產(chǎn)前和產(chǎn)后運動訓練對DRAM的影響解讀課件

1、產(chǎn)前和產(chǎn)后的運動干預對腹直肌分離的影響：一項系統(tǒng)回顧匯報人：楊雪卉 中山大學醫(yī)學院指導老師：鄭停停 陳可迪1第1頁，共37頁。腹部相關解剖腹直肌分離系統(tǒng)回顧背景和目的 Background and Objectives方法 Methods結果 Results討論 Discussion結論 Conclusion2第2頁，共37頁。腹部相關解剖前外側群 形成腹腔的前外側壁，包括腹直肌、腹外斜肌、腹內斜肌和腹橫肌等3第3頁，共37頁。腹部相關解剖腹直肌鞘 包裹腹直肌，前層由腹外斜肌腱膜與腹內斜肌腱膜的前層愈合而成，后層由腹內斜肌腱膜后層與腹橫肌腱膜愈合而成。4第4頁，共37頁。腹部相關解剖腹筋膜 包

2、括淺筋膜、深筋膜和腹內筋膜。 淺筋膜 在腹上部為一層，在臍以下分淺、深二層。淺層含有脂肪，稱脂肪層；深層內有彈性纖維，稱為膜性層。 深筋膜 可分數(shù)層，分別覆蓋在前外側群各肌的表面和深面。 腹內筋膜 附貼在腹腔各壁的內面。各部筋膜的名稱和所覆蓋的肌相同。白線 為兩側三層腹壁闊肌腱膜的纖維在正中線交織而成，其上方起自劍突，下抵恥骨聯(lián)合，約在白線中部有-臍環(huán)。5第5頁，共37頁。腹部相關解剖腹筋膜 包括淺筋膜、深筋膜和腹內筋膜。 淺筋膜 在腹上部為一層，在臍以下分淺、深二層。淺層含有脂肪，稱脂肪層；深層內有彈性纖維，稱為膜性層。 深筋膜 可分數(shù)層，分別覆蓋在前外側群各肌的表面和深面。 腹內筋膜 附貼

3、在腹腔各壁的內面。各部筋膜的名稱和所覆蓋的肌相同。白線 為兩側三層腹壁闊肌腱膜的纖維在正中線交織而成，其上方起自劍突，下抵恥骨聯(lián)合，約在白線中部有-臍環(huán)。6第6頁，共37頁。腹直肌分離 D R A M 概述腹壁的前內側由腹直肌覆蓋，腹直肌中間被白線分離成左右兩部分。The anteromedial abdominal wall consists of the abdominal rectus muscles separated by the linea alba, which is a fascia stretching from the xyphoid process to the pubi

4、c symphysis.It consists of the aponeuroses of the transverse abdominal, external and internal abdominal oblique muscles.獲得性的腹直肌分離是一個復雜的情況，由于腹白線的張力減弱，最終導致腹部的膨出。Acquired rectus abdominis diastasis (RD) is a complication of conditions weakening the linea alba resulting in abdominal protrusion. 7第7頁，共37

5、頁。腹直肌分離 D R A M 病因腹直肌分離的出現(xiàn)是由于激素水平的改變以至于連接組織彈性的改變、胎兒的增大以至于對腹壁的機械性壓力的增大、或者腹腔臟器的移位導致的。腹內壓的增大例如妊娠或者肥胖，或者先前的腹部手術都可以導致腹直肌分離。DRAM occurs due to hormonal elastic changes of the connective tissue, mechanical stresses placed on the abdominal wall by the growing fetus, and displacement of the abdominal organs

6、47. Thus, it can be caused by elevated intra-abdominal pressure, such as in pregnancy and obesity 1, or by previous abdominal surgery 2. 8第8頁，共37頁。腹直肌分離 D R A M 流行病學腹直肌分離通常出現(xiàn)在孕期的46月，并且研究者發(fā)現(xiàn)在孕期的79月發(fā)生的頻率最高。腹直肌分離會在產(chǎn)后1天到8周內達到恢復的最大限度，之后會出現(xiàn)恢復的平臺期。DRAM usually appears in the second trimester of pregnancy a

7、nd is found most frequently in the third trimester 6. Natural resolution and greatest recovery of DRAM occurs between 1 day and 8 weeks after delivery, after which time recovery plateaus 8.孕期79月：66%100%產(chǎn)后：53%9第9頁，共37頁。腹直肌分離 D R A M 不良影響腹壁對于姿勢，軀干和骨盆的穩(wěn)定，軀干的移動和腹腔臟器的支撐有重要意義。腹直肌間距的增加對這些功能會造成不利影響，并且會削弱腹部肌

