Prostate cancer survivors sometimes fall into the gap between pelvic floor PT & OncoPT – who should be treating the patient & when?
The short answer is all hands on deck, but Dr. Matthew Johnston, PT, breaks down exactly how to prioritize your patient’s impairments & which team your patient should see first.
In today’s year-end replay episode, we dive into the physical, cognitive, emotional, & psychological aspects of a prostate cancer survivor’s experience, plus how to truly understand the barriers your patient faces in their home, work, & life environment.
Join us for an enlightening & eye-opening episode with Dr. Matthew Johnston, PT!
Prostate cancer survivors experience a multitude of cancer-related impairments.
Common side effects of prostate cancer treatment include urinary incontinence, sexual dysfunction, bowel issues, and abdominal problems.
Treating prostate cancer survivors requires a comprehensive approach that addresses both physical and emotional aspects of care. Prostate cancer survivors require individualized care that addresses their unique needs, including physical, cognitive, emotional, and psychological aspects.
Pelvic floor therapy is crucial for addressing side effects such as urinary incontinence, sexual dysfunction, and bowel issues in prostate cancer survivors.
BUT – not every patient needs pelvic floor therapy first.
Understanding the patient’s goals and priorities is crucial in developing an effective treatment plan.
Dr. Johnston discusses how important it is to talk with your patient & discuss their goals, priorities, & what they want to get out of therapy.
This helps you & your patient determine the most appropriate course of action, whether it be pelvic floor PT or OncoPT first (or something else entirely).
A holistic and patient-centered approach is essential in the care of prostate cancer survivors.
The most crucial way to implement this approach is by building a strong therapeutic alliance with your patient. This requires a safe space for patients to discuss their concerns AND for their concerns to be heard.
Active listening & being open to your patient’s perspective leads to better outcomes. In our interview, Dr. Johnston shared a powerful patient anecdote about how his patient struggled when coming home from work. By listening to what his patient and what his patient wasn’t saying, Dr. Johnston picked up on crucial details that were impeding his patient’s progress with incontinence issues.
Prefer to watch the interview instead?
About Dr. Matthew Johnston, PT
My goal is to expand the field of Men’s Pelvic Health Physical Therapy. I am building a program to treat men with pain conditions (pelvic pain, testicular pain, low back and hip pain), bowel issues (constipation, incontinence, pain, etc., urologic symptoms (frequency, urgency and incontinence) and post-prostatectomy care.
My background is in Orthopedic Physical Therapy. I am interested in the treatment of hip and groin conditions as well as the relationship between the lumbar spine, pelvis and hips. I am also trained in Vestibular therapy.
I am a former clinic leader who enjoys coaching and working with colleagues to grow as clinicians, develop critical thinking skills and form clinical frameworks to make efficient decisions. My former role included managing all operations and key performance indicators. I have led my team through various changes during the COVID-19 pandemic, clinic renovation, a rebranding and acquisition process all while maintaining an excellent NPS score and high patient satisfaction.
I my new role is working with a full caseload of male patients with pelvic health issues. I utilize real time ultrasound to localize pelvic contractions and ensure accuracy with exercise technique.
I am looking to learn, connect and collaborate! Reach out and message me to learn more about me, my patients or how we can connect!
Connect with Dr. Johnston on LinkedIn.
Email Dr. Johnston at matthewjohnston719@gmail.com
Transcript
Elise Cantu (00:20)
Hey, Onco PT and welcome back to this episode of the Onco PT podcast. We are continuing our countdown of the top episodes of 2024 this week, clocking in at number three. Now this episode was actually a guest who was asked back by popular demand. So the first part of this episode, well, let me back up here. I’m getting a little ahead of myself because I’m so excited. The first interview I did with this particular
physical therapist, Dr. Matthew Johnston, was all about prostate cancer rehab. And it was really, really good, really, really good. And we kind of got into the like the what and the how. But in this episode, which I am going to share with you today, we got into the soft skills associated with how to be the best physical therapist showing up for the person with prostate cancer in front of you.
And I love the distinction, and again, this was literally an episode. The first one was so popular, we had to have Matt back to talk about this more, and it was even more popular, per the listeners, which was so exciting. One of the things that I’ve really leaned into, and I’m going to continue leaning into, because I have so much more to learn about this, is the soft skills when it comes to cancer rehab. So not the, how do you perform range of motion on the shoulder joint, for example, or, know,
how do you perform a grade three mobilization of blah, blah, blah? That’s not what we’re talking about here. The soft skills are the interpersonal skills. Or as Adam Matichak likes to say, how are you showing up as a human for the human in front of you? And frankly, we need more of that in cancer rehab and in OncoPT which is why I’m so excited that our top three episode for 2024 is this interview with Dr. Matt Johnston.
You are going to love it and I cannot wait for you to hear this powerful, impactful conversation.
Elise – @TheOncoPT (02:17)
Hey Onco PT and welcome to this episode of the Onco PT podcast. Now earlier this spring, we had a fantastic episode on prostate cancer and really the soft skills around what it takes to treat this very amazing dynamic patient population. Well, the response from that episode was so positive. I brought Dr. Matt Johnston back on the podcast to continue this conversation on prostate cancer rehab. So Matt, welcome back to TheOncoPT podcast.
Matthew Johnston (02:47)
Thanks for having me, I’m happy to be back.
Elise – @TheOncoPT (02:50)
Would you mind introducing yourself or reintroducing yourself for the listeners who maybe haven’t listened to our previous interview yet?
Matthew Johnston (02:58)
Sure, I am a physical therapist based in Philadelphia and I treat orthopedics and I treat pelvic health for men who have a variety of issues, particularly prostate cancer for this particular conversation. And happy to talk more about prostate cancer and rehab process.
Elise – @TheOncoPT (03:18)
So if you haven’t already listened to our previous interview, that was episode 299 and you can find that episode at theoncopt .com slash 299 but we’re gonna jump right into it Matt because you and I were talking off air and we were already getting into some of the things we’re like okay we got to stop we got to save this for the episode. So when a patient comes to you with a diagnosis of prostate cancer
What does the evaluation process look like for you? Like, let’s hit the ground running.
