise or ADLs, including 28 prospective studies, four reviews and four expert opinion papers. Table 3 provides a graphical representation of such cut-off values. Table 3 Hemoglobin count cut-off values (g/L) at which activity is indicated *Rate of hemoglobin decrease is important, a rapid decline was considered more significant than an insidious decline Colour code: Nil restrictions; activity modified; activity contraindicated; authors unable to determine accurately as cut-off related to participation in study and did not specify platelet cut-off related to exercise/ADLs during the study

Of the 28 prospective studies that referenced hemoglobin count cut-off values, three (12%) did not have cut-off values for exercise or ADLs [ 13 , 29 , 52 ]. No reported adverse events were attributable to exercise or ADL participation in any of these papers. Møller et al. [ 29 ] reported that transfusions were given based on symptoms and co-morbidities. Of the eight reviews included that referenced hemoglobin count cut-off values, two (29%) recommended no fixed parameters for engagement in exercise or ADLs [ 43 , 49 ]. The more recent article [ 49 ] references the earlier article [ 43 ] and advised to consider the rate of hemoglobin decline and symptomology, rather than to set values in adaptation of activity. The remainder of the papers reported cut-off values ranging between 50 and 100 g/L for cessation or adaptation of training/activities (further details in the online resource , section “Extended results”).

Six of the eight reviews (75%) referenced 80 g/L as a parameter for exercise, with four of these recommending a hemoglobin count < 80 g/L as a contraindication to exercise [ 46 , 47 , 50 , 51 ]. Of these, two articles recommended to complete only ADLs at this level unless approved by a physician to exercise [ 44 , 50 ]. Another recommended an assessment of risk and benefit of exercise with low hemoglobin count in context of the participant’s overall clinical picture and considered a transfusion prior to exercise [ 47 ]. One paper (14%) recommended continuing exercise at 80 g/L [ 45 ], with two papers recommending close monitoring of vital signs and adverse events [ 44 , 45 ].

Summary of papers that included neutrophil count cut-off values

Sixteen papers meeting the inclusion criteria referenced neutrophil counts. Of these, 11 were prospective studies, four were expert opinion papers and one was a review paper. Nine (56%) of the 16 papers that referenced neutrophil count recommended no neutrophil cut-off value to contraindicate ADLs or exercise [ 13 – 15 , 18 , 32 , 43 – 45 , 49 ]. However, six studies did advise to cease or adapt sessions if the patient has a fever or severe infection, or is febrile [ 13 – 15 , 32 , 43 , 49 ]. The eight remaining papers (50%) that referenced neutrophil count recommended adaptation or cessation of exercise based on neutrophil count cut-off value < 1.0 × 10 9 /L or ≤ 0.5 × 10 9 /L. People were excluded from one of the studies [ 39 ] where the exercise intervention was a home-based, non-supervised exercise program, if their neutrophil count was < 1.0 × 10 9 /L. Another study [ 50 ] advised participants could continue to exercise if neutrophil count was < 1.0 × 10 9 /L but should avoid group participation. Three of the studies recommended exercise to be contraindicated if neutrophil count was ≤ 0.5 × 10 9 /L [ 26 , 34 , 36 ] and four recommended adaptations to therapy or activity, such as therapists wearing personal protective equipment (PPE), cleaning of equipment before and after use [ 44 , 45 ], completion of therapy in a single room [ 44 , 52 ], and adapting leisure and instrumental ADL activities such as avoiding crowded public places (cinemas, restaurants and supermarkets), adhering to strict food preparation, avoiding people who are unwell [ 29 ] and wearing a face mask outside of the room [ 44 , 45 ]. There were no adverse events identified in any of the included papers that were linked to low neutrophil count and exercise. There were no specific recommendations in any article in relation to personal ADLs and specific neutrophil counts.

Adverse events and other considerations for engagement in exercise or ADLs

Six of the 47 papers reported adverse events directly related to exercise intervention. These included four prospective studies [ 11 , 12 , 20 , 36 ] and two retrospective studies [ 4 , 41 ]. One study reported two falls during the baseline assessment [ 27 ]. Six prospective studies reported adverse events, however did not specify if this was directly related to the exercise intervention or study protocol [ 14 , 15 , 19 , 28 , 32 , 52 ]. One study reported a death due to intracranial bleed; however, this was not related to the exercise intervention [ 33 ]. One retrospective study reported a fall in the shower resulting in laceration otherwise reporting no adverse events during therapy [ 42 ]. One study reported dyspnoea, infections and bleeding signs; however, none of these was related to the intervention [ 30 ]. A detailed summary of adverse events reported in prospective and retrospective studies is provided in the online resource (Tables S 3 and S 4 ).

