Prevention of Osteoporosis with Impact + Resistance (POWIR)
Developed by Dr. Kerri M Winters-Stone, at the Bone Research Laboratory, Department of Nutrition and Exercise Science, Oregon State University.
Study Interpretation by Justin Fassio.
Translating research into practice
This article is a translation of a study that concluded that specific exercises can have a beneficial effect on the density of bones in sites that pose a risk of fracture for women with osteoporosis. The language of the study is highly technical and scientific in nature. With the help of advisors that have conducted these or similar studies, we are translating the beneficial aspects of the study into a practical program for men diagnosed with prostate cancer.
At times, we recommend the specific exercises done exactly as the study prescribes because they have the highest quality of data driving them, but as we know, science is always looking at what could be, so we sometimes “a posteriori” or based on our own experience, recommend that a replacement or modified exercise should have a better result for the average man with prostate cancer conducting the workout without supervision.
In the end, we are simply looking at the science, talking to the researchers and doing our due dilligence to give you the best workout with the information at hand. And for all intents and purposes, any exercise will prove to be beneficial in your treatment plan with very little risk of injury or side effect.
“Nearly all patients with cancer are at increased risk for bone loss and fractures” (1)
Dr. Kerri Winters-Stone developed the POWIR set of exercises while researching how to prevent injury to the hip and spine caused by osteoporosis. Her research in this area concluded that resistance and impact exercises “showed significant differences” (2) between the exercise groups and controls on Bone Mineral Density (BMD) at the lower trochanter (the ball joint at the top of your femur) and “approaching significant difference” in the spine. Hip and spine fractures are the most common related to osteoporosis.
The conclusions from Dr. Winters-Stone’s initial research utilizing POWIR are important because most cancer treatments affect BMD (1). The loss of BMD is often the cause of disability during and after treatment.
Disability in the context of treatment for prostate cancer refers to an additional injury such as a fractured hip or vertabrae that is linked to the loss of BMD related to cancer in general and specifically ADT for prostate cancer.
MATERIALS & METHODS
JUMP SQUATS, SQUATS, BENT KNEE DEADLIFT, FORWARD LUNGE, LATERAL LUNGE, SINGLE ARM ROW, SEATED ROW, CHEST PRESS, LATERAL RAISE, PUSHUPS.
What this paper concludes and which has been further studied on men with prostate cancer is that performing exercises at a similar intensity and of similar type as conducted in this study can have a beneficial effect on strength and Bone Mineral Density thereby possibley reducing your risk of injury associated with prostate cancer.
Exercise participants were asked to attend three exercise sessions per week with at least 1 day of rest between sessions. Compliance was 71%, which means the results are based on about two resistance + impact exercise sessions a week. All participants performed a warm-up and cool-down.
In the study exercises consisted of upright rows, one-arm rows, lat pull-downs, chest presses, chest flys, bicep curls and tricep extensions. To minimize the time cost of training, upper and lower body exercises were often combined into one movement. Some combined exercises were bicep curls or upright rows with squat, tricep extensions or one-arm rows with side lunge, lat pull-downs or chest press/flys with front lunges. Every major muscle group was trained every week but some of the resistance exercises changed.
“Our data support the site-specific response of spine and hip bone density to upper and lower body exercise training, respectively.” (2)
The findings of Dr. Winters-Stone and her team’s research established a baseline exercise protocol that is known to be effective against bone density loss in premenopausal women. Because the findings that included uper and lower body exercises increased the BMD of both the hip and spine, this makes the site-specific response a significant finding for men undergoing ADT.
A number of follow up studies specific to ADT have utilized the POWIR protocol and have proven that it is effective at preventing and even reversing bone density loss for men undergoing ADT as well.
There are 9 lower and upper body exercises included in our version of the POWIR4ADT protocol. Because these 9 exercises have data that support their effectiveness in preventing disability in Prostate Cancer Survivors (PCS) undergoing ADT, we utilize them as the performance watermark to achieve in our prescribed program.
