Role of physiotherapy rehabilitation strategies in prostate cancer survivors: A systematic review and meta-analysis

Abstract

Background

Prostate cancer (PCa) patients may suffer a host of adverse effects of the disease or its treatments. The role of physiotherapy in PCa rehabilitation in dealing with these problems is less understood. This study aims to qualitatively and quantitatively assess the existing literature on PCa survivors that studies the role of various physiotherapy rehabilitation strategies in managing problems like cancer-related fatigue (CRF), urinary incontinence (UI), sexual dysfunction (SD), and quality of life (QoL).

Objectives

To review and quantitatively assess the existing body of literature on the role of physiotherapy strategies and their impact on CRF, UI, SD, and QoL in PCa survivors.

Methods

A digital search was conducted in PubMed, CINAHL, Google Scholar, PEDro, and Cochrane databases between October 2013 and October 2023. Studies meeting the eligibility criteria were evaluated using the PEDro scale followed by descriptive synthesis. The meta-analysis was done using the software Stata version 16. 29 studies were included in this review. 28 were RCTs and 1 was a pre- and post-interventional study. 28 studies were evaluated for risk of bias. Only 10 studies were included for meta-analysis due to insufficient data.

Results

The results showed significant trends favoring intervention groups regarding CRF (theta = 1.83, z = 2.16; p = 0.03), UI (Theta = −0.60, z = −5.05; p = 0.0000), and QoL (theta = 0.335, z = 2.75; p = 0.01) of PCa survivors. However, non-significant trends favoring the intervention groups regarding SD (theta = 0.36, z = 1.25; p = 0.21) were seen.

Conclusion

The study highlights that physiotherapy interventions can reduce CRF, UI, and SD and thereby help to improve health-related QoL of PCa survivors.

Keywords

Introduction

Prostate cancer (PCa) accounts for 3.8% of all male cancer-related fatalities and has an incidence of 7.1%, making it the second most common malignancy afflicting males globally.¹ Active monitoring, chemotherapy, radiation therapy (RT), hormone replacement therapy, surgical procedures, and cryosurgery are among the treatment options for PCa.² Since there are now many more effective treatment options for PCa, most men who are diagnosed with the disease have longer longevity. Nevertheless, patients could have negative side effects from the illness or its therapies.³ The patients may experience long-term negative physical side effects including erectile dysfunction, bowel issues, and incontinence, in addition to more generalized symptoms like fatigue, and a state of despair.⁴ The combination of two factors—disease-related or treatment-related factors—and decreased physical activity leads to fatigue.⁵ Erectile dysfunction primarily occurs as a result of alteration in the neural and vascular system controlling erectile function following radical prostatectomy (RP), RT, and androgen deprivation therapy (ADT).⁶ PCa patients also experience a decline in their quality of life (QoL) as a result of various issues related to the illness or its therapies. Consequently, the significance of comprehensive cancer care beyond medical therapies is increasingly acknowledged.

Physiotherapy rehabilitation strategies have gained attention as an essential component of multidisciplinary care for PCa patients.⁷ These strategies encompass a broad spectrum of interventions that address the functional, physical, and psychosocial challenges faced by individuals undergoing treatment and recovery from PCa.⁸ The surgical treatment of PCa often leads to urinary incontinence (UI). Early institution of combined pelvic floor muscle (PFM) exercises and biofeedback after a prostatectomy procedure contributes to regaining continence. There is growing support and a compelling theoretical explanation in favor of using exercise to treat erectile dysfunction in men who have survived PCa. The protective impact of exercise on sexual activity was thought to be mediated by improved QoL. Previous research established the significant associations between changes in sexual activity and changes in general health and role-emotional QoL categories. Exercises that are recommended for treating sexual dysfunction (SD) include resistance and aerobic training.⁹ Energy-conservation measures and exercises are part of the physiotherapy management of cancer-related fatigue (CRF).¹⁰ Physiotherapy interventions help increase physical activity, reduce CRF, and improve functional ability, thereby enhancing QoL of PCa survivors.⁵ This systemic review and meta-analysis aim to explore the role of various physiotherapy interventions in the management of CRF, UI, SD, and QoL in PCa survivors.

Methods

This review was framed according to the PRISMA guidelines.¹¹ The study’s search strategy used the PICO (Population, Intervention, Comparator, Outcomes) format, focusing on PCa patients/survivors. The PICO format guided the inclusion criteria.

PCa survivors who were at least 18 years old and complained of fatigue, UI, SD, and decreased QoL while undergoing exercise or physiotherapy interventions, such as stretching, resistance exercises (RE), PFM exercises, aerobic exercises, and electrical stimulation, were included in all studies with experimental designs or clinical designs published only in the English language between October 2013 and October 2023. Excluded criteria were case reports and case series, research procedures, abstract-only studies, duplicate studies, and gray literature.

The search strategy was prepared with the discussion among the authors who searched the five databases independently which included PubMed, CINAHL, Google Scholar, PEDro, and Cochrane in the period of October 2013 and October 2023 using the keywords PCa, physiotherapy, exercises, QoL, pain, fatigue, UI, SD, pelvic floor exercises, Kegel’s exercises, electrical stimulation, transcutaneous electrical nerve stimulation, and RE. Articles were selected per the defined eligibility criteria from these databases. The records obtained from the electronic search were evaluated and screened for titles and abstracts. The irrelevant articles and duplicate records were excluded following the screening. The full-text versions of all the relevant articles were obtained and underwent screening. The articles satisfying the inclusion criteria were included in the studies.