Matthew Johnston (03:50)
Yes. So let’s, I guess let’s talk about preop first, because there is a percentage of patients that come preop. And that really looks at like a general health history. I’m looking at their pelvic health history, what their urination habits, do they leak currently? Do they have urgency currently? What are their bowel movements look like? Do they have any other like preexisting conditions, if you will? And then we dive into education. What is surgery going to be like? Expectations, timeframes, you know, having them learn about body parts.
Elise – @TheOncoPT (03:53)
Yeah.
Matthew Johnston (04:18)
an area that they’ve never even talked about before. So really a lot of it is education, understanding where, what region of the body we’re talking about and what is the pelvic floor, what does it do and how we’re going to get them from where they’re going to be post -op and all the way through recovery process and then long -term, when they are at the point of no evidence of disease, what does that look like and how can we help them long -term health -wise.
Elise – @TheOncoPT (04:21)
Yeah!
Mm -hmm.
Matthew Johnston (04:48)
If they have to go a different route, additional chemotherapy, radiation, hormone replacement therapy, what does that look like? What does that pathway look like? And how do we fit in and who could be part of our team? So that’s kind of the pre -op and then post -op is really understanding where do they fall on the continuum? Are they having no leakage or are they having a tongue? And how do we quantify that? How do we get some baseline data? And then we dive into the evaluation treatment process.
So that’s really in a nutshell from like both of those perspectives and we can talk definitely more about where do we go for treatment too.
Elise – @TheOncoPT (05:29)
Now, one of the things I wanna make sure that we’ve kind of, we call to mind just so we’re abundantly clear for the listener here. So, Matt comes at this patient population from both the oncology, like, knowledge -y side of things, but also from the pelvic floor. And I think that’s what’s so unique is that in a lot of areas, and Matt, you and I were talking about this off air.
there may not be easy access or really well established referrals at this point back and forth between oncology and pelvic floor. Now, if you’re in a facility where you are extremely privileged to have both pelvic floor and oncology on one staff, then amazing. But that’s not really what we’re talking about here. A lot of my listeners are in areas where they might be the sole oncology PT on staff. And maybe they have to refer
out of clinic or out of their facility to a pelvic floor therapist. And so Matt has this capability right now to kind of serve as both. But for the listener who is like, ooh, I’m just an Onco PT. I don’t have a lot of pelvic floor knowledge at this point. And I don’t even know where to refer patients to if that’s even available. So my question is, Matt, what can, let me back up a little bit.
When it comes to some of these like basic questions that we should be asking from the OncoPT side of things in the evaluation with our patients to kind of be crossing off some pelvic floor boxes to determine like, okay, do they actually need pelvic floor more than me? Like what are some of those things that I can be working through to make that determination?
Matthew Johnston (07:05)
Okay.
I think that’s a great place to start. Because it’s going to give you some ideas other than like, you know, the toolbox that you guys have is like fatigue and strengthening and like comorbidity side effects and like all that treatment side effects. So what I think big things that we talk about in Pelvic Health is like, are you having a urinary leakage? Like that question, we take for granted that people should be asking that and it’s not being asked I think a lot of times. Enough that you need a pad or an undergarment of some sort.
Elise – @TheOncoPT (07:22)
Totally.
Matthew Johnston (07:44)
Are you having bowel issues, especially if you’re having radiation, constipation, like small narrow stools or that kind of stuff, bowel seepage or leakage? Are you having any sexual dysfunction? That again, sometimes we make assumptions as providers, the doctor’s gonna take care of that, the other provider’s gonna take care of that. That doesn’t happen. 20 % of…
Elise – @TheOncoPT (08:09)
Yeah. Yeah.
Matthew Johnston (08:11)
Patients don’t ever talk about their sexual health with their referring provider, with their surgeon, with their oncology team. We need to talk about that. And if you don’t feel comfortable with that, that’s okay. There are forms and surveys and things we can kind of use to start the conversation. But just ask, be the advocate for your patient and then you can help direct them where to go and find someone that maybe has a better skill set than you. And then pain, I think is the last thing. Are you having any pain in your genitals, your testicles?
Do you have any swelling? Are you having lymphedema in your testicles? That is a newer thing that I am, even I’m asking my patients now, is like a couple patients recently have had a lot of abdominal bruising post -op and swelling in the testicles and perineum area. And I don’t even know that could happen, to be honest. But now when you think about, okay, well, they’re getting lymph nodes removed and…
Elise – @TheOncoPT (09:03)
man, yeah.
Matthew Johnston (09:08)
things are getting dissected and especially ones that get radiation on top of that, well, that’s a perfect recipe for lymphedema. You know, their legs not blown up, but they’re having swelling and maybe they’re uncomfortable and maybe they don’t want to divulge that information to a stranger. So that’s, I think, another really important question to ask.
Elise – @TheOncoPT (09:28)
I’m mental note to self I’m making right now in the podcast. I need to add that question onto my like screen questionnaire about the swelling. I’m asking about like, you know, urinary bowel and sexual dysfunction, but at no point am I even considering swelling. So, ooh, Matt, first pearl of the day already.
Matthew Johnston (09:33)
Yeah.
Yeah, it was kind of eye opening when I had like two people in a row and they both were talking about swelling and I was like, okay, well that makes sense. And it’s just like any surgery really. And then we’re talking about removing lymph nodes. Well, that’s another layer of swelling, right? Like how do we triage those people? And do we need to get you to a lymphedema therapist or bring someone on the team or like even talk about just compression or strategies or just like notifying their doctor? I think that’s even like…
Elise – @TheOncoPT (10:04)
Mm -hmm.
Matthew Johnston (10:13)
Just having a conversation with a provider that’s sending them to you. by the way, did you know that Mr. Jones has swelling in this area? And it’s persisting, right? That kind of stuff.