Dr. Winters-Stone’s research shows that lower and upper body exercises proved more effective than lower body exercises alone in increasing BMD in the spine.
We are also following the American College of Sports Medicine FITT Principal in exercise recommendation: Frequency, Intensity, Time and Type. Not everyone can engage immediately in the recommended routine. Progressing to the desired range of motion, form, intensity and duration of exercise often is part of a progression from a very light physical activity moving towards a more intense, routine workout.
Please remember to not get overwhelmed by all of the information. It is good that so much research exists, but we don’t want all this information to cloud what we need to do, which is simply: move. We find it can be overwhelming as well but we do enjoy reading through it and doing our best to simplify it and turn it into a program that benefits you.
THE COMPONENTS OF EXERCISING
F.I.T.T
There are two primary components to being healthy through movement; physical activity and exercise. Physical activity is anything you do that is not at rest, exercise is a structured period of time that you dedicate to a workout. Parking at the back of a large parking lot to increase your walk intentionally is physical activity, going on a 2 mile hike is exercise. If exercise seems like a lot to get started with, you can begin any type of routine by increasing your physical activity. Once you feel comfortable with advancing to exercise, you will need to know more about the principals below.
FREQUENCY
The number of times you workout each week.
INTENSITY
Your perception of the level of effort the workout requires.
Time
The overall time you spend each week doing physical acitivity or exercise.
Type
The physical activity or exercise that you do.
What is impact training?
Impact training, also known as plyometrics, is defined by ACSM as “exercises that link strength with speed of movement to produce power.”(3) A simple example of an impact exercise is the squat jump, which is a basic squat that generates enough power in the concentric (upward) phase to drive your feet off the ground.
Impact exercises are considered by the average person to be part of a high intensity routine and are very important to bone health.
There are many techniques and modifications we utilize to get you safely to completing the impact exercise in the POWIR protocol, so don’t worry about it if you can’t do it day one.
The first exercise in POWIR is the Jump Squat, the principal impact exercise in the program. You may not perform this for sometime after beginning your exercise presciption.
Resistance exercise
What is resistance training?
Muscular fitness is optimized through the implementation of resistance training, which can encompass free weights, machines, body weight, bands/tubing, or any other object that requires one to exert force against a resistance. (4)
Resistance training starts with bodyweight exercises and should progress to incorporate an external object that increases resistance. We recommend bands in most instances but just about anything around that house that you feel comfortable holding will work.
Lower Body
- Squats: 1 set of 10
- Bent Knee Deadlift: 1 set of 10
- Forward Lunge: 1 set of 10 each side
- Lateral Luge: 1 set of 10 each side
Upper Body
- Single Arm Row: 1 to 2 sets of 10 each side
- Chest Press: 1 to 2 sets of 10
- Single Arm Lateral Raise: 1 to 2 sets of 10 each side.
- Push Up: 1-2 sets of 10
PLANNED PROGRESSION
INCREASING INTENSITY?
PROGRESSIONS
A progession in training intensity is required to get the best results. For this study the progression was resistance based, this means that you start with no or little weight and increase the resistance ‘load’ over time. We recommend starting with bodyweight and very light bands until you are confident in your form and range of motion, then adding resistance in the form of thicker bands or whatever you have immediatly available to you. In the study participants went from body weight to 13% of body weight using weighted vests for lower body exercises. Using elastic bands for upper body exercises, participants advanced through three thicknesses of bands that increased in tension incrementally from band-to-band by 50-60%. The number of sets and reps remained constant throught the 12 month course of the study. Once participants began doing more than 12 reps of an exercise they increased the resistance to the point that they could not exceed 8 repetitions
Here is a sample planned progression from a study on ADT using the POWIR protocol.
This progression leaves the squat jump out the first month, allowing you to build your legs up to it with the lower body exercises. Percentage of bodyweight isn’t as important as how you feel in the last 3 reps. In your first 4-6 weeks you should be able to perform the reps without too much difficulty. When you start adding or increasing resistance, you should begin to feel like you can’t complete much more than the designated number of reps. Towards the end of the 12 month progression you should be hitting ‘negatives’ by rep 9 and 10, which means that you’ve added enough resistance that you could not complete more than 9 or 10 reps without quitting.