Study design

Experimental designs including clinical trials, and randomized controlled trials published between October 2013 and October 2023 were considered for inclusion in the study.

Population

Studies that involved participants (over the age of 18) with a diagnosis of PCa and undergoing adjuvant therapy, chemotherapy, radiation, or surgery were eligible to be included. Participants in the studies must be experiencing fatigue, UI, SD, pain, and reduced QoL.

Interventions

Patients receive strengthening, stretching, PFM exercises, aerobic exercises, biofeedback, and electrotherapy.

Comparator

The comparators were no intervention group, other physiotherapy interventions, or usual pharmacological and medical care.

Outcomes

Outcomes for fatigue, UI, SD, and QOL were the outcomes of interest.

Literature search

Following the creation of the search strategy, a review process was put in place. The results obtained from the digital search were thoroughly screened, and duplicates were removed. The full texts of the studies satisfying eligibility criteria were then examined separately to see if they met the PICO requirements. Disagreements were settled through conversation or, if necessary, by consulting with another reviewer.

Data extraction

Using Microsoft Excel, the author extracted data for the year, research design, participant demographics, interventions used, choice of outcome measures, and results. Discussions were done to settle any disputes.

Quality assessment

The included articles were qualitatively assessed independently using the PEDro (Physiotherapy Evidence Database) Rating Scale. It is the most commonly used tool to assess the methodological quality of clinical trials. Items in the scale were rated yes or no (1 or 0) based on the criteria satisfied in the study. A higher score of the study stated superior methodological quality.¹¹ The reviewer autonomously rated the studies and disputes were resolved by discussion.

Meta-analysis

The meta-analysis was done using the software Stata version 16.¹² The post-interventional values from the intervention and control groups were used for all analyses. All the analyses were done using a random effect model. Cohen’s d was chosen as an effect size that indicates the standardized mean difference between the two groups. The overall effect size is calculated using the test of theta. The p-value less than 0.005 for the test of overall effect size (theta) is considered a significant overall effect across the studies. Heterogeneity was expressed using I² statistics whereas homogeneity was expressed using chi² statistics. For the test of homogeneity, p <0.05 is considered significant.

The forest plots display the graphical presentation of the results of studies included in the meta-analysis. In all the plots, the effect sizes of the studies lying right to the null effect line represent the results in favor of the intervention group and those lying left to the null effect line favor the control group except the forest plot of studies with urinary symptom domain of EORTC QLQ-PR25 where the effect sizes lying left to the line suggest the results in favor of the intervention group and those lying right to the line suggest the results in favor of control group.

Results

Study selection

1088 articles were found from the database search out of which 680 irrelevant records and 111 duplicates were removed. 297 records underwent title and abstract screening. Following the screening 194 records were excluded and 103 articles were sought for retrieval. Out of 103 articles, 80 articles could be retrieved. Thus, full-text screening of 80 articles was performed independently of which 29 satisfied the defined eligibility criteria and included in this review (Figure 1).

Figure 1.

The PRISMA 2020 flow diagram showing the identification, screening, and inclusion of studies in the review. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Participants’ characteristics

A total of 2000 adult participants underwent various physiotherapy interventions across all the included studies. The frequency, duration, and type of exercise varied among the studies. The participants were PCa patients undergoing ADT, RT, and/or surgery.

Quality assessment

The PEDro Rating Scale was used to independently assess the methodological quality of the studies included in this review. This tool is commonly used to evaluate the methodological quality of clinical trials related to physiotherapy, health, and medical research. Items in the scale are rated yes or no based on the criteria satisfied in the study. ‘Yes’ is numbered as 1 and ‘no’ as 0. The higher the score, the better the methodological quality of the study (Table 1). 23 out of 28 RCTs have scores between 6 and 8 indicating a good quality of evidence with a low risk of bias, whereas 4 studies scored 4–5 indicating fair quality evidence with a moderate risk of bias and one study scored 2 which suggests a high risk of bias.

Table 1.

PEDro scale quality assessment of included articles. PEDro scale = Physiotherapy Evidence Database scale. Total score 0–3 = Poor, 4–5 = Fair, 6–8 = Good, 9–10 = Excellent.