8、肉，影響其功能。The abdominal wall has important functions in posture, trunk and pelvic stability, respiration,trunk movement and support of the abdominal viscera. An increase in the inter-recti distance puts these functions in jeopardy 1113, and can weaken abdominal muscles and influence their functions 14

9、,15. 這些會導致軀干生物力學的改變，降低骨盆穩(wěn)定和姿勢的改變，那么就會導致腰椎和骨盆的更易受傷。This may result in altered trunk mechanics, impaired pelvic stability and changed posture, which leave the lumbar spine and pelvis more vulnerableto injury 4,7,13.10第10頁，共37頁。腹直肌分離 D R A M 診斷標準J Plast Surg Hand Surg, 2014; 48: 163169 Informa Healthca

10、re Rectus abdominis diastasis Javed Akram & Steen Henrik Matzen 測量150名初產(chǎn)婦白線的普遍寬度 尸體研究白線的寬度11第11頁，共37頁。系統(tǒng)回顧 - 背景和目的手術法非手術法有氧運動 aerobic exercises姿勢和背部護理教育 postural and back care education外部支撐：如束腹等 external support (e.g.tubigrip or corset) 因此這項review的目的就是確定非手術干預措施是否能預防或減少產(chǎn)前DRAM的發(fā)生，并且減少產(chǎn)后DRAM和與其相關的不利影響。

11、Therefore, the aims of this review were to determine whether non-surgical interventions can prevent or reduce DRAM in the antenatal period, and reduce DRAM and health-related negative effects of DRAM in the postnatal period.12第12頁，共37頁。系統(tǒng)回顧 - 方法 - 數(shù)據(jù)來源 電子數(shù)據(jù)庫（涉及到非手術干預措施來預防或減少產(chǎn)前或產(chǎn)后DRAM的，出版的研究）Electron

12、ic databases：Medline, EMBASE, CINAHL, PEDro, PubMed and AMED(published studies involving non-surgical interventions to prevent and/or reduce DRAM during the ante- and postnatal periods)手動搜索（參考目錄和引文）（不限制語言和研究設計）Manual searching of the reference lists of included studies and citation tracking were con

13、ducted to ensure that all relevant studies were found.No study design or language restrictions were applied.13第13頁，共37頁。系統(tǒng)回顧 - 方法 - 研究選入回顧、專家意見、社論都被包括在內。Reviews, editorials, opinions and theses were excluded. 兩個研究者(DB和CP）根據(jù)標題和摘要，獨立的運用納入標準，完成所有研究的檢索。對于潛在合格的研究，會進行再定標準下的全文檢索和審查。Two reviewers (DB and CP

14、) applied the inclusion criteria independently (Table A, see online supplementary material)to the titles and abstracts of all studies retrieved. Full-text articles were retrieved and reviewed by re-application of the criteria for potentially eligible studies. 14第14頁，共37頁。系統(tǒng)回顧 - 方法 - 數(shù)據(jù)摘取the Cochrane

15、 Consumers and Communication Review Groupdata extraction template先是通過選擇一個研究的過程來測試這種選擇模式是否合適，之后對其進行精確調整。The form was pilot tested on a selection of studies and subsequently refined.從每個研究中摘取出指定的數(shù)據(jù)，例如受試者特征（年齡，經(jīng)產(chǎn)狀況，生產(chǎn)方式），干預（類型，持續(xù)時間，頻率，變化，設置），結局（首要和次要，方法和評估時間），結果和不利的事件。Data were extracted from each study

16、 on participant characteristics (age, parity, mode of delivery), intervention (type, duration, frequency, delivery,setting), outcomes (primary and secondary, method and timing of assessment), results and adverse events.15第15頁，共37頁。系統(tǒng)回顧 - 方法 - 結局最基本的結局指標是是否出現(xiàn)DRAM或DRAM的寬度。其次的結局指標是背痛，腹部力量，完成日常生活的能力和生活質

17、量。The primary outcomes of interest were the presence/absence of DRAM and DRAM width (cm). Secondary outcomes were back pain, abdominal strength, ability to complete activities of daily living and quality of life. 超聲檢查是診斷腹直肌分離的金指標，測量標準誤為0.050.2cm。其他測量方法比如測徑器（測量標準誤0.010.41cm）或觸診（指寬法）也可以應用在測量腹直肌分離上，但是可