Elise – @TheOncoPT (10:29)
I feel like this is, I’m gonna keep the lid on the can of worms that I feel like I’m about to open right now. So keep it on track, Matt. When it comes to, so patient comes to you and you’re really kind of centering that first visit around education, which wonderful, wonderful opportunity to really kind of assess not only like where the patient is at, but also.
knowing now that we’ve done our evaluation and we’ve established like what are some of those goals that you have, then we can really kind of cater that to, you know, not only like what do you hope to accomplish in therapy, you know, working with me, but also looking ahead to the treatment. And I think that’s so, so important, especially in oncology. So from my own experience over the past couple of months, I’ve had a few patients who have had a significant gap in what they understand is coming.
because of treatment, and again, I mentioned this in a previous podcast episode. When you have cancer, it’s like you’re trying to drink from a hurricane of just how much information and the intensity of the information that you’re getting, and on top of that, you’re getting all this other information from all these different places, but what a great place to start at the evaluation with your patient to say, here’s where we’re going. Here’s what you might need to expect. Here’s how I’m going to be with you on this path.
Matthew Johnston (11:29)
you
Elise – @TheOncoPT (11:49)
to help with this. So in addition to education, what else, like what are some treatment things that you’re doing with this patient population?
Matthew Johnston (12:00)
Sure. In both of these scenarios where we’re talking about pre -op or post -op, pelvic floor strengthening is kind of the first step. Now, for the purpose of today’s conversation, we’re going to keep it simple and talk about big picture ideas, but we can go deep into all of these things. And certain patients need certain combinations of both, but I think by and large, pelvic floor strengthening and abdominal strengthening, particularly transverse abdominal strengthening are kind of
very prominent in the research and very prominent interventions that will help speed the recovery of urine leakage, especially. So understanding what these muscles are, how do we get them to contract? Usually we’ll start with the the pelvic floor. I have the luxury of doing this through rehabilitative ultrasound. So I ultrasound their pelvic floor and they see an image on a screen. It’s just very easy. Obviously not everyone has access to that.
Elise – @TheOncoPT (12:54)
Mm -hmm.
Matthew Johnston (12:58)
So sometimes even just like palpating the perineum and getting them to understand this is where we’re talking about. Obviously, if you’re not a pelvic floor therapist, not everyone’s gonna feel comfortable having a patient undressed from the waist down and look at their perineum and look at that kind of type of exam if you’re not trained in that. But I think the average therapist, if we’re talking to access, most physical therapists should be able to palpate a perineum, over close and feel
is that what we’re doing? Is this pelvic floor actually contracting? And then you can put a hand on their stomach maybe and say, okay, well, I don’t want you to hold your breath or push your stomach out or squeeze your glutes. This is what it should feel like and get the ball rolling that way. So I think that’s a basic maybe skill set that people could have or learn to find over time and start patients that way.
And especially too, I think something to be mentioned is access to pelvic health therapy now is very challenging. Waitlists are super long and sometimes you need to bridge that gap. And if it’s just saying, okay, we’re gonna add some pelvic floor strengthening exercises to what we’re doing from an oncology perspective, that might be a great starting point. And then we dive into, you know, pelvic floor therapy later on. I think a lot of patients say like, well,
How can I exercise if I’m leaking urine? I don’t want to exercise. I’m afraid to exercise. So as an oncology therapist, sometimes I think that’s very challenging for therapists to navigate. And patients might not want to start. They might want to start with the pelvic floor. But if that’s not an access point for them, well, we’ve got to start somewhere. Maybe we need to bridge that gap. So I think pelvic floor strengthening is number one. Transverse abdominal strengthening and endurance.
Elise – @TheOncoPT (14:36)
Mm -hmm.
Mm -hmm.
Matthew Johnston (14:52)
and the synergy between those things can be number two. I think most therapists should be able to palpate and get the basics of how to do a transverse abdominis contraction. Those are probably from a muscle strengthening, maybe hip strengthening, you know, glute med, again, how that kind of relates to each other. Those can all be helpful for urinary leakage. And then kind of on the other side of it, it’s like managing intra -abdominal pressure.
Elise – @TheOncoPT (15:02)
Mm -hmm.
Yeah.
Matthew Johnston (15:20)
which I think is a foreign concept to a lot of therapists. It’s really hard. It’s really hard. And I think, you know, the first place is don’t hold your breath. You know, like don’t hold your breath. Don’t push that air down and start there. You know, encourage patients to learn how to time breathing and exercise, especially lifting, right? You know, if I’m going to lift my groceries up and I, or sit to stand even, even more basic, right? If I hold my breath and bear down.
Elise – @TheOncoPT (15:24)
yeah, I’m over here like, how do we do that?
Yes.
Matthew Johnston (15:50)
All that air pressure is going down into my pelvic floor, all my bladder, and it’s going to not be able to sustain that closure pressure. And that’s where League of Chap is. So until they learn how to manage that better, well, that can be a problem. So intra -abdominal pressure can be a challenging thing, even for, I think, some pelvic therapists to patients. Men do not like to, they are not easy when they’re talking about.
Elise – @TheOncoPT (15:59)
Boom.
Matthew Johnston (16:18)
abdominal pressure, right? You know, they like to grunt and hold and make a face and like more is better and I’m going to strain as much as possible. Like that is very classic and very hard to train people out of because we’re talking about age demographic from like 45, 50 to 80, right? They’ve lived most of their lives this way. And now we’re training them to change, you know, if they’re into sports or they, they grew up as an exerciser or they’re
Elise – @TheOncoPT (16:25)
Mm -hmm.
Yeah.
Matthew Johnston (16:46)
They have really good body awareness or motor awareness. Like, okay, that’s easy, but that’s not everyone and it can be really challenging. So intra -abdominal pressure, I think is a huge concept. I think those are two big concepts to start with.
Elise – @TheOncoPT (16:52)
Mm -hmm.
You know, when you first said intra managing intra abdominal pressure, I straight up was what? I’m sorry. I’ve never thought about this before. But when you put it, we as, as physical therapist period, you know, onco PT’s included in that we should be teaching our patients to exercise appropriately to lift because we know that resistance training and strength training is so beneficial for our patients for so many different reasons. And I mean, even in my
Matthew Johnston (17:09)
Yeah.
Alright.
