物理治療於尿失禁婦女的應用

Abstract

骨盆底肌訓練在近幾年被建議為尿失禁婦女的第一線保守治療，尤其是針對應力性尿失禁和混合性尿失禁，且骨盆底肌運動的運動遵從性被認為是影響療效的重要因子。骨盆底肌訓練的療效機制被認為是藉由密集的阻力訓練，以改變骨盆底肌的肌肉型態學，進一步穩定膀胱頸，增進膀胱頸抵抗腹壓的能力。然而，究竟規律的骨盆底肌肌力訓練是否可以改變膀胱頸的位置及其抵抗腹壓的能力，目前仍然未知；此外，也尚沒有直接證據顯示運動順應性是尿失禁婦女在接受骨盆底肌訓練後症狀減輕的顯著因子。訓練橫膈膜、深層腹肌和骨盆底肌的協調性，是近來興起的一種新的運動介入方法，但截至目前為止僅有一篇單盲設計的隨機分配試驗曾探討其療效，其療效是否與傳統的骨盆底肌肌力訓練一樣好，目前亦未知。 因此，本系列研究的目的包括：（研究一）探討骨盆底肌肌力訓練對尿失禁婦女膀胱頸活動度的影響；（研究二）橫膈膜、深層腹肌與骨盆底肌的協調性訓練與骨盆底肌訓練於尿失禁婦女的療效比較；及（研究三）探討尿失禁婦女在接受骨盆底肌肌力訓練後，其症狀減輕的預測因子。 第一個研究結果顯示骨盆底肌主動收縮時，將膀胱頸向上提高的能力在四個月的骨盆底肌肌力訓練後顯著進步，但咳嗽及腹部用力時膀胱頸抵抗腹壓減少向下位移的能力並無改變。建議在臨床上除了給予尿失禁婦女密集的骨盆底肌肌力訓練外，亦須教導婦女在腹壓增加的情況時（例如咳嗽、腹部用力），先自行收縮骨盆底肌以穩定膀胱頸來避免漏尿。第二個研究則顯示橫膈膜、深層腹肌與骨盆底肌的協調性訓練對尿失禁婦女的療效，與骨盆底肌訓練的療效一樣有效，可適用不適合接受骨盆底肌訓練的尿失禁婦女。然而，這套新的運動方法卻無法改善骨盆底肌的肌力，因此可能不適用於骨盆底肌肌力較弱的個案。此介入方法的療效可能來自於骨盆底肌肌力之外的其他功能改善，包括骨盆底肌之耐力、收縮的速度、或與其他周遭肌肉之間的協調性。第三個研究則顯示，婦女在接受骨盆底肌肌力訓練後，其症狀減輕的預測因子僅有漏尿嚴重度及骨盆底肌肌力的改善程度，而非運動遵從性。一開始漏尿症狀較嚴重的婦女，或在訓練過程中骨盆底肌肌力進步較多的婦女，其症狀減輕的幅度也較大。 總結而言，單純只進行密集的骨盆底肌肌力訓練並不足以改善膀胱頸抵抗腹壓的能力。新的運動方法對尿失禁婦女的療效與骨盆底肌訓練相當。雖然在骨盆底肌肌力訓練過程後，一開始漏尿嚴重度較高的婦女及骨盆底肌肌力進步愈多的婦女，其症狀的減輕也愈明顯，但骨盆底肌肌力卻不是尿失禁婦女症狀減輕的唯一指標。在臨床上，針對骨盆底肌肌力較弱的婦女，應給予密集的骨盆底肌肌力訓練；若婦女就醫時已有良好的骨盆底肌肌力，則建議給予橫膈膜、深層腹肌與骨盆底肌的協調性訓練。

Pelvic floor muscle training (PFMT) was recommended as one of the first-line conservative managements for women with urinary incontinence (UI), especially for stress UI (SUI) and mixed UI (MUI). Exercise adherence was supposed to be an important factor of its treatment effectiveness. It is hypothesized that intensive resistance training could change morphology of pelvic floor muscles (PFM), and then stabilize the bladder neck by improving its stiffness against increased intra-abdominal pressure. However, it is unknown whether a regular strengthening of PFM would change the bladder neck position and stiffness. And there was no direct evidence demonstrated if exercise adherence is a significant predictor on symptom reduction for symptomatic women after PFM strengthening. Retraining coordinated function of diaphragmatic, deep abdominal and PFM was a new approach to treat SUI. To date, there was only one single-blinded randomized controlled trial demonstrated the treatment effect of this new approach for symptomatic women. Whether this approach has equivalent effectiveness as intensive PFMT is still unknown. Hence, the purposes of this series of studies were: Study I: to investigate the effect of PFM strengthening on bladder neck mobility for women with UI; Study II: to compare the treatment effects of retraining coordinated function of diaphragmatic, deep abdominal and PFM with intensive PFMT for women with UI; and Study III: to explore the predictors of treatment effectiveness for women with UI receiving PFM strengthening. Results of the study I showed that the ability of the PFM to elevate the bladder neck voluntarily was improved, but the stiffness of the bladder neck during cough and Valsalva was not improved after the 4-month PFM strengthening. The findings suggested that the use of volitional PFM contractions during cough or Valsalva maneuver should be taught in addition to PFM strengthening program for clinical implications. Results of the study II showed that the effect of treating UI by retraining coordinated function of diaphragmatic, deep abdominal and PFM was comparable with intensive PFM strengthening. This new approach may be an alternative approach for symptomatic women who are not suitable to receive PFM strengthening. However, it could not improve the strength of PFM and should be applied carefully for women with poor PFM strength. Its treatment effects may come from other aspects of PFM function beyond PFM strength, such as muscle endurance, velocity of contraction, or coordination with other muscles around. The results of multiple regression analysis in study III revealed that exercise adherence was not a significant predictor of symptom reduction for women who received PFM strengthening program. The severity of symptom and improvement score of PFM strength had more impacts on the effectiveness than exercise adherence. Women who had more significant symptom of leakage and who had more improvement of PFM strength showed more improvement of symptom after PFM strengthening. In summary, an intensive PFM strengthening program may not be sufficient to enhance the stiffness of bladder neck against intra-abdominal pressure. The new approach for women with UI, retraining coordinated function of diaphragmtic, deep abdominal and PFM, had comparable treatment effect with PFMT. Although women who has more severe symptoms and who get more improvement of PFM strength would get more symptom reduction, PFM strength may not be the only indicator to ensure the treatment effectiveness for women with UI. For clinical implications, women who have poor PFM strength should strengthen her PFM by intensive PFM strengthening program firstly. Instead, women who already have good PFM strength could retrain the coordinated function of diaphragmatic, deep abdominal, and PFM to relieve the symptom of UI.