不同盆底肌功能康复训练方法对产后盆底肌功能降低初产妇的恢复作用

doi:10.3877/cma.j.issn.1673-5250.2019.03.015

中华妇幼临床医学杂志(电子版) ›› 2019, Vol. 15 ›› Issue (03) : 334 -342. doi: 10.3877/cma.j.issn.1673-5250.2019.03.015

所属专题：文献；

论著

不同盆底肌功能康复训练方法对产后盆底肌功能降低初产妇的恢复作用

程芳¹, 杨云洁¹, 罗亚², 马乐²^,^†(

)

^1. 江苏省淮安市妇幼保健院产后保健科　223000
^2. 首都医科大学附属北京妇产医院泌尿外科　100000

收稿日期:2019-01-11 修回日期:2019-05-13 出版日期:2019-06-01
通信作者: 马乐

Clinical effects of different methods of pelvic floor muscle rehabilitation for primiparae with postpartum pelvic floor muscle function hypotonia

Fang Cheng¹, Yunjie Yang¹, Ya Luo², Le Ma²^,^†()

^1. Department of Postpartum Health Care, Huai′an Women and Children Health Hospital of Jiangsu Province, Huai′an 223000, Jiangsu Province, China
^2. Department of Urology Surgery, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100000, China

Received:2019-01-11 Revised:2019-05-13 Published:2019-06-01
Corresponding author: Le Ma
About author:
Corresponding author: Ma Le, Email: malef163bj@qq.com

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引用本文：

程芳, 杨云洁, 罗亚, 马乐. 不同盆底肌功能康复训练方法对产后盆底肌功能降低初产妇的恢复作用[J]. 中华妇幼临床医学杂志(电子版), 2019, 15(03): 334-342.

Fang Cheng, Yunjie Yang, Ya Luo, Le Ma. Clinical effects of different methods of pelvic floor muscle rehabilitation for primiparae with postpartum pelvic floor muscle function hypotonia[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2019, 15(03): 334-342.

目的

探讨盆底肌功能康复训练方法，如Kegel训练和阴道康复器辅助训练，对于改善初产妇产后盆底肌功能的效果，评估阴道康复器辅助训练，对于初产妇产后盆底肌功能的恢复作用。

方法

选取2016年1月至6月，在江苏省淮安市妇幼保健院足月经阴道分娩，并于产后第42天返回医院接受盆底肌功能评估的60例盆底肌肌力下降初产妇为研究对象。按照随机数字表法，将其分为研究组(n＝30)与对照组(n＝30)。对研究组受试者采用阴道康复器辅助训练至产后第18周，再改为Kegel训练至产后1年。对对照组受试者采用Kegel训练至产后1年。2组受试者在产后第6、10、18周及1年时，盆底Ⅰ、Ⅱ类肌纤维不同级别肌力发生率比较，采用Cochran-Mantel-Haenszel检验。受试者产后盆底Ⅰ、Ⅱ类肌纤维肌力影响因素分析，分别以其产后盆底Ⅰ、Ⅱ类肌纤维肌力为因变量，治疗措施、时间、治疗措施与时间交互效应为自变量，进行非线性混合效应模型(NLMIXED)分析。本研究遵循的程序符合江苏省淮安市妇幼保健院人体试验委员会制定的标准，并经过该伦理委员会批准(批准文号：2014016)，并与所有受试者签订临床研究知情同意书。

结果

①2组受试者年龄、孕次、人体质量指数(BMI)、新生儿出生体重及治疗前盆底Ⅰ、Ⅱ类纤维的肌力分级构成比等一般临床资料比较，差异均无统计学意义(P>0.05)。②控制治疗措施因素后，受试者产后盆底Ⅰ、Ⅱ类肌纤维肌力变化，均具有显著时间趋势，即随着训练时间延长，产后盆底肌功能不断恢复，并且差异均有统计学意义(χ²＝133.204、116.344，P<0.001)；控制时间因素后，研究组治疗措施对受试者产后盆底Ⅰ类肌纤维肌力的恢复情况，显著优于对照组，差异亦有统计学意义(χ²＝22.239，P<0.001)，但是2组治疗措施对受试者产后盆底Ⅱ类肌纤维肌力的恢复情况比较，差异无统计学意义(P>0.05)。③对受试者产后盆底Ⅰ、Ⅱ类肌纤维肌力进行分析的结果显示，治疗措施、时间、治疗措施与时间交互效应，均为受试者产后盆底Ⅰ、Ⅱ类肌纤维肌力的影响因素，并且差异均有统计学意义(盆底Ⅰ类肌纤维肌力：t＝－3.220、6.280、4.340，P＝0.002、<0.001、<0.001；盆底Ⅱ类肌纤维肌力：t＝－3.080、5.350、3.510，P＝0.003、<0.001、<0.001)。