Elise – @TheOncoPT (17:28)
non -pelvic floor patient population, the breathing while exerting ourselves with lifting is already a problem. And that’s something that we’re probably already working on with our patients. That’s another thing that I was thinking of when you were talking about different interventions to start with, Matt, is even if you, the listener, are completely, completely uncomfortable with
You know, a lot of the pelvic floor specific stuff that Matt has talked about so far, you know how to strengthen hips. And we also know that hip strengthening can be so beneficial for improving balance and stability in our patient population. So some of this, I’m seeing a lot of crossover already. Yes. Yeah.
Matthew Johnston (18:10)
There’s carryovers. Yeah, totally. Totally. And I think, you know, just to go back to intra abdominal pressure, it can be complicated concept. I can have, I can, if I take a deep breath in, I’m thinking I’m like stabilizing my spine, right? And that’s how we naturally will lift. And if it happens kind of laterally, that’s fine, but it’s going down. If I’m bearing down onto my pelvic floor, that’s the problem. So it’s, we can use air for a lot of different things. And it’s not just about like exhaling, but.
I think for the, for the therapists in this context, like just get people to breathe. Or we work on like rib cage breathing. Just get people to breathe through the rib cage instead of like up by their shoulders. Right. Can we start that process? Talk about accessory muscles and you know, especially if someone’s going through like chemotherapy and like, you know, muscle wasting. I mean, I don’t want to go down the rabbit hole, but you know, when we’re talking about that type of impact to your physiology, well, breathing becomes is very important. Diaphragm strength becomes important.
Elise – @TheOncoPT (18:47)
Yeah. my gosh. Yes.
Matthew Johnston (19:09)
And how can we get patients to learn these skills now? And that’s kind of, you know, I try to get patients to like, let’s get to a clean slate before, because most of the time they’re going to have a PSA at like month three and month six. And unless they had like advanced disease of kind of from the get go, nothing’s really going to happen until at least three to six months at minimum or at earliest. Typically, you know, obviously every patient is different. Like if they go and do surgery and they find stuff more than they expected, okay, maybe that person is going to get managed earlier.
Elise – @TheOncoPT (19:26)
Mm -hmm.
Okay.
Matthew Johnston (19:39)
But for the average patient, at least from the physician pathway that I experienced, most of them are looking for that first PSA to say, okay, I want that to be zero or negligible or whatever. So I want to clean the slate, clear the deck as quickly as possible before something else gets added on. So we really try to get that pelvic strength kind of up and running before, and that’s the benefit of pre -hab, man, like six to eight weeks runway, patients do so, so much better.
Elise – @TheOncoPT (19:39)
Mm -hmm.
Okay.
Mm -hmm.
man.
Matthew Johnston (20:08)
Because all the education, all the upfront work, all the like motor planning and control and all that stuff is already done. They pick up the ground running on day one and they already know what they’re doing now. It’s just like relearning. You know, it’s just like relearning. And that happens so much faster when you already know what you’re doing.
Elise – @TheOncoPT (20:22)
Yeah. my gosh. Again, talk about how much of a foundation can you lay beforehand so then you don’t have to start at square zero or square negative one after treatment has started. I mean, holy cow.
Matthew Johnston (20:37)
And that doesn’t need to be like 18 visits. It can be three visits, you know, an evaluation and two follow -ups before surgery. And that goes along. And patients, I think, really appreciate having a guide. They want a tour guide. They don’t want to fumble through on their own. And I stole that from my coworker, so I’ll just give him credit. But like, imagine going through a cancer journey by yourself or with, obviously with family support and all that stuff. And that I think can’t, you know, I don’t want to understate that piece of it.
Elise – @TheOncoPT (20:42)
Yeah.
genius.
Matthew Johnston (21:06)
But when we’re trying to help and how my body works and you know, sometimes the prevailing thought on the internet or even through some providers, it’s like, it will get better. Like it’s just going to get better. And it doesn’t always get better. And like minimal leakage is still, you know, that’s okay. Or, you know, like that’s good enough. And sometimes it’s just easy fixes or drinking a little less irritants, bladder irritants. You know, sometimes it’s just like easy strategies and you know, not everyone wants to give up their coffee, but
Elise – @TheOncoPT (21:16)
Yeah.
Matthew Johnston (21:36)
If I choose to do that when I’m going on the plane, so I don’t have to like, leak urine maybe that’s a willing thing I’m going to be able to do for a week or two before I go on the plane, right? So I think, again, it’s about asking questions and like being advocates for patients. And sometimes I’ll steal orthopedic patients in the clinic and, you know, we’ll talk about past medical history and they’ll have a cancer history. And we just kind of talk, if you have any of these problems, and they’ll say, yeah, I’ve been dealing that for 10 years. No one’s ever, I didn’t even know that was an.
Elise – @TheOncoPT (21:43)
Right.
Matthew Johnston (22:05)
And that I think, you know, I don’t want to go down that rabbit hole, but you know, that, that always breaks my heart. You know, when people are, you’re living with these things and they just think it’s normal and this is the way everyone lives. And, you know, maybe they weren’t ever offered something or maybe they tried early on and it didn’t really work or the timeframe was off or there’s some sort of other variable and they need a second, you know, go at it or we missed something, you know, you know, we miss stuff all the time. People don’t always get better and they need intervention and that’s okay too. But are they being offered stuff?
you know, sling procedures and, you know, artificial sphincters and whatnot, you know, like, are they having conversations with that, with their doctor? Same thing with the sexual side effects, you know, are you, are you having conversations with your doctor about things that aren’t as good as you want them to be? And sometimes the answer is, this is, this is actually where it needs to be. And that’s your physiology. But if you don’t have that conversation, we’re missing the boat on a very large percentage of patients.
Elise – @TheOncoPT (22:55)
Bye.
Right. So I’m gonna push back. I know you said, we’re not gonna go down that rabbit hole. I’m gonna say like, this is a rabbit hole, Matt, let’s go down. So this is actually a point that we were going to cover later in the episode, but I think now is like a really good time to do so. So you had said to me leading up to this conversation, don’t let patients live, just live with stuff. And this is so common in oncology.
I would wager to say it’s common in pelvic floor. And this is only, I’ve only had very limited experience with male pelvic floor, like patients who are having those issues. Most of it has actually been my breast cancer survivors who are women who have given birth years ago and still have to cross their legs to sneeze in the clinic. And that’s where I’m like, I forgot to screen. I did not screen my patient for this.
