Indirect training of the pelvic floor muscles via transversus abdominis for females with urinary incontinence: a randomized controlled trial

尿失禁指的是任何不自主之漏尿症狀，而應力性尿失禁則是指在用力過程或打噴嚏、咳嗽時出現不自主之漏尿症狀。女性之尿失禁比例比男性高，其中又以應力性尿失禁佔最大比例。漏尿問題不但影響病患之生理層面，亦影響其心理層面，降低生活品質；而應力性尿失禁則因與身體之出力有關，更有降低運動意願之行為出現，降低日常之規律運動與婦女之心血管疾病、骨質疏鬆、糖尿病皆有相關，為健康之重要議題。一般認為應力性尿失禁之致病因與骨盆底肌功能不足有關。目前雖已有許多隨機分配試驗證明骨盆底肌訓練對應力性尿失禁婦女之療效，但傳統骨盆底肌訓練需由治療師經由陰道觸診以教導正確之骨盆底肌收縮，國人往往因羞於內診而使接受診療之意願降低。近年來有文獻指出可經由腹橫肌間接訓練骨盆底肌，其方式不必經由陰道觸診，或許可以增加失禁婦女之就診意願，然目前尚無相關之臨床療效試驗，故本篇研究欲探討經由腹橫肌間接訓練骨盆底肌對尿失禁婦女之療效。 本研究共徵召71位患有尿失禁之婦女，先根據骨盆底肌在腹橫肌收縮情況下移動的方向作分層，再隨機分配至訓練組及對照組。所有受試者於四個月之介入期前後將進行兩次之完整評估，評估項目包括基本資料與完整之泌尿症狀、自覺漏尿症狀評估、72小時解尿日誌、骨盆底肌肌力評估、一小時棉墊測試、20分鐘棉墊測試及生活品質之問卷調查。 對照組除於第一次評估時教導正確之骨盆底肌運動，並給予衛教單張外，在介入期間皆不主動與之聯絡。訓練組則進行四個月之運動療程，於第 1, 2, 4, 6, 8, 10, 13, 16週進行約30∼60分鐘之個別化運動訓練，以確定受試者之運動正確性、強度及進展。介入方式採用經由腹橫肌間接訓練骨盆底肌模式，分為腹式呼吸、強直誘發期、肌力訓練期、功能性吐氣訓練模式、衝擊性活動五個階段進展。 所有資料分析皆以SPSS 11.0版進行，以描述性統計呈現訓練組與對照組兩組之特性，並利用Shapiro-Wilk test檢定依變項是否呈常態分佈；以獨立兩樣本t檢定(independent two samples t-test)或卡方檢定(chi-square)來檢定訓練組與對照組兩組間在各干擾因子上是否有差異；以two-way mixed ANOVA檢定兩組受試者治療前後之常態分佈連續依變項是否有差異；以Wilcoxon signed-rank test檢定兩組受試者治療前後之有序依變項是否有差異；以卡方檢定或Mann-Whitney rank-sum test分析非連續數或非常態分佈之依變項之組間差異。 結果發現尿失禁婦女經由腹橫肌訓練骨盆底肌四個月後，比起對照組可更有效降低婦女自覺之整體漏尿嚴重度及應力性漏尿嚴重度、72小時解尿日誌之整體漏尿次數、一小時棉墊測試之漏尿量、20分鐘棉墊測試之漏尿量，並可更有效地促進骨盆底肌耐力表現及生活品質。在家自行運動之對照組婦女，若能確實執行80%以上運動量之運動處方，亦能有效促進其骨盆底肌最大肌力，並改善其漏尿。 建議臨床上不適合或不願意接受內診之漏尿婦女可經由腹橫肌間接訓練骨盆底肌以改善其漏尿問題，然適合或願意接受內診之漏尿婦女則只需於門診經由內診教導一次正確之骨盆底肌收縮，加上高順應性之居家運動，即可見其療效，未必需要定期回診接受骨盆底肌訓練。Urinary incontinence (UI) is the complaint of any involuntary leakage of urine. Stress urinary incontinence (SUI) is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. The prevalence of female UI is greater than that of male, and the commonest type is SUI. UI has significant impact on the quality of life including physical, mental and social issues. SUI may also lead to withdraw from regular physical exercise and fitness activities that are important in the prevention of osteoporosis, coronary heart disease, and so on. The cause of SUI is related to the impairment of pelvic floor muscles (PFM). So far, the effects of intensive pelvic floor muscle training for female SUI were proved in many randomized controlled trials. However, training of accurate contraction of PFM depends on vaginal palpation. The willingness to seek for medical help may be lowered due to being embarrassed with vaginal palpation. Sapsford proposed a concept to treat SUI via transversus abdominis (TrA) that does not need to palpate the vagina. Maybe the new intervention can promote the willingness to seek medical help. However, to date there is no randomized controlled trial comparing the effect of indirect training of the PFM via TrA with either untreated control or other intervention. Therefore, the purpose of this study is to compare the effect of indirect training of PFM via TrA with control group for female UI. Seventy-one women with UI were recruited in this study and randomized to intervention or control group after being stratified by the moving direction of PFM during contraction of TrA. All subjects were evaluated pre- and post- 4-month intervention. The measurements included basic data