On a Saturday morning I would usually wear my exercise instructor’s hat for a ‘Move More’ or ‘CanDo’ session, both of which are initiatives for people living with and beyond cancer. These sessions have materialised thanks to the amazing efforts by Edinburgh Leisure, Macmillan Cancer Support, Teenage Cancer Trust, and the physiotherapy team of Edinburgh’s Royal Hospital for Sick Children. In the afternoon, I would then follow my own personal routine which would involve some running or resistance/strengthening exercises. Unfortunately, all these have been placed ‘on hold’ since March, and I find myself in front of a computer screen more often than ever.
The key question is how can we cope with quarantine in terms of maintaining an active lifestyle? Aerobic activities (walking, jogging, running etc) are still easily accessible but what about resistance exercises? Do we need to bother with these exercises if we go out for a walk five days/week for 30 mins each time?
Well… it is certainly positive but there is room for improvement. From a resistance exercise perspective, the UK Chief Medical Officer’s Physical Activity Guidelines state that we should perform exercises that ‘increase or maintain muscle strength (resistance training)’ at least twice a week (UK CMO 2019). Unfortunately, although we have noted improvements in adherence to aerobic exercises, strength exercises remain part of the ‘forgotten guidelines’ in Scotland (Strain et al. 2016) and other countries (Bennie et al. 2018).
But why is muscle mass (quantity) and strength (quantity) important?
Firstly, I appreciate that referring to ‘muscle mass’ may initiate voluntary ocular movement (also known as eye-rolling) in some, but we seem to forget that muscle is the main compartment of our lean tissue. Unfortunately, when we talk about muscle and strength some people still tend to bring to mind the likes of Arnold Schwarzenegger and not Sir Chris Hoy, Sir Andy Murray, or Tom Daley, all of whom perform strengthening exercises (as well as aerobic of course). Many people worry that it will make them look bigger but in reality, it will have the opposite effect, it will make them look leaner.
What are the links between muscle quantity & quality with health?
We start losing muscle mass and strength around the age of 30 which is when most of us experience also an increase in body fat, especially around the waist area (I bet that the eye rolling is now replaced by affirmative nodding). The loss of muscle quality and quantity that comes with advancing age (a condition known as sarcopenia) can increase the risk of falls, fractures, physical disability, cardiac and respiratory disease, cognitive impairment, hospitalisation, and death (Cruz-Jentoft et al. 2019). These are likely to be exacerbated in the presence of high body fat, a condition termed sarcopenic obesity (Baumgartner 2000, Stenholm et al. 2008).
Older adults are more likely to experience one of the previous conditions and are also more likely to be diagnosed with cancer than their younger counterparts. Moreover, the prevalence of low muscle/function upon cancer diagnosis may range from ~16% to 70%, depending on the criteria, population study, and type of cancer (Villasenor et al. 2012; Psutka et al. 2014). Therefore, it is important to maintain a healthy muscular system as we age.
Muscle strengthening exercises and cancer prevention.
Muscle is the main tissue responsible for glucose uptake during elevated insulin concentration in healthy individuals (DeFronko et al. 1981; Honka 2018). Therefore, low muscle mass may predispose individuals to dysregulated glucose update, insulin resistance, and higher risk of cancer (Kim et al. 2019). However, it is important to note that impairments in glucose uptake, regulation of insulin and insulin-like factors (that have been implicated in the pathogenesis of cancer) can be improved by strength training (Smitz et al. 2002). In fact, strength training has been associated with lower risk of several adverse health conditions such as obesity, diabetes, cancer, and all-cause mortality (Stamatakis et al. 2017; Bennie et al. 2018)
Importance of muscle quantity and quality upon/after cancer diagnosis
Upon diagnosis, sarcopenia is a strong prognostic factor for morbidity and mortality, regardless of body mass index (Biolo et al. 2014). Patients with sarcopenia are likely to encounter health complications and poor prognosis for various types cancers, such as lung (Tsukioka et al. 2017), colon (Lieffers et al. 2012), colorectal (Huang et al. 2015), bladder (Psutka et al. 2014), liver (Iritani et al. 2015), skin (Sabel et al. 2011) and pancreas (Tan et al. 2009). Sarcopenia with obesity may also exacerbate chemotherapy-induced toxicity, increase the risk of infection, and pose an independent risk factor for mortality (Prado et al. 2008; Mei et al. 2016).
But is it easy for someone to follow the guidelines without any sophisticated/ expensive equipment?
The answer here is a clear YES. There is a plethora of exercises that adults, young and old, can perform at home with minimal equipment to improve muscle size and strength (Watanabe et al. 2020). For both beginners and experienced trainees, it is important to engage in exercises that stimulate the growth of major muscle groups, and improve our strength, posture, balance and overall functionality. Therefore, exercises focusing on the legs, back, chest and trunk muscles are of primary interest.