Other considerations were recommended outside of blood cell count that occupational therapists and physiotherapists should consider when making recommendations about safe ADLs and exercise participation. These articles recommend either postponement or cessation of therapy sessions if certain physical symptoms arose. The most common symptoms referenced in the reviewed articles requiring alterations to therapy were development of fevers or temperatures [ 5 , 12 , 17 – 24 , 26 , 27 , 30 – 32 , 35 , 38 – 40 , 46 , 49 , 51 , 52 , 54 ], subjective malaise/nausea/headache [ 5 , 14 – 17 , 19 , 20 , 24 , 40 , 45 , 49 , 52 , 54 ], cardiac symptoms (such as arrythmias or chest pain) [ 24 , 32 , 45 , 46 , 49 , 50 ], bleeding [ 17 , 18 , 20 , 24 , 27 , 33 , 45 , 54 ], pain [ 5 , 16 – 18 , 21 , 24 , 40 , 51 , 52 ], respiratory symptoms (such as dyspnoea or respiratory distress) [ 24 , 45 , 46 , 49 , 50 ] and neurological changes [ 17 , 46 , 50 ]. It was also recommended to monitor vital signs during sessions [ 42 ]. Sessions were recommended to be ceased or adjusted if heart rate [ 14 , 15 , 23 , 24 , 26 , 27 ], blood pressure [ 12 , 14 , 15 , 20 , 23 , 24 , 27 , 49 ] or respiratory rate and oxygen [ 24 , 49 ] fell outside normal set parameters or changed too suddenly. Seventeen studies also used rate of perceived exertion as outlined in activity intensity [ 2 , 11 , 13 – 15 , 17 , 21 , 22 , 25 , 26 , 29 , 31 , 34 , 35 , 37 , 39 , 54 ].

Discussion

The aim of this scoping review was to summarize the current literature in relation to the safe platelet, hemoglobin and neutrophil counts for people with hematological cancers to engage in exercise and activities of daily living. We have found a broad range of platelet, hemoglobin and neutrophil cut-off values for exercise or ADLs across the 47 included papers. Of note, the findings of this review demonstrate the changing nature of some of these cut-off values. That is, for platelet count, it seems that more rigid contraindications based on cut-off values were found in older papers when compared to more recent papers. Regarding hemoglobin levels, there were much more distinct criteria for cessation or adaptation of exercise/activity compared to platelet values. Neutrophil cut-off values were only reported in 17 papers, and the message across the papers was that minimization of infection risk is the focus when neutropenia is detected. These findings suggest a shift from contraindicating exercise or engagement in ADLs based on blood cells levels towards an emphasis on modifying exercise/activities, acknowledging that safe prescription of exercise and ADLs is multifactorial.

There is a growing body of evidence demonstrating safety and feasibility with exercise and the importance of preventing deconditioning in people with hematological malignancies. The papers included in this review use multiple factors when determining safety with regard to exercise, indicating the importance of considering the entire clinical picture rather than just the blood values independently. A recent qualitative study investigating therapist’s understanding of contraindications of physical activity in stem cell transplantation reported that physicians with additional training in the field of physical activity agree that a platelet count of < 50 × 10 9 /L is not a contraindication to exercise and were more permissive in their judgement of patients undertaking exercise during treatments [ 55 ]. In people with low platelets, clinicians are often required to balance the risk of bleeding with prevention of deconditioning. The results of this review show that there are no consistent criteria for platelet counts and participation in exercise or ADLs. From analyzing the platelet count in the included studies, the cut-off values suggest overall a platelet count of > 20 × 10 9 /L appears to be safe for participation in exercise and ADLs. The majority of included studies either adapted or contraindicated exercise with platelets less than 20 × 10 9 /L with over half of this majority adapted or contraindicated exercise and activity with platelets less than 10 × 10 9 /L. One emerging trend, identified in Table 2 , is that recent studies appear more likely to adapt activity than absolutely contraindicate it. Camacho Pérez et al. [ 17 ] reported a limitation to the exercise intervention of their participants undergoing stem cell transplantation was a platelet count of < 15 × 10 9 /L, and suggested lowering this level to allow cytopenic patients to participate in exercise. Of the papers included in this review, only one prospective study was able to definitively determine adverse events related to exercise and the retrospective studies identified low percentages of bleeding events related to exercise or therapy interventions indicating that exercise within these parameters as a guideline are safe. There was limited evidence outside of expert opinion specifically referencing ADL participation in related to blood counts; however, multiple articles [ 20 , 24 , 42 , 43 ] recommended completion of basic personal ADLs despite low counts.

