PHYSIOTHERAPY SERVICE PROVISION IN PROSTATE CANCER

A new qualitative study highlights the important role of physiotherapy in supporting people undergoing treatment for prostate cancer, while revealing significant gaps in access, particularly in regional and public healthcare settings. First author Alesha Sayner agreed to answer some questions about the study. 

Your study highlights the fact that many patients are unaware physiotherapy can help. Why does this gap in awareness still exist?

The limitations in awareness are multifactorial. Significantly, men do not have the same societal messaging about pelvic health as women. 

Alesha Sayner MACP

For example, many women naturally accept that they may see a physiotherapist following childbirth. 

Many men never consider having bladder or bowel problems in their lifetime and have therefore never considered where they might get help. 

There is also the preoccupation and the weight of a cancer diagnosis, leading many men without a mental plan of action beyond treating the disease. 

This means that they rely on their GPs, specialists and other members of the multidisciplinary team to educate them and refer appropriately. 

However, there are still referrers who do not understand the specialised skills required by male pelvic health physiotherapists, resulting in missed opportunities for early referral and specificity of care. 

Participants emphasised early referral but what difference does starting physiotherapy before treatment make? 

Physiotherapy can be effective for people with prostate cancer, even before their treatment begins. 

There is evidence that prehabilitation, particularly pelvic floor muscle training, improves return to continence following radical prostatectomy. 

Positive benefits also extend to improved quality of life and a quicker return to occupational and social participation. 

Engaging people early builds a therapeutic alliance from day 1 and helps to promote participation and adherence. 

Pelvic floor muscle training was seen as essential but challenging. What support do patients need to do it effectively? 

Pelvic floor muscle training is more than just a physical intervention. 

It requires a complex interplay of contextual and behavioural elements that impact participation. 

Previous research has explored the influences on pelvic floor muscle training and identified capabilities (eg, being able to achieve a pelvic floor muscle contraction and self-confidence) and opportunities (eg, access to services and trained clinicians and competing demands) as mostly impacting participation (Sayner et al 2022). 

Supportive care can be optimised through ensuring individualisation of prescribed programs, ideally through an initial face-to-face consultation; biofeedback strategies; promoting the purpose and benefits of pelvic floor muscle training; building a trained workforce; and incorporating hybrid models of care. 

The use of ultrasound for biofeedback was highly valued. How does this change patient engagement and outcomes?

Transperineal real-time ultrasound is highly valued by patients for optimising confidence in technique, gaining a visual understanding of the role of the pelvic floor muscles and being able to view their progress. 

This was reported to contribute to adherence and motivation. 

One study participant described transperineal real-time ultrasound as providing a ‘breakthrough moment’ in their treatment and recommended that patients find a physiotherapist skilled in this modality. Clinicians also highly value transperineal real-time ultrasound, reporting that it optimises their ability to teach, prescribe and progress pelvic floor muscle training (Sayner et al 2025). 

You found clear inequities in access, especially in regional and public settings. What are the biggest barriers driving this? 

Our studies identified that patients accessing public physiotherapy services faced longer waiting times and occasionally missed opportunities for prehabilitation. 

Variability in allied health access and a shortage of physiotherapists with specific skills in male pelvic health were key barriers. 

These barriers were further emphasised in rural healthcare. 

Retention and recruitment of a skilled workforce means that patients face substantial travel burdens, expenses and reduced access to care. 

What changes are needed at a system level to ensure that all patients with prostate cancer can access appropriate physiotherapy care? 

Health-system-level change could include: 

• the embedding of physiotherapy into standard care for people with prostate cancer by ensuring that referrers and members of the multidisciplinary team have a comprehensive understanding of the role of physiotherapy and clear referral pathways 
• consideration of dedicated Medicare item numbers for pelvic health physiotherapy that accommodates hybrid models of care 
• government funding to improve infrastructure through the establishment of multidisciplinary hubs and mobile outreach services in rural and regional areas 
• financial incentives for physiotherapists working in public health and remote, rural and regional settings who wish to undertake postgraduate qualifications in male pelvic health 
• the establishment and further development of mentorship programs and communities of practice that are tailored specifically to male pelvic health physiotherapy, particularly for rurally placed clinicians. 

>>Alesha Sayner MACP is an APA Titled Women’s, Men’s and Pelvic Health Physiotherapist and a PhD candidate with the University of Canberra. She has over 15 years of experience in public and private continence settings.

RESPIRATORY MUSCLE STRENGTH IN PD 

A group of physiotherapists in Brazil collaborated on a randomised trial estimating the effect of high-intensity, combined inspiratory and expiratory muscle training in people with Parkinson’s disease. The senior author, Christina Faria, agreed to answer some questions about the trial. 