As a rule of thumb, the exercises should initially aim to make our muscles and body familiar with the movement in order to prevent injuries. The initial resistance should be light, and repetitions should be in the range of 8-12 and increase to ~15 after a few sessions, when our body feels stronger. Once we are able to perform 15 repetitions consistently and with good technique, we can increase the resistance/load and start again with a lower repetition range of 6-12 until we can gradually build this up to 15 (and this circle of increasing resistance/ decreasing number of repetitions continues) (see example in Table 1). Each exercise should be performed for 2 to 4 sets, with 1-2 min breaks in between each set (please note that four sets are better, but if you don’t have time even one set can be beneficial, and is definitely better than none).
What you will need to start with: You can start just with no equipment, but it is recommended to invest in a set of elastic bands (small elastic loops; Figure 1), that are affordable (~£10-15) and very practical (they come in varied resistances and can be stored together in a small pouch). Otherwise some common household items can also do the trick (e.g. plastic bottles filled with water). The benefit of the bands is that they do not need to work against gravity like traditional weights do, and as such they allow us to adopt safer positions (e.g. seated or standing upright) for those who are not very familiar with the exercises, at least during the first stages of a programme.
You can perform the following routine 2-3 days per week, with at least 48h separating the sessions. This is a programme for beginners or people who want to do some basic exercises at home. It is not intended to treat any conditions, and people with special requirements should seek appropriate help.
Warm up: 5 – 10 mins
– Knee-raise with support (Figure 2) or freestanding (Figure 3). The latter also works as a balance exercise. You can start by supporting yourself on a chair or the wall until you feel confident to perform it unsupported.
– Half-squat with arm movement (pull-push motion) (Figure 4). Again, if challenging you can stand behind a chair and move one arm at a time. Try to repeat these two exercises for a total of 5-10 mins. Warm-up is important in order to get the body prepared for the main exercises and allow enough time for our heart to adapt to the intensities.
Main body ~ 20-30 mins
Exercise 1: Repeated Sit to Stand (simulation of squats) (Figure 5)
Tips: Maintain a straight back and try to avoid rolling forward when standing up. Remember that maintaining a straight back helps us engage our core muscles. For extra resistance you can hold a small bottle of water in each hand or your elastic band, maintaining a straight back throughout (Figure 6).
Exercise 2: Leg Extensions.
Tips: While seated, lift your foot up until your shin is parallel to the floor, and then slowly allow it to step down again (Figure 7). If using bands, step on the band with one foot (this will serve as your anchor point) and place the other end of the loop around the ankle of the exercising leg (Figure 8). You can swap legs after completing the required amount of repetitions.
Tips: Maintain a straight back. You can interlace your fingers under your thigh to add some extra height, if your chair is not high enough and your shoe is scraping the floor. If the band is rolling up your shin you can make one extra loop and hook it around your toes (Figure 9).
Exercise 3: Leg curls.
While standing up with feet at shoulder width, bend one knee and try to bring your heel as close to your glutes as possible (Figure 10). If using a band, step on it with one foot and bring it around the heel of your other foot (Figure 11). Always keep your knees parallel.
Exercise 4: Wall press-up (Figure 12) / One arm chest press (Figure 13).
Tips: Relax the neck and keep your shoulders down, if the wall press is very easy using both arms, you can use a single arm to push yourself back for 8-12 repetitions and then alternate arms.
If using a band, you can attach it on a safe/sturdy point and push forward with one arm (Figure 13). Maintain a straight back and extend your arm forward. Let your arm return back in a safe and slow manner.
Exercise 5: Row.
Tips: Grab something stable and pull yourself towards it by driving your elbows back (Figure 14). While pulling, imagine that you have a golf ball between your shoulder blades and you want to squeeze it. Have a strong base with your legs (you can bend your knees slightly), relax your neck and shoulders. Maintain a straight back.
If using a band: Grab the band and drive your elbow back while squeezing your back muscles (Figure 15). Then relax your back and let your arm go all the way forward. Repeat. Make sure you use a secure anchor point e.g. the door handle (Figure 16) and you stand at the other side of the closed door.
Cool down – stretching:
Walk/march around the room for 2-3 minutes. Then try to perform the following stretches in sets of 10 seconds. Over time try to increase the duration to 30 s for each side for a total of ~ 2 mins for each stretch position.
I could not finish without highlighting the importance of a healthy diet, but this topic warrants a whole new article! Until then, happy exercising 🙂
Christos Theodorakopoulos, MSc, PhD
Lecturer in Nutrition, School of Health Sciences, Queen Margaret University Edinburgh
& Exercise Professional – Level 4 in Cancer & Exercise Rehabilitation