Matthew Johnston (23:44)
Mm -hmm.
Yeah.
Elise – @TheOncoPT (23:59)
But there’s such a culture of things being normalized and look, that’s a rabbit hole, we’re not gonna go down. We’re gonna pump that for a different episode. But there is very much this common experience for oncology survivors to just live with it for so many different reasons. For a long time, we didn’t really have established rehab for these patients to say, hey, these are not issues, you have to live with the rest of your life. Or like, hey, we can make this better.
Now, in 2024, we know better, but we don’t always do better.
So let’s chat about more of what you meant by don’t just let your patients live with this.
Matthew Johnston (24:43)
I think that, you know, I think urine leakage is a very common thing. You know, patients will, especially the ones we’ve, you know, 10 years, I’ve had my surgery 10 years ago, or, you know, I had pelvic pain 10 years ago after surgery and I just, everyone said I was fine. I didn’t have any cancer, you know, disease state, and I went through all the treatments and that was it. That’s where the, the, the ball stopped rolling.
Elise – @TheOncoPT (24:47)
Mm -hmm.
Matthew Johnston (25:11)
And I think it can be a very, and the internet, I think is a great place, but it doesn’t always give very tactical steps who to talk to, where to talk to, you know, how to broach that conversation with your provider. And even when you broach it with your provider is that, are they willing to give you options? And maybe they just don’t have the connection, right? There are so many urologists or oncology providers that have never interacted with a pelvic floor therapist before.
Elise – @TheOncoPT (25:34)
Definitely. Definitely.
Matthew Johnston (25:41)
you know,
Elise – @TheOncoPT (25:41)
Yes.
Matthew Johnston (25:44)
And I think that is, I think that’s the biggest barrier. I don’t think providers are unwilling to refer to pelvic therapy. I think they’re begging for people to help them. And I think it’s just about people asking the right questions, you know? Being the primary care PT, having that hat on all the time and using that to help you take care of the person around you. You know, I think that is like, that goes a long way.
Elise – @TheOncoPT (25:53)
Yes.
Matthew Johnston (26:13)
And I think patients appreciate it. And even if we make 25 to 50 % change, that’s, I, that, could you imagine using like two or three less pads a day? That, that’s significant, right? Or sleeping a couple more hours at night. you know, that those are meaningful changes for patients. And maybe for some patients, maybe the answer is not zero leakage for whatever reason. but
Elise – @TheOncoPT (26:24)
my God, that’s huge. That’s huge.
my God.
way.
Matthew Johnston (26:41)
Again, if we can make a 20, and that’s kind of how I propose this to those patients who come in 10 years later, what would it mean to you if we made a 25 % change in this? And they’re thrilled. Obviously, in the back of my mind, I’m like, I’m shooting for 100, you know, like we’re going all the way here. But like to frame that in that way, and they kind of light up and they’re like, wow, I didn’t think that this was possible. Well, that can go a long way and we can kind of figure that out.
Elise – @TheOncoPT (26:57)
Of course, of course, right?
Yeah.
That makes me smile so much just, you know, because you have those cases where the patient’s been experiencing this for a long time, maybe knew it was an issue they could, you know, get addressed, but there were barriers, maybe didn’t know this was an issue that they could have addressed. You know, I’ve had patients, which I’m sure you have too, who, you know, they finally come in to see me and they’re like, well, I figured I should just be happy that I was alive, or sometimes worse, they’re
Matthew Johnston (27:29)
Yeah.
Yeah, yeah, yeah.
Elise – @TheOncoPT (27:41)
that they should just be happy to be alive and that is no way to live. Like that is no way to live in any set of circumstances but especially after a cancer diagnosis. And so again going back to what Matt was talking about at the very very beginning of this episode it starts with just asking the question. Whether that is face -to -face, whether that is on a questionnaire, it starts these kinds of conversations start by asking the question. You won’t know until you ask the question.
Matthew Johnston (28:10)
Yeah, yeah. And I think sometimes just bouncing off your other comment is like, sometimes patients are afraid to change this. They don’t want it to get worse. And I’ve had patients come in and come for an evaluation and it’s been going on for a couple years, a year or two or three, and they seem like they’re happy and they call a day or two later and they’re like, I can’t do this. And I think they’re afraid about what it is going to make me worse. Is it not going to get better? And I just wasted my
Elise – @TheOncoPT (28:18)
good point.
Matthew Johnston (28:39)
I got my hopes up, right? And I say, okay, call me when you’re ready. I’m here. I’m happy to tackle this when you want to or if you want to, but know that there’s someone who can help you. And if I’m not the right person for whatever reason, let’s find you someone. But I think just, again, knowing that there’s an option, imagine if everyone with back pain didn’t know that there was an option of…
Elise – @TheOncoPT (28:41)
Yeah.
Yes.
Yes.
Matthew Johnston (29:07)
physical therapy or chiropractor or injection. Like that’s such common place. If you ask anyone on the street and say, if you have back pain, what are your options? They’re going to say a billion things, a billion heat packs and surgery and like, you know, everything. These people with cancer don’t know anything. They have like, I have no idea. You know, I didn’t know this was even existed, you know? So I think that is just like a common, a very, very common thread that adds like a…
Elise – @TheOncoPT (29:17)
Mm -hmm.
Yeah.
Matthew Johnston (29:34)
healthcare provider in general. And like this even as orthopedic patients, you know, or orthopedic therapists that are listening to this, as your patients, you know, so often we like see that checkbox of cancer and say, you’re in remission, okay, moving on, you know, and we never do anything about it. So I think that’s just a very, you know, again, going back to asking the questions.
Elise – @TheOncoPT (29:56)
And it does not hurt to ask the question. And again, you know, this is something I’ve covered previously with Dr. Alexandra Hill, @OncoPelvicPT is the worst that could happen is if you ask the question, the patient’s like, I don’t want to talk about that. Like, okay, that’s fine. If you ever want to talk about that, I’m more than happy to have that conversation. Otherwise, like, let’s move on to our next step. And it’s okay. It is okay. But you will not know until you ask the question.
Matthew Johnston (30:06)
Careful, man.
Yeah. Done.