Author (year)	Criteria 1	Criteria 2	Criteria 3	Criteria 4	Criteria 5	Criteria 6	Criteria 7	Criteria 8	Criteria 9	Criteria 10	Criteria 11	Total
Bourke et al (2013)¹³	Yes	1	1	1	0	0	1	0	0	1	1	6
Cormie et al (2013)¹⁴	Yes	1	1	1	0	0	0	1	0	1	1	6
Campo et al (2014)²⁹	Yes	1	1	1	0	0	1	0	0	1	1	6
Buffart et al (2014)¹⁵	Yes	1	0	1	0	0	0	1	1	1	1	6
Rajkowska-Labon et al (2014)³¹	Yes	0	0	1	0	0	0	1	1	1	0	4
Zhang et al (2015)³²	Yes	1	1	1	0	0	1	1	0	1	1	7
Zopf et al (2015)³³	Yes	0	0	1	0	0	0	1	1	1	1	5
Cormie et al (2015) (2016)	Yes	1	1	1	0	0	0	1	0	1	1	6
Nilsen et al (2015)¹⁷	Yes	1	1	1	0	0	1	1	1	1	1	8
Buffart et al (2015)¹⁸	Yes	1	1	1	0	0	1	1	1	1	1	8
Hojan et al (2016)¹⁹	Yes	1	1	1	0	0	1	1	1	1	1	8
Ben-Josef et al (2017)²⁸	Yes	1	1	1	0	0	1	1	0	1	1	7
Hojan et al (2017)²⁰	Yes	1	1	1	0	0	0	1	0	1	0	5
De Santan e Santos et al (2017)³⁴	Yes	1	1	1	0	0	1	1	0	1	1	7
Laurienzo et al (2018)³⁵	Yes	1	0	1	0	0	0	0	0	0	Not applicable	2
Mardani et al (2018)³⁶	Yes	1	1	1	0	0	1	1	0	1	1	7
Tantawy et al (2019)³⁷	Yes	1	1	1	0	0	1	1	0	1	1	7
Villumsen et al (2019)²¹	Yes	1	1	1	1	0	0	1	0	1	1	7
Ndjavera et al (2020)²²	Yes	1	1	1	0	0	1	1	1	1	0	7
Heydenreich et al (2020)³⁸	Yes	1	1	1	0	0	0	1	1	1	1	7
González et al (2020)³⁹	Yes	1	1	1	0	0	0	1	0	1	1	6
Galvão et al (2020)⁴²	Yes	1	1	1	0	0	0	1	0	1	1	6
Kaushik et al (2021)³⁰	Yes	1	1	1	0	0	0	1	0	1	1	6
Strojek et al (2021)⁴⁰	Yes	1	1	1	0	0	0	1	0	1	1	6
Ashton et al (2021)²³	Yes	1	1	1	0	1	1	1	0	1	1	8
Harrison et al (2022)²⁴	Yes	1	1	1	0	0	0	1	1	1	1	7
Moon et al (2022) (25)	Yes	1	1	0	0	0	0	0	0	1	1	4
Faithfull et al (2022)⁴¹	Yes	1	1	1	0	0	0	1	0	1	1	6

Interventions

14 studies delivered RE and/or AE in one or the other form. Various forms of resistance training included high-load strength training, body weight-based strength training, impact loading, and progressive resistance exercises. Aerobic training usually involves walking, cycling, jogging, and treadmill training. The intensity and frequency of the training varied in different studies.^13–26 Two studies delivered flexibility exercises in combination with AE and RE.^18,27 A study also delivered RE and AE through video games. Participants in two studies performed yoga and one study performed qigong exercises.^28–30

11 studies delivered PFM strengthening exercises individually or in combination with other interventions. Pelvic floor exercises are administered along with biofeedback, whole-body vibration training, oscillating rod therapy, bladder training, electrical stimulation, and AE and RE.^31–41

Outcome measures

The studies included in this review used FACIT-F (Functional Assessment of Chronic Illness Therapy – Fatigue), Brief fatigue inventory (BFI), and fatigue subscales of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Prostate (EORTC QLQ PR25) to assess the fatigue level of the participants. The most commonly used outcome measures for urinary function are the 1-hour pad test, 24-hour pad test, International Prostate Severity Score (IPSS), Visual Analogue Scale (VAS), and urinary questionnaire of Expanded Prostate Index Composite (EPIC). Whereas to assess sexual function, the studies used International Index of Erectile Function (IIEF) and the sexual function questionnaire of EPIC. The most commonly used QOL questionnaires were Functional Assessment of Cancer Therapy-Prostate (FACT-P), EORTC QLQ-PR25, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core (EORTC QLQ-C30), Short form Health Survey-12 Items (SF-12), Short Form Health Survey-36 Items(SF-36), University of California, Los Angeles Prostate Cancer Index (UCLA-PCI), Functional Assessment of Cancer Therapy-General(FACT-G), and (EuroQol-5 Dimension-5 Level Descriptive System) EQ-5D-5L. Table 2 depicts the characteristics of the studies included in this review.

Table 2.

Characteristics of included studies.