and comprehensive urogynaecological history, women’s observations, quantification of symptoms, clinician’s measures and quality of life. Women in the control group learned correct contraction of pelvic floor muscles in first evaluation and received customary information of PFM exercise. The intervention group followed a specially designed exercise course including diaphragmatic breathing, tonic activation, muscle strengthening, functional expiratory patterns and impact activities. They were individually trained by a physical therapist for 30-60 minutes eight times during the intervention period. Descriptive and inferential statistics were completed using SPSS for windows, version 11.0. Descriptive statistics was computed for subject demographics. Normality was evaluated by using the Shapiro-Wilk test for all variables. The confounding factors between two groups were tested by the independent t-test or Chi-square test. A two-way mixed analysis of variance (ANOVA) and Wilcoxon signed-rank test were used to assess possible differences between pre- and post- intervention and two groups. The Chi-square and Mann-Whitney rank-sum test were used to assess the discrete dependent variables. The present study found the self-reported incontinence severity, self-reported stress incontinence severity, frequency of incontinence during 72 hours diary, leaking amount of 1-hour pad test and 20-minute pad test were statistically significant lowered (p＜0.05), and the endurance of pelvic floor muscles and quality of life were statistically significant improved more for intervention group compared to control group. The women in the control group who had administered 80% PFM exercise sessions also found the urinary incontinence better, and the maximal voluntary strength of pelvic floor muscles improved. The women with urinary incontinence who are not suitable for vaginal palpation can be trained via TrA. These who are suitable for vaginal palpation can learn correct pelvic floor muscle exercise only once, and who has high exercise compliance also improve the incontinence.目 錄 2 摘 要 4 第一章 前言 10 第一節 研究背景與動機 10 第二節 研究目的 12 第三節 研究問題與假說 13 第二章 文獻回顧 14 第一節 尿失禁之相關研究 14 第二節 應力性尿失禁之評估 18 第三節 應力性尿失禁之物理治療相關研究 24 第四節 經由腹橫肌間接訓練骨盆底肌之相關研究 26 第三章 研究方法 31 第一節 受試者 31 第二節 本研究的變項定義 32 第三節 研究流程 33 第四節 測量方法與工具 34 第五節 介入方式 37 第六節 資料統計與分析 39 第四章 結果 40 第一節 收案流程 40 第二節 受試者基本資料及相關泌尿症狀 41 第三節 骨盆底肌表現之測量結果 41 第四節 婦女自覺漏尿症狀之測量結果 42 第五節 72小時解尿日誌之測量結果 43 第六節 棉墊測試之測量結果 43 第七節 生活品質之測量結果 43 第八節 順應性 44 第五章 討論 46 第六章 結論與建議 52 第七章 參考文獻 53 表一、骨盆底肌訓練之療效 60 表二、樣本數估計 61 表三、訓練組之運動進展 62 表四、受試者介入前之基本資料及組間比較 63 表五、介入前兩組有之泌尿相關症狀 64 表六、骨盆底肌徒手肌力測試表現 65 表七之一、最大陰道壓力值、平均陰道壓力值、收縮時間 66 表七之二、最大陰道壓力值、平均陰道壓力值、收縮時間(post hoc分析) 67 表八、婦女自覺漏尿頻率 68 表九、婦女自覺漏尿量 69 表十、婦女自覺漏尿嚴重度 70 表十一、婦女自覺進步率 71 表十二、72小時解尿日誌 72 表十三、棉墊測試結果 73 表十四之一、生活衝擊問卷(平均值、標準差) 74 表十四之二、生活品質衝擊問卷 75 表十五之一、將對照組依順應性不同分組之骨盆底肌徒手測試肌力表現 76 表十五之二、將對照組依順應性不同分組之陰道壓力值表現 77 表十六、婦女自覺進步率(訓練組與高順應性對照組與中低順應性對照組之比較) 78 表十七、初次評估棉墊測試漏尿量小於2g之人數及百分比 79 圖一、尿道縱向解剖圖 80 圖二、尿道支持系統之側面圖 81 圖三、陰道壓力儀 82 圖四、陰道肌力儀 (vaginal dynamometer) 83 圖五、收案流程圖 84 圖六、經由腹橫肌訓練骨盆肌改善應力性尿失禁之可能機制 85 附錄一、衝擊指數問卷中文版本 (Questionnaire of Impact Index) 86 附錄二、倫理委員會公文 87 附錄三、問卷 88 附錄四、對照組之衛教單張 95 附錄五、訓練組之預定運動進展表及訓練內容 9