Elise – @TheOncoPT (30:26)
Ugh, like full stop, period, end, fin. As far as, so we’ve talked a little bit about, you know, like urinary leakage and whatnot, but one of the things that you also are such a big proponent of is being an advocate for sexual health. Now, of course, this starts with asking the question, right? Starting the conversation, but where do we go from there when it comes to the patient with prostate cancer?
Matthew Johnston (30:28)
Hehehehe
Yeah.
Yeah, this is certainly a collaborative effort and a team effort. Physical therapists can’t do this in isolation. There’s only so many tools in the toolbox to deal with this. And I think a large role is being an advocate and saying, what are your goals? What do you want? And helping them frame that and saying, okay, well, I’m not very interested, you know, and that’s okay. Okay, here are some things that you might do to help kind of move this tissue in X, Y, and Z.
Elise – @TheOncoPT (31:00)
Yeah
Matthew Johnston (31:20)
And here’s some things if the need or whatever arises, you’re going to be prepared. Your physiology is going to be prepared. If they’re on the other side of the table, it’s okay. I am interested and I’m eager to get back into participating. How do I do that? Right. And having a good relationship with your referring provider or understanding what they offer is like step one. Picking up the phone and saying, Dr. Smith,
Tell me more about how you deal with sexual function and how can I help you with that? And there’s lots of strategies that pelvic therapists can do to help kind of facilitate that. There’s also sex therapists who also sometimes will play a large role in that process. There’s a lot of fear, there’s a lot of anxiety. These are very important intimate body parts that have just been changed and had surgery and identity. I mean, there’s a lot of psychology that goes into that.
Elise – @TheOncoPT (32:16)
Mm -hmm.
Matthew Johnston (32:19)
So they can be part of the team and the physician can be a large part of the team too. Some patients don’t want to take medications. They don’t understand why they’re taking it or they don’t want injections or other interventions. And again, like we spend a whole 45 minutes to an hour with patients. That’s a lot of time that we can answer questions and start the ball rolling. And we’re encouraging, hey, your next follow -up with Dr. Smith, you know, ask him about this or.
approach that conversation or hey, you know, you’re doing really good. Keep going. Keep doing what you’re doing. You know, aerobic exercise, blood pressure management, you know, diabetes management, like those health concepts are also playing a role into sexual wellness as well. And there’s a lot of neglected side effects from prostate cancer treatment that show up in these men that aren’t just erectile dysfunction. So there’s a lot of other things that might happen from a symptom.
symptomology perspective that no one’s asking. No one’s asking about those things. So sometimes we’ll go deeper dive. If someone’s really interested, maybe we deeper dive. Are you having any issues or tell me more about these kinds of scenarios? But I think it’s a team effort. It’s very, very, it has to be collaborative. You can’t do it by yourself as a physical therapist. And you need to have that team collaboration. Cause some of this is obviously pharmacological and we don’t do that.
Elise – @TheOncoPT (33:23)
Mm -hmm.
Right.
Matthew Johnston (33:47)
But we can do pelvic floor strengthening. We can do aerobic exercise. We can do other interventions that can help facilitate that process and help patients really feel comfortable with that. A lot of times patients will be prescribed something and say, I don’t want to use this device and it doesn’t feel comfortable. And we can help troubleshoot that process with that.
Elise – @TheOncoPT (33:48)
Right.
Yeah. And don’t think just because your patient is on the older side of the age spectrum that they’re not interested in this. One of my favorite patient encounters that was like such a lesson learned. I had this patient who was 80, I think, and she was coming to see me after cancer treatment for something completely different, but I was screening her because
Matthew Johnston (34:15)
Yes, totally agree.
Elise – @TheOncoPT (34:31)
Alexandra Hill told me so and I was like, okay, I’m gonna do it and sure enough so I’m asking this patient, you know, are you having any urinary issues any, you know, bowel issues and then any sexual dysfunction and she says actually I really want to get back to having sex with my husband and it blew me away. I was like, my god, she’s 80. It’s like, well, that doesn’t matter. Like, and so again, don’t assume that just because your patient is older or you know, like
Matthew Johnston (34:33)
Hehehehe
Hehehehehe
Yeah.
Elise – @TheOncoPT (34:59)
Maybe they’re not married or any number of things. Don’t assume that this isn’t something of importance to them because it very well could be. It very well should be at that point.
Matthew Johnston (35:12)
And it goes back to like patient center goals. If that’s a center, a patient center goal for that person, we got to talk about it. And we have, or find someone who can or wants to, you know? But it needs to be part of the conversation, certainly. Yeah.
Elise – @TheOncoPT (35:21)
Mm -hmm. Mm -hmm.
We’ve talked a bit about what can we expect to see after a person has a prostatectomy, a little bit about radiation, but this patient population is also commonly treated with hormone replacement therapy. So how does that affect pelvic floor and what are you working on with this patient population?
Matthew Johnston (35:45)
Sure, sure. I think this is probably the patient population that sees the traditional oncology therapist the most frequently because these are kind of systemic side effects and really great suited, right? Like the fatigue and the sweats and the weight changes and all that stuff, bone health, like there’s a lot of muscle changes that is really suited to like this very traditional oncology exercise program.
from a pelvic health standpoint, we see changes in sexual function particularly. And I think there is also things about like, well, if I’m not moving as much, well, does that affect my bowel movements? Muscle changes affect pelvic floor and hip and transverse abdominis just like we talked about. And those changes don’t always happen right away, right? Obviously muscle hypertrophy and muscle atrophy take time, right?
So if we’re talking about someone who’s been on hormone replacement therapy for a year or more than one year or multiple years, well, does that, and they have had a regression in their urine leakage or a change in their bowel movements that they just thought was a side effect of medication. Well, can we support them? Can we support them in, you know, well, are you doing your pelvic floor strengthening exercises? Like how has that changed? Maybe we need to do some like mobilizing or lengthening or, you know, that kind of,
of treatment. Maybe we need to get those muscles to elongate again and then strengthen them again, you know, kind of take that step back. And that sometimes, you know, just like someone who has radiation, you know, I think it’s getting stiff. We need to move them and then we need to get them stronger. And hormone replacement can sometimes do that systemically. But I do think that probably the biggest concern that patients have is like their sexual function impact.