Author (year)	Study type	Participants	Sample size	Interventions	Outcome measures	Results
Bourke et al (2013)¹³	RCT	PCa patients on long-term ADT	100	IG: Supervised AE and RE plus dietary advice and behavior change support.	FACT-P, FACT-F	Improvements in QoL and fatigue after 12 weeks of interventions.
Bourke et al (2013)¹³	RCT	PCa patients on long-term ADT	100	CG: Usual care	FACT-P, FACT-F	Fatigue level was maintained at 6 months.
Cormie et al (2013)¹⁴	RCT	PCa patients on ADT	57	IG: AE and RE for 12 weeks	Sexual subscale of EORTC QLQ PR25, SF-36	Significant between-group differences in terms of sexual activity at 12 weeks.
Cormie et al (2013)¹⁴	RCT	PCa patients on ADT	57	CG: Usual care	Sexual subscale of EORTC QLQ PR25, SF-36	QoL improved significantly in IG than CG.
Campo et al (2014)²⁹	RCT	Fatigued and sedentary senior PCa survivors	40	IG: Qigong exercises	FACIT-F scale	Significant improvements in fatigue level in IG than CG.
Campo et al (2014)²⁹	RCT	Fatigued and sedentary senior PCa survivors	40	CG: Non-aerobic stretching exercises	FACIT-F scale	Significant improvements in fatigue level in IG than CG.
Buffart et al (2014)¹⁵	RCT	Men with PCa who completed 2 months of ADT	57	IG: PRE and AE	SF-36, fatigue subscale of EORTC QLQ-C30	Significant improvement in QoL and reduction in fatigue in the intervention group.
Buffart et al (2014)¹⁵	RCT	Men with PCa who completed 2 months of ADT	57	CG: Usual care	SF-36, fatigue subscale of EORTC QLQ-C30
Rajkowska-Labon et al (2014)³¹	RCT	Males with urinary incontinence following radical prostatectomy	81	Subgroup 1A: PFMT with spinal segment stabilization and biofeedback, home exercises	1-hour pad test and 24-hour pad test	Significant improvement in UI in Group 1 than in Group 2. More continent patients in Subgroup IA than in Subgroup IB.
Rajkowska-Labon et al (2014)³¹	RCT		81	Subgroup 1B: PFMT without BF home exercises same as subgroup 1A.	1-hour pad test and 24-hour pad test
Zhang et al (2015)³²	RCT	PCa survivors with persistent urinary incontinence	244	IG: Biofeedback-assisted PFMT and problem-solving therapy.	Pad tests, 7-item I-PSS, UCLA-PCI, VAS	Improvements in urinary incontinence and associated symptoms in IG than CG at 6 months.
Zhang et al (2015)³²	RCT	PCa survivors with persistent urinary incontinence	244	CG: Usual care	Pad tests, 7-item I-PSS, UCLA-PCI, VAS
Zopf et al (2015)³³	Non-randomized controlled trial	Men who had RP or combination therapy for PCa	85	AE and RE with exergaming	EORTC QLQ-C30, EORTC QLQ-PR25, IIEF	Significant increase in QoL within the IG.
						Significant improvements in urinary symptom, and sexual function scores in the IG.
						No improvements in erectile function in either groups.
						Comparatively more patients became sexually active in IG.
Cormie et al (2015)¹⁶	RCT	Men with PCa scheduled for ADT	63	IG: Moderate–high-intensity AE and RE CG: Usual care	SF-36, sexual subscale of EORTC QLQ	Improvements in QoL in IG.
Cormie et al (2015)¹⁶	RCT	Men with PCa scheduled for ADT	63	IG: Moderate–high-intensity AE and RE CG: Usual care	PR25, FACIT-F	The exercise group reported better improvements in sexual function and less fatigue than the usual-care group.
Nilsen et al (2015)¹⁷	RCT	Intermediate- or high-risk PCa patients	58	IG: High-load strength training program	EORTC QLQ-C30	No changes in EORTC QLQ-C30 scores in IG and CG.
Nilsen et al (2015)¹⁷	RCT	Intermediate- or high-risk PCa patients	58	CG: General physical activity	EORTC QLQ-C30	No changes in EORTC QLQ-C30 scores in IG and CG.
Buffart et al (2015)¹⁸	RCT	Older long-term PCa survivors	100	IG: AE and RE CG: General physical activity	EORTC QLQ-C30	Significant improvements in QoL of IG than CG.
Buffart et al (2015)¹⁸	RCT	Older long-term PCa survivors	100	IG: AE and RE CG: General physical activity	EORTC QLQ-C30	Significant difference in IG and CG in terms of physical function domain of HRQoL at 12 months in favor of IG.
Hojan et al (2016)¹⁹	RCT	Men with high-risk	72	IG: AE and RE CG: Usual care	FACT-F, FACT-G, EORTC QLQ-C30, QLQ-PR25	Patients in the IG showed significantly higher scores for FACT-F and FACT-G compared with controls after 12 months. Significant differences in QoL (QLQ-C30) between IG and CG. Significant improvement in sexual functioning, bowel symptoms, and incontinence aid domains of QLQ PR25 in the IG as compared to CG.
		and intermediate-risk
		PCa planned for RT
Ben-Josef et al (2017)²⁸	RCT	PCa patients undergoing RT	50	IG: Eischens yoga classes	BFI, FACT-G, IIEF-5, SHIM, IPSS	Significant improvements in fatigue level and sexual health in IG than CG. Non-significant improvements in QOL.
Ben-Josef et al (2017)²⁸	RCT	PCa patients undergoing RT	50	CG: Usual care	BFI, FACT-G, IIEF-5, SHIM, IPSS
Hojan et al (2017)²⁰	RCT	High-risk or intermediate-risk PCa men planned to receive RT or ADT	72	IG: moderate-intensity AE and RE CG: Daily physical activity	FACT-F, QLQ-C30, QLQ-PR25	Significant improvement in fatigue at 8 weeks and after 10 months.
de Santana e Santos et al (2017)³⁴	RCT	Men with PCa men with UI after retropubic or laparoscopic prostatectomy	16	IG: PFMT plus biofeedback	1-hour pad test, Occurrence of nocturia, number of pads used	A significant improvement in 1-hour pad test score, nocturia, and reduced use of pads in IG than and CG.