结论

阴道康复器辅助训练和Kegel训练，均可显著改善初产妇产后盆底Ⅰ、Ⅱ类肌纤维肌力，而且随着训练时间延长，肌力不断恢复。与Kegel训练相比，阴道康复器辅助训练可以更快、更有效、更持久改善初产妇产后盆底Ⅰ类肌纤维肌力，并且疗效优于Kegel训练。

关键词: 盆腔脏器脱垂, 肌张力过低, 康复, 盆底肌功能，产后, Kegel训练, 阴道康复器辅助训练, 治疗结果, 初产妇

Objective

To observe the efficacy of different pelvic floor muscle function rehabilitation training methods, such as measures of Kegel training and vaginal rehabilitation device auxiliary training, for improving pelvic floor muscle function of postpartum primiparae, and to assess the effect of vaginal rehabilitation device auxiliary training can improve the pelvic floor muscle function.

Methods

A total of 60 cases of primiparae with pelvic floor muscle function hypotonia after delivery who underwent term vaginal delivery in Huai′an Women and Children Health Hospital of Jiangsu Province and returned to evaluate the pelvic floor muscle function 42 d after delivery from January to June 2016 were selected as research subjects. They were randomly divided into the study group (n=30) and control group (n=30) by random digits table method. In study group, postpartum primiparae were trained by measure of vaginal rehabilitation device auxiliary training until the 18 weeks after delivery, and then were trained by Kegel training until 1 year after delivery. Postpartum primiparae in control group were treated by measure of Kegel training until 1 year after delivery. At the 6 weeks, 10 weeks, 18 weeks and 1 year after delivery, the rates of different grades of type Ⅰ and Ⅱ muscle fiber strength of postpartum pelvic floor between two groups were compared by Cochran-Mantel-Haenszel test. The influencing factors of muscle strength of type Ⅰ and Ⅱ muscle fibers of pelvic floor in postpartum primiparae were analyzed by nonlinear mixed effect model (NLMIXED). This study was approved by the Ethics Committee of Human Beings in Huai′an Women and Children Health Hospital of Jiangsu Province (Approval No. 2014016). Informed consent for clinical research was signed with each postpartum primipare.

Results

①There were no statistically significant differences between two groups in terms of age, gravidity, body mass index (BMI), birth weight of newborns and constituent ratios of different grades of muscle strength of type Ⅰ and Ⅱ muscle fibers of pelvic floor before treatment (P>0.05). ②With the control of treatment factor, there was a significant time trend of type Ⅰ and Ⅱ muscle fibers strength changes of postpartum pelvic floor, that was, the function of pelvic floor muscle in postpartum primiparae was continuously improved with the extension of training time, and the differences were statistically significant (χ²=133.204, 116.344; P<0.001). With the control of time factor, the recovery effect of study group on type Ⅰ muscle fiber strength of postpartum pelvic floor was significantly better than that of control group, and the difference was statistically significant (χ²=22.239, P<0.001), while there was no significant difference in the recovery effect of type Ⅱ muscle fiber strength of postpartum pelvic floor between two groups (P>0.05). ③The results of NLMIXED analysis with type Ⅰ and Ⅱ muscle fiber strength of postpartum pelvic floor classified as dependent variable respectively, and the treatment measures, time, interaction of treatment measures and time classified as independent variables showed that the treatment measures, time, and interaction of treatment measures and time all were the influencing factors of type Ⅰ and Ⅱ muscle fibers strength of postpartum pelvic floor, and the differences were statistically significant (type Ⅰ muscle fiber strength of pelvic floor: t=-3.220, 6.280, 4.340, P=0.002, <0.001, <0.001; type Ⅱ muscle fiber strength of pelvic floor: t=-3.080, 5.350, 3.510, P=0.003, <0.001, <0.001).

Conclusions

Vaginal rehabilitation device auxiliary training and Kegel training can significantly improve type Ⅰand Ⅱ muscle fibers strength of postpartum pelvic floor, and with the extension of training time, the muscle strength of postpartum pelvic floor is gradually strengthened. Compared with Kegel training, vaginal rehabilitation device auxiliary training can be faster, more effective, and more lasting in improving type Ⅰ muscle fiber strength of postpartum pelvic floor, and the curative effect is superior to Kegel training.