Elise – @TheOncoPT (37:39)
Mm -hmm. Again, going back to what we just talked about, it’s all related. It’s all connected here. So this is very much one of those treatments that patients can be on, like you mentioned, for a long period of time. We think about chemotherapy, while it sucks, is a lot of times a little more time limited. Surgery, usually like a very finite period of time. Same thing with radiation.
But that doesn’t mean that these patients are only experiencing these symptoms and these side effects for the short term. These can be very long -term experiences for patients. So what does the rehab process look like for the person with prostate cancer who is now, you know, we’re several months post -treatment or maybe even years beyond treatment?
Matthew Johnston (38:26)
Sure. You know, the person just with the prostatectomy that we’re going through the long -term rehab, well, I expect that person on average to get better in three to six months, typically. Some patients do take longer. They have comorbidities or some sort of other thing going on. And they might take a whole year, you know? And that recovery process might look longer or different. You know, when we’re talking about hormone replacement therapy or these long -term treatment options for patients, now we’re talking about long -term lifestyle changes. You know, how can you…
Elise – @TheOncoPT (38:41)
Mm -hmm.
Matthew Johnston (38:56)
And that’s probably very similar to what the oncology therapist typically talks about is like, how can I make exercise part of my life? Well, how can I make pelvic wellness as part of my life? How can I manage my bowel movements? Because they affect so much. How can I keep them regular and easy and not strainful? And then how can I continue to participate in sexual activity the way I want to? How can I manage my urinary function and not…
Elise – @TheOncoPT (39:19)
Mm -hmm.
Matthew Johnston (39:22)
regress in my leakage as my body changes over time, the longer I have exposure to some of these modalities, biotinic treatment options, you know, those kinds of things. So how can my body blunt the curve of impact over time, you know, and that’s very similar to like the big picture exercise 150 minutes and those kinds of aerobic and strength training and intensity. But maybe we kind of also add in these pelvic wellness things.
Elise – @TheOncoPT (39:32)
Yeah, yeah.
So you mentioned kind of the long -term exposure to these kinds of treatments. I want to also bring in another factor. What about aging and how does that kind of play into this?
Matthew Johnston (40:06)
Love that. Patients ask me off the time, am I gonna have to do this forever? And the answer is typically yes. Your anatomy is forever changed. That prostate is not going to grow back. It provides so much support to the bladder. Your urinary sphincter is changed forever. So yeah, I typically say you need to be on a maintenance plan and do this forever. And I try to make it as low barrier as possible.
Elise – @TheOncoPT (40:16)
Yeah.
Matthew Johnston (40:21)
I’m
and try to incorporate that into your normal exercise routine. And if you’re at the gym, that’s a great opportunity to do a couple of repetitions between sets. Make it as easy, when you’re brushing your teeth, make it as easy as possible because you’re not gonna stop your day and do your kegel pelvic floor exercises. That’s not happening. Especially like five, 10, 15 years later. I always try to give everyone the benefit of the doubt of like…
Elise – @TheOncoPT (40:37)
Mm -hmm.
Yeah!
definitely not.
Matthew Johnston (40:59)
decade one, decade two, decade three, maybe decade four, depending on the age, and really kind of get them to look out into the future. Obviously muscles change over time. Obviously we want patients to be as active as much as possible over their lifespan, but muscles change over time. We know that. Sarcopenia is a thing that is going to affect your pelvic area, not only your pelvic floor, but your hips, your glutes, your trunk muscles, right? Like all that stuff starts to change.
Elise – @TheOncoPT (41:17)
Mm -hmm.
Matthew Johnston (41:29)
If you’re using that as your compensation strategy to support pelvic wellness, whether that’s urinary incontinence or otherwise, well, if that changes, well, your compensation mechanism is changing and you need to continue that for forever. And keeping robust and healthy in terms of muscle strengthening in that area is gonna help with that. When I engage my hip and glute during squats, my pelvic floor is doing something. It is stabilizing me, just like my trunk muscles are doing that same thing.
So people who are active and healthy and have big strong muscle masses going into this aging process, well, they’re probably going to have a little bit slower change over time compared to someone who just kind of becomes sedentary. And obviously there’s comorbidity things or surgery things or, you know, I broke my leg and here we are. You know, I was in a wheelchair and I just never regained my mobility or like momentum again. Well, that impacts you, right? That impacts you or a death of a family member or.
You know, those like psychosocial things that also, you know, retirement, we are talking about retirement people. How does that change your activity? If you had a super active job and you were easily meeting your 150 minutes of exercise because you are a mailman. Well, if you retire, you’re not walking all those steps again. And how, and like, that’s the conversation to have. Like what does exercise or activity look like for you when you retire? Because we’re hitting, you’re, you’re getting this done at like in that age range.
Elise – @TheOncoPT (42:34)
Yep. Yep.
Matthew Johnston (42:57)
And when you stop exercising, your muscles change.
Elise – @TheOncoPT (43:01)
I never would have thought to think about retirement in that capacity as far as like big potential change in physical activity. Right, right.
Matthew Johnston (43:11)
I mean, it goes the other way around too. You know, if you’re the CEO and you’re doing office work and all of a sudden you retire and then you’re like an exercise fiend. Well, that’s great. That’s a good, that’s the direction we want, but, you know, but sometimes it doesn’t work that way. And especially when we’re talking about, you know, certain patient populations or demographics, well, we’re talking about people who do physical jobs and that, that can really change their trajectory. It sometimes makes it harder to go through the rehab process, right? You know, if my job is lifting 50 pound boxes all day, cause I work at the airport.
Elise – @TheOncoPT (43:21)
Yay!
Yeah.
Mm -hmm.
Matthew Johnston (43:41)
that’s a lot of demand on your pelvic floor. Your recovery process for your incontinence might be harder than someone who’s the CEO and he might go back to work at week six and feel really good about that. That’s much different.
Elise – @TheOncoPT (43:53)
Well, and again, the age range that we’re talking about here, typically the patients who are developing prostate cancer, they are older. And so they’re around that retirement age, maybe older than retirement age. So I think that’s, it’s obviously pertinent for all of our patients, but this, I think especially, this is such like a mind shift for me as far as.