de Santana e Santos et al (2017)³⁴	RCT		16	CG: Only active exercises.
Laurienzo et al (2018)³⁵	RCT	PCa survivors experiencing UI after 1 month after RP	123	Group 1: only the routine instructions,	1-hour pad test, ICIQ-SF, IIEF-5, IPSS, pelvic floor muscle strength using a perineometer.	No significant improvements in muscle strength, erectile function and QoL in all the groups. Significant improvement in prostate cancer symptoms at the sixth months in all the groups.
				Group 2: Home-based PFMT
				Group 3: home exercises + anal electro-stimulation therapy
Mardani et al (2018)³⁶	RCT	PCa survivors receiving treatment for 3–12 months.	80	IG: AE, RE, flexibility exercises, and PFMT.	QLQ-C30	IG showed improvements in physical function, role function, fatigue, and sexual activity domains in the control group,
Mardani et al (2018)³⁶	RCT	PCa survivors receiving treatment for 3–12 months.	80	CG: Usual care	QLQ-C30
Tantawy et al (2019)³⁷	RCT	PCa survivors with mild stress UI who underwent RP	64	Group 1: PFMT and WBVT	I-VAS, ICIQ-SF and 24-hour pad test.	There was a significant improvement in urinary incontinence and QoL in IG after 4 weeks of intervention.
Tantawy et al (2019)³⁷	RCT	PCa survivors with mild stress UI who underwent RP	64	Group 2: PFMT	I-VAS, ICIQ-SF and 24-hour pad test.
Villumsen et al (2019)²¹	RCT	Patients with PCa undergoing ADT	46	IG: Fitness Evolved 2012 game promoting AE and RE CG: Usual care	FACT-P, EORTC QLQC30, FACT-F	No between-group differences in QoL and fatigue. Insignificant increase in physical function and global health domains of QoL in IG than CG.
Ndjavera et al (2020)²²	RCT	PCa patients beginning LHRH agonist treatment with or without RT, are anticipated to remain on ADT for more than 6 months.	50	IG: AE and RE CG: Usual care	FACT-P, FACIT-F	FACT-F and FACT-P scores were higher at 6 months as compared to baseline in IG.
Heydenreich et al (2020)³⁸	RCT	Patients with urinary incontinence after prostatectomy for PCa	184	IG: PFMT and oscillating rod therapy	1- and 24-hour pad test, FACT-P	Significant improvement in UI and QoL IG than CG.
Heydenreich et al (2020)³⁸	RCT		184	CG: PFMT and relaxation therapy	1- and 24-hour pad test, FACT-P	Significant improvement in UI and QoL IG than CG.
González et al (2020)³⁹	RCT	Stress-incontinent patients who underwent RP due to PCa	47	IG electrotherapy and EMG BF plus a home-based PFMT.	1 and 24‐hour pad tests, ICIQ‐SF	Significant improvements in UI and QoL in IG than CG at 3 months and 6 months in favor of the treatment group.
González et al (2020)³⁹	RCT	Stress-incontinent patients who underwent RP due to PCa	47	CG: Home-based PFMT	1 and 24‐hour pad tests, ICIQ‐SF
Galvão et al (2020)⁴²	RCT	PCa with established bone metastases	57	IG: RE, AE, and flexibility exercise	IIEF, EPIC, EORTC-PR25	Non-significant improvements in sexual function, sexual activity, and QoL in both groups.
Galvão et al (2020)⁴²	RCT	PCa with established bone metastases	57	CG: Usual care	IIEF, EPIC, EORTC-PR25
Kaushik et al (2021)³⁰	RCT	PCa patients scheduled for RP	29	IG: Yoga exercises	FACT-P, FACIT-F, EPIC-urinary questionnaire, EPIC-sexual function questionnaire	Clinically meaningful improvements in fatigue, urinary function, sexual function, and QoL.
Kaushik et al (2021)³⁰	RCT	PCa patients scheduled for RP	29	CG: Usual care
Strojek et al (2021)⁴⁰	RCT	Men with PCa who received radical prostatectomy	37	IG: PFMT, postural corrections, sacral mobilization, thoracic and abdominal respiration before PFMT.	EPIC-26	Significant improvements in EPIC-26 scores in IG than CG.
Strojek et al (2021)⁴⁰	RCT	Men with PCa who received radical prostatectomy	37	CG: Usual care	EPIC-26	Significant improvements in EPIC-26 scores in IG than CG.
Ashton et al (2021)²³	RCT	PCa patients, undergone RARP in the previous 8–12 weeks	42	IG: RE CG: Usual care	EQ-5D-5L and FACT-P QoL Questionnaires, Brief Fatigue Inventory	No changes in EQ-5D or BFI scores in both the groups. Improvements in HRQoL in the intervention group at 3 and 6 months.
Harrison et al (2022)²⁴	RCT	Men with recurrent PCa undergoing ADT and enzalutamide	26	IG: AE and RE CG: Usual care	FACT-P, FACIT-F	No significant between-group changes in FACT-P and FACIT-F.
Moon et al (2022)²⁵	RCT	PCa patients under active surveillance	27	IG: Home-based AE and bodyweight-based exercises	SF-36, FACT-F	Significant improvements in FACT-F scores in IG than CG. No significant changes in QoL scores in either group.
Moon et al (2022)²⁵	RCT	PCa patients under active surveillance	27	CG: Usual care	SF-36, FACT-F
Faithfull et al (2022)⁴¹	RCT	PCa patients starting RT and experiencing urinary symptoms	63	IG: PFMT, pharmacotherapy and coping strategies, self-management and social support, peer discussions	IPSS, ICSM-SF, EORTC QLQ-PR25, EORTC QLQ-C30, SESCI	No significant difference in IPSS scores between the IG and CG.
						Significant improvement in ICS voiding symptoms, incontinence symptoms, SESCI in IG.
				CG: Usual care		No observed differences in QoL between groups.
Brown et al (2023)²⁶	Single-group feasibility study	PCa patients on active ADT and ARPI	30	Home-based progressive, moderate intensity walking and RE.	FACT-P, FACIT-F, EQ-5D-5L	Non-significant improvements in FACIT-F, FACT-G and EQ-5D-5L scores.