Key words: Pelvic organ prolapse, Muscle hypotonia, Rehabilitation, Pelvic floor muscles function, postpartum, Kegel training, Vaginal rehabilitation device auxiliary training, Treatment outcome, Primipara

表1 2组产后盆底肌肌力下降受试者一般临床资料比较

组别	例数	年龄(岁，±s)	孕次(次，±s)	BMI(kg/m²，(±s)	新生儿出生体重(g，±s)	治疗前盆底Ⅰ类肌纤维的肌力分级[例数(%)]		治疗前盆底Ⅱ类肌纤维的肌力分级[例数(%)]
组别	例数	年龄(岁，±s)	孕次(次，±s)	BMI(kg/m²，(±s)	新生儿出生体重(g，±s)	Ⅰ级	Ⅱ级	Ⅰ级	Ⅱ级	≥Ⅲ级
研究组	30	26.4±3.0	1.5±0.7	22.1±2.8	3 428±404	28(93.3)	2(6.7)	16(53.3)	14(46.7)	0(0)
对照组	30	27.1±3.2	1.3±0.5	21.6±1.8	3 454±305	29(96.7)	1(3.3)	16(53.3)	12(40.0)	2(6.7)
检验值	?	t＝0.873	t＝1.489	t＝0.863	t＝0.274	χ²＝0.000 ^a		χ²＝2.154
P值	?	0.386	0.142	0.392	0.785	1.000		0.341

表1 2组产后盆底肌肌力下降受试者一般临床资料比较

组别	例数	年龄(岁，±s)	孕次(次，±s)	BMI(kg/m²，(±s)	新生儿出生体重(g，±s)	治疗前盆底Ⅰ类肌纤维的肌力分级[例数(%)]		治疗前盆底Ⅱ类肌纤维的肌力分级[例数(%)]
组别	例数	年龄(岁，±s)	孕次(次，±s)	BMI(kg/m²，(±s)	新生儿出生体重(g，±s)	Ⅰ级	Ⅱ级	Ⅰ级	Ⅱ级	≥Ⅲ级
研究组	30	26.4±3.0	1.5±0.7	22.1±2.8	3 428±404	28(93.3)	2(6.7)	16(53.3)	14(46.7)	0(0)
对照组	30	27.1±3.2	1.3±0.5	21.6±1.8	3 454±305	29(96.7)	1(3.3)	16(53.3)	12(40.0)	2(6.7)
检验值	?	t＝0.873	t＝1.489	t＝0.863	t＝0.274	χ²＝0.000 ^a		χ²＝2.154
P值	?	0.386	0.142	0.392	0.785	1.000		0.341

表2 2组产后盆底肌肌力下降受试者产后不同时间盆底Ⅰ类肌纤维中，不同肌力分级比较[例数(%)]

组别	例数	产后第6周			产后第10周
组别	例数	Ⅰ级	Ⅱ级	≥Ⅲ级	Ⅰ级	Ⅱ级	≥Ⅲ级
研究组	30	28(93.3)	2(6.7)	0(0)	4(13.3)	22(73.3)	4(13.4)
对照组	30	29(96.7)	1(3.3)	0(0)	13(43.3)	16(53.3)	1(3.4)
组别	例数	产后第18周			产后1年
组别	例数	Ⅰ级	Ⅱ级	≥Ⅲ级	Ⅰ级	Ⅱ级	≥Ⅲ级
研究组	30	2(6.7)	11(36.7)	17(56.6)	0(0)	1(3.3)	29(96.7)
对照组	30	5(16.7)	14(46.7)	11(36.6)	3(10.0)	12(40.0)	15(50.0)

表2 2组产后盆底肌肌力下降受试者产后不同时间盆底Ⅰ类肌纤维中，不同肌力分级比较[例数(%)]

组别	例数	产后第6周			产后第10周
组别	例数	Ⅰ级	Ⅱ级	≥Ⅲ级	Ⅰ级	Ⅱ级	≥Ⅲ级
研究组	30	28(93.3)	2(6.7)	0(0)	4(13.3)	22(73.3)	4(13.4)
对照组	30	29(96.7)	1(3.3)	0(0)	13(43.3)	16(53.3)	1(3.4)
组别	例数	产后第18周			产后1年
组别	例数	Ⅰ级	Ⅱ级	≥Ⅲ级	Ⅰ级	Ⅱ级	≥Ⅲ级
研究组	30	2(6.7)	11(36.7)	17(56.6)	0(0)	1(3.3)	29(96.7)
对照组	30	5(16.7)	14(46.7)	11(36.6)	3(10.0)	12(40.0)	15(50.0)