With regard to hemoglobin, there were much more distinct criteria for cessation or adaptation of activity compared to platelet values, with nil substantial change in recommendations over time. Most of the articles adapted or contraindicated exercise at hemoglobin counts of less than 70 g/L or 80 g/L, with nil adverse events being linked to low hemoglobin counts when using this cut-off. There was minimal evidence on adaptation or cessation of ADLs due to low hemoglobin counts; however, basic personal ADLs were encouraged to be completed despite low counts in a review paper [ 43 ] and prospective study [ 24 ].

Management decisions based on neutrophil count were varied in the included studies and it was identified that the most important safety precautions for neutropenic patients were those that minimize infection risk (such as exercising within the patients room, cleaning equipment after use). Neutropenic patients were still encouraged to exercise and engage in ADLs, with cessation or adaptation occurring in situations where the patient was febrile or unwell. No adverse events related to exercise were identified due to low neutrophil counts in isolation.

Granger [ 44 ] advised that “clinical decision making is required to tailor an appropriate mobilization or exercise treatment that takes the patient to their highest functional level within safety limits”. Rather than solely utilizing blood counts, studies also recommend taking the entire clinical picture into account when selecting safe exercise interventions. These papers utilized standardized measures of exertion (such as the BORG scale), monitored vital signs such as heart rate, and took into account clinical factors such as if a patient was febrile or unwell to optimize the safety of exercise and ADL participation [ 5 , 12 , 14 – 24 , 26 , 27 , 30 – 33 , 35 , 38 – 40 , 42 , 45 , 46 , 49 – 52 , 54 ]. The qualitative study by Meyer-Schwickerath [ 55 ] reported acute infection being reported by all healthcare professionals in their study as a contraindication to physical activity. Supervision of activity by a trained health practitioner was also an important factor in the studies to be able to make clinical decisions to adjust exercise if required.

Strengths and limitations

This novel scoping review included a broad range of papers, from original studies to expert opinion papers. This can be considered both a strength, since we scoped a vast literature in the field, but also as a limitation, due to the wide range of study designs and wide range of interventions considered across the 47 papers, which made it challenging to compare individual papers and draw specific conclusions regarding blood cell count cut-off values. Whilst interventional studies were included in this review to determine safety of exercise interventions in participants with low blood counts, most studies did not directly report adverse events, or were not able to link adverse events with the intervention being delivered and cut-off values for blood cell count used. It was only the retrospective studies that directly looked at bleeding events related to low platelet counts with activity.

Overall, the implication of the evidence found in this scoping review is that exercise is safe and feasible in patients with low blood counts, with low numbers of adverse events identified across the papers that were designed to report on adverse events. Exercise in patients with low blood counts should be of light to moderate intensity with therapists needing to take the entire clinical picture into consideration when selecting interventions for their patients. Low-intensity basic personal ADLs should still be completed with additional strategies considered to optimize safety, such as mitigating risk of falls and preventing deconditioning.

Further research is recommended to investigate safe mode, volume and intensity of exercise and ADLs in this patient group. This is particularly important as the emerging trend is for adapting exercise and activity, rather than using low blood counts as an absolute contraindication. Given the limited evidence of low platelet counts in relation to basic and more complex ADLs, further investigation on bleeding rates would be important to establish if further precautions should be taken in these situations. It would also be useful to consider the timing of intervention in patients with low blood counts and during their treatment regimes.

Conclusion

This scoping review emphasizes that, in people with hematological cancers, evidence for safe levels of blood cells cut-off values is evolving, and that prescription of safe exercise and functional rehabilitation is multifactorial. Blood cells count alone should not dictate prescription of exercise or ADL interventions in this population. Blood cells count is part of the decision-making process, with other clinical and patient factors being taken into consideration in order to mitigate risk and enable patients to experience the benefits of exercise and engagement in day-to-day activities.

Supplementary information

ESM 1 (DOCX 69 kb)

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Author contributions

All authors contributed to the study conception and design. Database searches were performed by [Joanne Houston], [Kieran Boyd] and [Vinicius Cavalheri], data extraction summary of the findings were performed by [Joanne Houston] and [Kieran Boyd]. The first draft of the manuscript was written by [Joanne Houston] and [Kieran Boyd] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

Open access funding provided by South Metropolitan Health Service, WA Health Libraries Network Consortium. This Scoping Review was completed with funding from the WA Chief Allied Health to the South Metropolitan Health Services (SMHS) Allied Health Service through the Allied Health “Building Research Capacity initiative”. Joanne Houston and Kieran Boyd received the funding which supported protected research time.

Data availability

No datasets were generated or analysed during the current study.

Declaration

Competing interests

The authors declare no competing interests.

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