RCT: randomized controlled trial, PCa: prostate cancer, IG: intervention group, CG: control group, ADT: androgen deprivation therapy, UI: urinary incontinence, RP: radical prostatectomy, RT: radiation therapy, RE: resistance exercises, AE: aerobic exercises, PFMT: Pelvic Floor Muscle Training, PRE: progressive resistance exercises, WBVT: whole-body vibration training, ARPI: , FACT-P: Functional Assessment of Cancer Therapy-Prostate Cancer, FACIT-F: Functional Assessment of Chronic Illness Therapy – Fatigue, FACT-G: Functional Assessment of Cancer Therapy-EORTC QLQ-PR25: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Prostate, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core, IIEF: International Index of Erectile Function, EPIC: Expanded Prostate Cancer Index Composite, ICIQ-SF: International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, BFI: Brief Fatigue Inventory, EQ-5D-5L: EuroQol-5 Dimension-5 Level Descriptive System, IPSS: International Prostate Symptom Score, UCLA-PCI: University of California, Los Angeles Prostate Cancer Index, VAS: Visual Analogue Scale, SESCI: Self-Efficacy for Symptom Control Inventory.

Results of individual studies

The summary of results of included studies related to CRF is given in Table 3. Aerobic exercises and resistance training are found to have a positive impact on the fatigue level experienced by PCa patients receiving ADT. The delivery of these interventions before the initiation of ADT or chemotherapy results in less decline in fatigue level during the treatment and further leads to improvement in fatigue level when delivered after the treatment. Qigong exercises and yoga are also promising interventions that can be used to reduce fatigue in PCa patients. Most of the included studies show that encompassing these interventions in the rehabilitation protocol improves the PCa-related QoL as well as symptom-related QoL of the patients.

A summary of studies related to UI, sexual function, and QoL of PCa patients is given in Table 4. PFM training or Kegel exercises either individually or in combination with other therapies like biofeedback, electrical stimulation, whole-body vibration training, and oscillating rod therapy are beneficial in treating PCa patients with UI. These interventions can be administered before the prostatectomy surgery and then continued further after the surgery. Thus, the physiotherapy interventions help to improve the UI symptoms and related QoL of PCa patients.

PCa patients usually experience SD after the initiation of ADT. This also reduced their QoL. Administration of pelvic floor exercises in combination with aerobic and resistance training helps preserve the sexual function of the affected individuals and thereby improve their QoL.

Effect of physiotherapy interventions on fatigue

The 5 studies included in the meta-analysis used the FACIT-F scale (Functional Assessment of Chronic Illness Therapy – Fatigue) as a measure of fatigue experienced by the participants.^16,19–22 Figure 2 shows the post-intervention effect sizes and forest plots of all the included studies with the FACIT-F outcome measure. Katarzyna Hojan (2016) and Katarzyna Hojan (2017) show large effect sizes of 4.04 and 3.84 suggesting substantial differences between groups. Brigitta R. Villumsen (2019) also demonstrates a moderate effect size of 0.68 indicating notable differences. Prue Cormie (2015) and Wilphard Ndjavera (2020) have smaller effect sizes of 0.29 and 0.42, respectively, showing a relatively smaller difference between the groups. For Katarzyna Hojan’s studies, the CI is narrow, indicating high precision in the estimation. The CIs for Cohen’s d overlap, indicating variability but also some consistency in effect size estimates across the studies. All studies have relatively similar weights, except for Brigitta R. Villumsen (2019), which has a lower weight. The test of overall effect size (theta = 1.83, z = 2.16) is significantly different from zero, with a p-value of 0.03 suggesting a significant overall effect. The test of homogeneity (Q = 98.89) with a significant p-value (0.0000) and I² value of 96.93% indicates heterogeneity among effect sizes across the studies. In forest plot, all the studies lie on the right side of the axis indicating the results in the favor of intervention group. The overall effect size also lies on the right side of the axis without overlapping. Thus, the overall effect size is significantly in the favor of intervention.