Matthew Johnston (44:03)
You know.
Yeah.
Elise – @TheOncoPT (44:19)
What a great opportunity to maybe positively influence someone to be like, maybe if they weren’t a lifelong mover, maybe if they weren’t an exerciser, how can we maybe influence it at that time period of like, hey, now you’re not going to be working. How can we make sure that you are going to get to 80 or whatever that is and be able to move around and spend time with the people who are important to you and do the things that you love to do? Ooh, the wheels are turning.
Matthew Johnston (44:24)
to be an exerciser, yeah.
Yeah.
Yeah. And I love my, you know, my usually early 50, 55, like your old patients, like they’re also super fun to work with too. Cause they are all, they’re the ones in pickleball and they’re the ones running and they’re, they’re doing stuff like that too. And, and that’s just like a whole different game and how can we, but they also have much more time. Like, you know, their trajectory of their lifespan is much different than someone who’s getting this done at 75. Right. so.
Elise – @TheOncoPT (45:03)
man.
Matthew Johnston (45:13)
And their psychosocial impacts are different and their identity impacts are different. So I like working with those folks too, because it just seems like more sport oriented. There’s also 70 year olds who are into those things too, but I think there’s a lot more different demands when we’re talking about the younger cohort too.
Elise – @TheOncoPT (45:27)
Right.
For the listener who is like, I’m an oncopete, I work by myself, I don’t have a pelvic floor in -house that I can easily refer to, what is your recommendation to help find and establish that connection somewhere, whether it’s in your immediate city, immediate community, or a little farther away, what would you suggest?
Yep.
Matthew Johnston (45:57)
in terms of finding your like pelvic health team in the neighborhood or like even beyond, I mean, there’s, there’s tons of like online, resources. APTA pelvic health section has one, Herman and Wallace has one, Nicole Cozine and the pelvic PT rising group has one too. Like they have all these maps that like, you can look at, you know, geography and where pelvic therapists are. And, and maybe some of the patients or the therapists who are like tech pregnancy and postpartum focused.
Elise – @TheOncoPT (46:01)
Yes.
Mm -hmm.
Yes!
Matthew Johnston (46:26)
they would love to help your patients, you know, or they know someone who’s gonna want to help your patient, right? So like network with folks and try to learn how who does what and if they don’t do it, pelvic PTs, well, they know all the other pelvic PTs. So they’re gonna know who does what in the neighborhood and find that person for you. So just find someone, you know, but those APTA resources and some of those other resources are good places to start to find.
who does what in the neighborhood.
Elise – @TheOncoPT (46:58)
Yeah, and I’ll link to those in the show notes as well for the listener. You can go and find those when this episode releases. And then kind of next phase of that question, Matt, is for the OncoPT who’s listening, who’s like, I have my first patient with prostate cancer on my schedule tomorrow. What would you recommend? What are some very tactical things to get started with? And then they can come back and re -listen to this episode and be like, OK, now I’m going to do this, this and this.
Matthew Johnston (47:24)
Yeah. And this can be something you can find your pelvic health therapist. Some programs are teaching this in school, but understanding how to palpate the pelvic floor externally. Learn how to like have that patient do a basic pelvic floor contraction and start them there. Start them on here’s where here’s what with the neighborhood that we’re talking about. I’m not the expert in this, but I think it’s valuable for you to get started.
obviously there’s, there’s good technique and bad technique and that’s a whole, that could be a whole nother podcast. but there’s resources to help you do the contraction. There’s tons, if you, you know, tons of easy open access articles that can teach you how to do this, or at least the anatomy. So you feel more comfortable with it. and we can link to some of those in the, in the show notes, certainly. start there, start with your transverse abdominus. Like.
Elise – @TheOncoPT (47:54)
Mm -hmm.
Matthew Johnston (48:20)
If I contract my transverse abdominis, my pelvic floor is automatically going to engage. So you don’t even have to do heel. I mean, obviously that’s the gold standard and that’s the whole thing. But if I am someone who lives in the middle of Nebraska and I don’t have access to people who can specialize in this area, well, what are the things I can start doing that’s going to help the ball get rolling? Well, transverse abdominis contraction is going to be helpful. Anything around the glute and hip can be also helpful. The deep rotators of hip also.
our pelvic floor muscles. So those could be things to get started with. And then learning how to do that pelvic floor heel contraction. That can be something that you can do and start patients on.
Elise – @TheOncoPT (49:03)
Matt, if people want to learn more from you, what is the best way to get in contact with you?
Matthew Johnston (49:09)
Sure. I’m on LinkedIn. I post a lot on there. And then you’re, I can put my email in the show notes. People can definitely reach out, email me with questions or, you know, if you’re looking for particular resources. And then there’s also a men’s health physical therapy Facebook group. And people have shared lots of resources or people ask like, Hey, is there a physical therapist in X town? Who can help me with this? There’s a lot of discussion on that too, in that group.
Elise – @TheOncoPT (49:28)
Wonderful.
Very cool. And again, I mentioned this in the last episode with Matt. Matt is a wealth of information on LinkedIn. If you are not following him, you need to do so because I mean, you are cranking out stuff. I feel like on the daily, like weekly for sure, but like daily, I feel like I’m seeing stuff. So definitely follow Matt. Matt, this was such an enjoyable conversation again. I’m so excited you came back on the podcast. Any last minute things you want to leave my listeners with today?
Matthew Johnston (50:08)
Know who’s in your neighborhood, ask the questions, and get started. Sometimes patients just need to start. It doesn’t need to be perfect on day one, and you can learn as you go if you’re in that situation where you’re kind of an isolated therapist or you don’t access or there’s long wait lists. You know, patients will, you can find with them where they need to go later on if that’s absolutely necessary. And pelvic health is such a deep and broad specialty and we have tons of value, but again, there’s barriers to that.
ask the questions, get people started, and then learn as you go.
Elise – @TheOncoPT (50:43)
Matt, thank you so much. This was wonderful and I’m really excited to share this with my listeners.
Matthew Johnston (50:49)
And thanks for having me. It was a pleasure as