Why is respiratory muscle weakness an important but often overlooked issue in people with PD? 

Non-motor signs and symptoms of Parkinson’s disease (PD) are often underestimated due to several factors, including symptom acceptance, limited awareness of their association with the disease and a predominant focus on its motor manifestations.

Specifically, respiratory muscle weakness is a respiratory dysfunction that may be present even in the early stages of PD and tends to worsen as the disease progresses. 

Weakness of these muscles has a significant impact on the health, functionality and quality of life of these individuals. 

It is not detected early due to the reduced level of physical activity in individuals with PD. 

As physical activity declines, these individuals may not engage in activities that require sufficient energy expenditure to elicit respiratory adaptations that would reveal underlying dysfunction. 

Consequently, interventions aimed at improving these outcomes are often initiated only in the more advanced stages of the disease. 

Your study used high-intensity, combined inspiratory and expiratory training. What makes this approach different from previous research? 

Previous studies have conducted inspiratory or expiratory training in isolation. 

Training the inspiratory and expiratory muscles within the same respiratory cycle – using a single device – is faster and more economical than training them separately. 

In addition, it facilitates adequate load progression, sufficient training duration and high training frequency, as performed in the present study. 

The intervention was home-based with high adherence. What factors do you think contributed to its success? 

First, we included participants who had inspiratory or expiratory muscle weakness and, consequently, the potential to benefit from the intervention. 

Christina DCM Farla

These participants likely perceived benefits as the training progressed. 

In addition, we provided the participants with equipment that is easy to use and allows training of both inspiratory and expiratory muscles within the same respiratory cycle, thereby reducing training time. 

The protocol consisted of two daily 20-minute sessions (morning and afternoon). 

Each session was divided into four three-minute blocks, with a two-minute rest period between blocks, which likely facilitated adherence and performance. 

It is also important to note that participants were instructed to record their perceived exertion using the Borg scale after completing the final two-minute rest period, which was considered in load progression. 

The home-based nature of the intervention may have contributed to the high adherence rate, as it minimises travel-related barriers and reduces the time burden for participants. 

Finally, a trained therapist visited each participant’s home once a week to perform the necessary procedures to ensure appropriate training intensity, which could have motivated participants to adhere to the program. 

You found improvements in breathing strength and endurance. How do these translate into meaningful changes for patients in daily life? 

The minimum detectable change and the minimum clinically important difference for respiratory muscle strength have not yet been established for individuals with PD. 

The magnitude of the effects observed in the present study appears clinically meaningful when interpreted in light of thresholds reported for other populations. 

In addition, before training, the individuals included in the present study had respiratory strength below that predicted for the Brazilian population. 

After training, these values were consistent with the predicted values. 

Besides breathing strength and endurance, participants also demonstrated reduced dyspnoea and increased exercise capacity. 

Some outcomes, like fatigue and quality of life, didn’t change. What does this tell us about the role of respiratory training in broader rehabilitation? 

The participants in this study did not exhibit fatigue at baseline, making it unlikely to observe improvements in this outcome. 

Quality of life was assessed using a multidimensional quality-of-life instrument with eight domains. 

It is possible that respiratory muscle training does not substantially influence several of the domains, such as stigma and social support. 

This may reduce the possibility that changes associated with this intervention will be detected through the PDQ-39 (a Parkinson’s disease questionnaire). 

Therefore, the use of structured questionnaires alone may not be sufficient to fully capture potential changes in quality of life related to respiratory muscle training. 

It is also important to consider that we have investigated an intervention strategy focused on a specific impairment (respiratory muscle weakness). 

A rehabilitation program must include different intervention strategies that should focus on function, disability, health and quality of life instead of only one impairment, as commonly observed in randomised trials. 

What are the next steps for research and how could this type of training be implemented in routine physiotherapy practice? 

Future studies must investigate the efficacy of combined inspiratory and expiratory muscle training, including individuals at other stages of the Hoehn and Yahr scale. 

Additionally, studies with specific eligibility criteria outcomes, such as fatigue, should be carried out. 

Future studies may also consider incorporating qualitative methods to explore patients’ perceptions and experiences of respiratory muscle training, as reported in other populations. 

>>Christina DCM Faria is a physiotherapist and associate professor in the Department of Physiotherapy at Universidade Federal de Minas Gerais, Brazil. Since 2016, she has received a fellowship as a senior researcher. In 2020, she became the leader of a research group in adult neurorehabilitation in Brazil called NeuroGroup. Christina is a member of the editorial board of the Disability and Rehabilitation journal and of the Brazilian Journal of Physical Therapy.