Figure 2.

Post-intervention effect sizes and forest plot of studies with FACIT-F outcome measure. The null effect line passes through “0. “Effect sizes lying right to the null effect line represent the results in favor of the intervention group and those lying left to the null effect line favor the control group.

Effect of physiotherapy interventions on urinary incontinence

Six studies were included in the meta-analysis that used the Urinary symptom domain of the EORTC QLQ PR25 questionnaire.^{19,20,27,33,36,41} Figure 3 shows the post-intervention effect sizes and forest plots of all the studies with the Urinary symptom domain of the EORTC QLQ PR25 questionnaire. The negative Cohen’s d values indicate that all studies observed a decrease in urinary symptoms post-intervention. Larger negative values represent greater reductions in symptoms. Katarzyna Hojan’s studies have relatively larger negative values (−0.98 and −0.92) indicating a greater reduction in symptoms. The CIs provide a range within which the true effect size is estimated to lie. They indicate the precision of the effect size estimates. All studies have relatively similar weights, suggesting a similar influence on the overall effect size estimate. The test of overall effect size (Theta = −0.60, z = −5.05) significantly differs from zero, with a p-value of 0.0000, indicating a significant overall effect of the interventions on urinary symptoms. The non-significant p-value (0.27) for the test of homogeneity and I² value of 19.70% suggests that the effect sizes across studies are homogeneous, indicating consistency in the observed effects. In the forest plot, all the studies lie on the left side of the axis indicating the results in favor of the intervention groups. The overall effect size lies within the left area from the axis with no overlap with the line of no effect suggesting the significant overall effect size is in favor of intervention groups.

Figure 3.

Post-intervention effect sizes and forest plot of studies with urinary symptom domain of EORTC QLQ PR25 questionnaire. The null effect line passes through “0.” Effect sizes lying left to the line suggest the results in favor of the intervention group and those lying right to the line suggest the results in favor of the control group.

Effect of physiotherapy interventions on sexual function

Five studies were included in the meta-analysis that used the sexual function domain of the EORTC QLQ PR25 questionnaire.^{14,19,20,33,36} Figure 4 shows the post-intervention effect sizes of all the included studies with the sexual function domain of the EORTC QLQ PR25 questionnaire. Positive Cohen’s d values indicate an improvement in sexual function post-intervention, while negative values indicate a decline. All the studies have positive Cohen’s d value indicating improvement in sexual function except Abbas Mardani’s study which has a negative Cohen’s suggesting a decrease in sexual function. Larger absolute values suggest a more substantial effect. Prue Cormie’s study has a comparatively larger effect size than other studies. The CI provides a range within which the true effect size is estimated to lie. If the CI includes zero, the effect size may not be statistically significant. All studies have relatively similar weights, suggesting a similar influence on the overall effect size estimate. The non-significant p-value (0.21) for the test of overall effect size suggests that the overall effect size (theta = 0.36, z = 1.25) is not significantly different from zero, indicating that the Interventions may not have a consistent effect on sexual function across studies. The significant p-value (0.0001) for the test of homogeneity indicates that the effect sizes across studies are heterogeneous, suggesting variability in the observed effects. In the forest plot, all the studies lie on the right side of the axis indicating the results in favor of intervention groups. The overall effect size also lies on the right side of the axis overlapping with the line of no effect suggesting that the overall effect size is in favor of intervention groups but not significant.

Figure 4.

Post-intervention effect sizes and forest plot of studies with sexual function domain of EORTC QLQ PR25 questionnaire. The null effect line passes through “0.” Effect sizes lying right to the null effect line represent the results in favor of the intervention group and those lying left to the null effect line favor the control group.

Effect of physiotherapy interventions on quality of life

Three studies were included in the meta-analysis that used FACT-P as an outcome measure for PCa-specific QoL.^21,22,38 Figure 5 shows the post-intervention effect sizes of all the included studies with the FACT-P questionnaire. Wilphard Ndjavera (2020) and Marc Heydenreich (2020) have larger effect sizes (Cohen’s d = 0.39 and 0.33, respectively), suggesting a relatively larger difference in FACIT-P scores. Brigitta R. Villumsen’s study (2019) has the smallest effect size among the listed studies, with a Cohen’s d of 0.15, indicating a smaller but still notable difference. Each study’s weight represents its contribution to the meta-analysis. Marc Heydenreich’s study has the highest weight (66.82%), indicating its substantial influence on the overall effect size estimate. The non-significant p-value (0.81) for the test of homogeneity (Q = 0.42) suggests that the effect sizes across studies are homogeneous, indicating consistency in the observed effects. The effect sizes of all the studies lie within the area right to the axis suggesting results in favor of intervention groups. The overall effect size lies right to the axis without overlapping with the line of no effect suggesting the significant result in favor of the treatment group. This is consistent with the result of the test of overall effect size (theta = 0.335, z = ) with a p-value of 0.0059 which indicates a significant overall effect across the studies.

Figure 5.

Post-intervention effect sizes and forest plot of studies with FACIT-P outcome measure. The null effect line passes through “0.” Effect sizes lying right to the null effect line represent the results in favor of the intervention group and those lying left to the null effect line favor the control group.