THE STUDY
WHAT THE PARTICIPANTS DID
The Training Program Verbatim
The lower body training program consisted of 9 sets of 10–12 jumps and 9 sets of 10–12 repetitions of lower body resistance exercises. Repetitions were performed in succession with approximately 15–30 s of rest between jumps and 2–3 min of rest between sets of resistance exercise. Jumping routines varied in type and height, but totaled 100 for each session. Jumps were performed in the following ways: (1) off the ground, (2) off 8-in. wooden boxes, (3) in the forward and side directions, and (4) in single- or double-leg stances. Participants performed the jumps on 2-in. gymnastics mats and were instructed to jump with shoes off and to land on both feet with approximately 30° of knee flexion.
Lower body exercises (squats, lunges, and calf raises) were performed immediately following jumps. Each session consisted of 3 sets of 10–12 squats, 6 sets of 10–12 lunges (2 sets in two directions), and 2 sets of calf raises. Intensity for both jump and resistance exercise was increased using weighted vests and calculated as a percentage of body weight (%BW), such that each participant exercised at the same relative intensity. Jump and resistance intensity were progressively increased over the program to a final intensity of 10%BW for jumps and 13%BW for resistance exercises.
Upper body exercise followed jumps, participants performed 3 sets of 8–12 repetitions of upper body exercises, with approximately 1–2 min of rest between sets. Exercises consisted of the following: upright row, one-arm row, latissimus dorsi pull-down, chest press, chest fly, biceps curl and triceps extension. In order to be time efficient and to have both groups complete resistance exercises at the same time, upper and lower body exercises were often combined into one movement. Examples of combined exercise include the following: biceps curl or upright row with squat, tricep extension or one-arm row with side lunge, lat pull-down or chest press/fly with front lunge. One type of exercise for each major muscle group was performed at each session, though over the week specific exercises were varied. Resistance to the exercises was delivered via elastic bands (TheraBand, Inc.) selected to achieve an intensity of ∼8–12 Repetition Maximum (RM), within the recommended range of repetitions for improving muscle fitness in novice resistance exercisers [18]. When participants could perform more than 12 repetitions with a given band, the band resistance was increased so that women could only perform ∼8 repetitions. This volume of elastic band training has been reported to produce significant increases in strength in premenopausal women [19].
CONCLUSION
POWIR4ADT
POWIR is the most estabilshed protocol for impact and resistance exercise pertaining to decreasing disability related to ADT and improving quality of life for PCS. There is room to add more exercises, especially as part of a periodized training schedule that other studies have also found to be effective. But for all intents and purposes, the goal of all PCS undergoing ADT should be to be able to perform all of the POWIR4ADT exercises listed in our program with proper form and at the prescribed intensity unless a physical or medical condition exists that would prevent the safe execution of any or all of the exercises.
We have simplified some of the exercise simply because men undergoing ADT are generally going to be of a more advanced age and limited mobility than the participants in this particular study. However, with the right training and progress, everyone should be able to conduct the exercises exactly as they were performed in the study as well as other, more advanced movements that could improve overall health even more.
CITATIONS
1. Drake, Matthew T. “Osteoporosis and cancer.” Current osteoporosis reports vol. 11,3 (2013): 163-70. doi:10.1007/s11914-013-0154-3
2. Winters-Stone KM, Snow CM. Site-specific response of bone to exercise in premenopausal women. Bone. 2006 Dec;39(6):1203-9. doi: 10.1016/j.bone.2006.06.005. Epub 2006 Jul 28. PMID: 16876495.
3. Faigenbaum, A. and Chu, D. Plyometric Training for Children and Adolescents. Indianapolis, IN: American College of Sports Medicine; 2017
4. Ratamess NA. ACSM’s Foundations of Strength Training and Conditioning. Philadelphia (PA): Lippincott Williams & Wilkins; 2012. 560 p.
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