表3 产后盆底肌肌力下降受试者的盆底Ⅰ类肌纤维肌力影响因素的非线性混合模型参数估计结果

模型参数	估计值	标准误	自由度	t值	P值
截距	－3.269	0.644	59	－5.080	<0.001
治疗措施	－4.186	1.300	59	－3.220	0.002
时间	0.951	0.151	59	6.280	<0.001
治疗措施与时间交互效应	1.585	0.366	59	4.340	<0.001
模型误差	1.100	0.295	59	3.730	<0.001

表3 产后盆底肌肌力下降受试者的盆底Ⅰ类肌纤维肌力影响因素的非线性混合模型参数估计结果

模型参数	估计值	标准误	自由度	t值	P值
截距	－3.269	0.644	59	－5.080	<0.001
治疗措施	－4.186	1.300	59	－3.220	0.002
时间	0.951	0.151	59	6.280	<0.001
治疗措施与时间交互效应	1.585	0.366	59	4.340	<0.001
模型误差	1.100	0.295	59	3.730	<0.001

图2 2组产后盆底肌肌力下降受试者产后不同时间盆底Ⅱ类肌纤维中，不同级别肌力发生率折线图(图2A：Ⅰ级肌力；图2B：Ⅱ级肌力；图2C：≥Ⅲ级肌力)

表4 2组产后盆底肌肌力下降受试者产后不同时间盆底Ⅱ类肌纤维中，不同肌力分级比较[例数(%)]

组别	例数	产后第6周			产后第10周
组别	例数	Ⅰ级	Ⅱ级	≥Ⅲ级	Ⅰ级	Ⅱ级	≥Ⅲ级
研究组	30	16(53.3)	14(46.7)	0(0)	1(3.3)	13(4.3)	16(53.3)
对照组	30	16(53.3)	12(40.0)	2(6.7)	3(10.0)	18(60.0)	9(30.0)
组别	例数	产后第18周			产后1年
组别	例数	Ⅰ级	Ⅱ级	≥Ⅲ级	Ⅰ级	Ⅱ级	≥Ⅲ级
研究组	30	1(3.3)	5(16.7)	24(80.0)	0(0)	0(0)	30(100.0)
对照组	30	0(0)	10(33.3)	20(66.7)	0(0)	4(13.3)	26(86.7)

表4 2组产后盆底肌肌力下降受试者产后不同时间盆底Ⅱ类肌纤维中，不同肌力分级比较[例数(%)]

组别	例数	产后第6周			产后第10周
组别	例数	Ⅰ级	Ⅱ级	≥Ⅲ级	Ⅰ级	Ⅱ级	≥Ⅲ级
研究组	30	16(53.3)	14(46.7)	0(0)	1(3.3)	13(4.3)	16(53.3)
对照组	30	16(53.3)	12(40.0)	2(6.7)	3(10.0)	18(60.0)	9(30.0)
组别	例数	产后第18周			产后1年
组别	例数	Ⅰ级	Ⅱ级	≥Ⅲ级	Ⅰ级	Ⅱ级	≥Ⅲ级
研究组	30	1(3.3)	5(16.7)	24(80.0)	0(0)	0(0)	30(100.0)
对照组	30	0(0)	10(33.3)	20(66.7)	0(0)	4(13.3)	26(86.7)

表5 产后盆底肌肌力下降受试者盆底Ⅱ类肌纤维肌力影响因素的非线性混合模型参数估计结果

模型参数	估计值	标准误	自由度	t值	P值
截距	－1.968	0.704	59	－2.790	0.007
治疗措施	－4.430	1.438	59	－3.080	0.003
时间	1.116	0.209	59	5.350	<0.001
治疗措施与时间交互效应	1.579	0.450	59	3.510	<0.001
模型误差	0.811	0.296	59	2.740	0.008

表5 产后盆底肌肌力下降受试者盆底Ⅱ类肌纤维肌力影响因素的非线性混合模型参数估计结果

模型参数	估计值	标准误	自由度	t值	P值
截距	－1.968	0.704	59	－2.790	0.007
治疗措施	－4.430	1.438	59	－3.080	0.003
时间	1.116	0.209	59	5.350	<0.001
治疗措施与时间交互效应	1.579	0.450	59	3.510	<0.001
模型误差	0.811	0.296	59	2.740	0.008

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Clinical effects of different methods of pelvic floor muscle rehabilitation for primiparae with postpartum pelvic floor muscle function hypotonia

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Clinical effects of different methods of pelvic floor muscle rehabilitation for primiparae with postpartum pelvic floor muscle function hypotonia