Discussion

This review explores the existing literature on various physiotherapy interventions that can address CRF, UI, SD, and QoL of PCa survivors. The qualitative analysis reveals that the included studies provide good quality evidence on the role of various physiotherapy interventions in treating CRF, UI, and SD, and improving QoL of PCa patients. The meta-analysis of the results suggests a substantial decrease in the fatigue level, a decrease in urinary incontinence problems, and an improvement in the QoL of the patients following the administration of physiotherapy interventions. However, a non-significant trend is observed in the improvement of sexual function in PCa patients following physiotherapy.

Physical exercise reduces adverse effects of RT and ADT, such as fatigue, SD, and related psychological impacts. For males who were sexually active before starting ADT, exercise helps maintain sexual function.²⁰ Men who undergo RP are prone to develop erectile dysfunction and urine incontinence, which can negatively affect their sense of self-worth, male identity, and health-related QoL (HRQoL). According to current recommendations, PCa survivors should engage in individually designed exercise programs to enhance their HRQoL and general health.²³ Rajkowska-Labon suggests that early administration of PFMT with biofeedback along with home-based exercises after a prostatectomy procedure contribute to regaining continence.³¹ PFM training combined with whole-body vibration training also showed considerable improvements in UI after RP.³⁷ Another study demonstrated improvements in UI and sexual function after the administration of home-based PFM exercises along with ano-electrical stimulation therapy twice a week for 7 weeks after RP.³⁵ Heydenreich et al recommend the clinical application of the combination of PFM training and oscillation rod therapy after RP.³⁸ The effects of resistance and aerobic training on sexual function and activity in men with advanced PCa were documented in the investigation.⁴²

Bourke et al demonstrated the benefits of combined aerobic and resistance exercises, and dietary behavioral support for up to 12 weeks on QoL, exercise tolerance, and fatigue of PCa survivors.¹³ The training can involve 6 to 12 repetitions of strengthening exercises targeting major muscle groups and 15–20 minutes of aerobic exercises.¹⁵ These interventions prevent the decline in HRQL of PCa survivors when initiated early during ADT.¹⁸ Additionally, it was discovered that resistance exercise training (RET) is a realistic, safe, and effective kind of exercise that improves HRQL, CRF, and cardiovascular and metabolic health in men with PCa who have had RP.²³ Practicing yoga for 60 minutes (two times/week) for 6 weeks before surgery and an additional 6 weeks beginning three to 6 weeks after surgery also showed clinical improvements in fatigue, sexual function, and HRQL in PCa survivors.³⁰

This review studied a total of 2000 participants across all the 29 studies which add significantly to the existing evidence. The majority of included studies were of low risk of bias and provided good quality evidence. Also, 28 out of 29 included studies were RCTs which is considered the gold standard in experimental studies.

This study has a few limitations. Firstly, this review included 29 studies for the qualitative analysis while only 10 studies were included for meta-analysis due to the unavailability of sufficient data. Secondly, the limitations can also be attributed to the eligibility criteria. This review included studies published only in the English language; the authors excluded case reports, case series, and gray literature. Only four variables, namely, fatigue, UI, SD, and QoL were considered for inclusion in this review. Thus, the authors might have missed the evidence from other study types, other languages, and other variables associated with PCa survivors. Thirdly, the diversity of outcome measures for each studied variable posed difficulties in assessing the effect of interventions. Finally, few studies included in the review failed to prove the effectiveness of physiotherapy interventions on fatigue, UI, SD, and QoL of PCa patients. This can be attributed to the biases involved during the conduct of those studies.

This review recommends the future scope for the conduct of more studies exploring the role of physiotherapy interventions on SD experienced by PCa survivors and related QoL. The studies must consider the improvements in the methodological quality while eliminating the risk of bias. The authors also recommend that more future studies should be carried out focusing specifically on each variable included in this review.

Conclusion

This systematic review and meta-analysis highlight that physiotherapy interventions have a positive impact on CRF, UI, and SD and thereby help to improve health-related QoL of PCa survivors. Aerobic and resistance exercises, yoga, and qigong exercises are found to be effective in treating PCa patients complaining of fatigue. The administration of PFM training combined with other forms of therapy like biofeedback, electrotherapy, whole-body vibration training, and oscillating rod therapy is demonstrated to improve UI in PCa patients. Therefore, physiotherapy should be included as an integral part of the comprehensive rehabilitation of PCa survivors to improve their QoL. The physiotherapy interventions are also found to have a positive impact on the sexual function of the patients but the results were not significant.

Supplemental Material

Supplemental Material - Role of physiotherapeutic rehabilitation strategies in prostate cancer survivors: A systematic review and meta-analysis

Supplemental Material for Role of physiotherapeutic rehabilitation strategies in prostate cancer survivors: A systematic review and meta-analysis by Renu B Pattanshetty, Abhishek N Daf and Nikita N. Pawar in Physiotherapy Practice and Research.

Footnotes

Acknowledgments

We thank the librarian, statistician, colleagues, peers, and institution for their valuable support of this systematic review.

ORCID iD

Abhishek N Daf

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

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