18、能會降低精確性。Ultrasound may be considered the gold standard for clinical measurement of DRAM width with a low standard error of measurement(SEM) of 0.05 to 0.20 cm 3,15. Other methods such as callipers (SEM 0.01 to 0.41 cm) or palpation/finger width have been found to be reliable for the measurement of D

19、RAM, but may be less valid to measure the exact inter-recti distance3,23.16第16頁，共37頁。系統(tǒng)回顧 - 方法 -質量控制the modified Downs and Black checklist總得分從028分。分數(shù)在2628分的被評價為極好的，2025分的為好的，1519分的為一般的，分數(shù)為14分或更少的被評價為低級的。Total scores ranged from 0 to 28 points. Studies were rated as excellent if they scored 26 to 28,

20、 good if they scored 20 to 25, fair if they scored 15 to 19, and poor if the total score was 14 or less 26.17第17頁，共37頁。系統(tǒng)回顧 - 方法 - 數(shù)據(jù)分析單獨分析產(chǎn)前運動干預和產(chǎn)后運動干預對DRAM的作用的研究數(shù)據(jù)。Analysis was performed separately for interventions to prevent DRAM during the antenatal period and for interventions to treat DRAM du

21、ring the postnatal period.對于有相似的干預措施及相似的結局的研究進行META分析：當存在充分合適的數(shù)據(jù)能相互結合時，META分析能為初步的結果（DRAM的發(fā)生與否）提供一個合適的有效的模型，利用倒方差法來產(chǎn)生一個擁有95%置信區(qū)間的風險率。Meta-analysis was performed among studies with similar interventions that reported on the same outcomes. Where there were sufficient and appropriate data to combine, a

22、 meta-analysis was conducted using a fixed effects model for the primary outcome (presence or absence of DRAM) using inverse variance to yield a risk ratio (RR) with 95% confidence interval (CI) using RevMan 5.1.18第18頁，共37頁。系統(tǒng)回顧 - 方法 - 數(shù)據(jù)分析統(tǒng)計學的異質性通過I2 統(tǒng)計，超過50%代表比較高的異質性。Statistical heterogeneity was

23、assessed using the I2 statistic, with values of more than 50% representing substantial levels of heterogeneity 27. 若實驗缺少明顯的異質性的話，將對合并后的數(shù)據(jù)進行META分析。若無法合并數(shù)據(jù)的話，將采取描述性總結的形式來完成。Fixed effects meta-analysis was applied to combine data in the absence of significant heterogeneity between the trials. Where it

24、was not possible to pool data, an arrative summary of the studies was completed.19第19頁，共37頁。系統(tǒng)回顧 -結果1682個潛在的相關研究根據(jù)題目和摘要篩選剔除1362篇，并且剔除重復性的研究300篇，剩余的20篇研究進行全文閱讀的審查剔除不符合要求的12篇（包括無干預辦法的研究7篇，無DRAM預后報道的研究4篇和出版物類型不符的1篇）最終剩余8篇滿意度高的研究Effects of exercise on diastasis of the rectus abdominis muscle in the ante

25、natal and postnatal periods: a systematic review D.R. Benjamina, A.T.M. Van de Waterb, C.L. Peirisa,b20第20頁，共37頁。系統(tǒng)回顧 -結果Sheppard 21 defined it as 2 cm separation Lo et al. 4 and Candido et al. 10 defined it as2.5 cm Mesquita et al. 28 defined it as 3 cm separationChiarello et al. 3 defined it as a

26、two-finger separation on sit-up.Thornton and Thornton 29 did not provide a definition of DRAM.21第21頁，共37頁。在三個研究中對比無運動干預的小組，產(chǎn)前的運動干預對于DRAM的出現(xiàn)頻率減少了35%，每三個通過運動干預的懷孕女性中，就有一個能有效預防DRAM的發(fā)展。Compared with non-exercising controls in three studies(n = 228), antenatal exercise reduced the presence of DRAM by 35%

27、 (RR 0.65, 95% CI 0.46 to 0.92). Pooling of data showed low to moderate heterogeneity (I2= 39%) 31. From this RR, the number needed to treat was 3. This means that for every three pregnant women treated with exercise, one woman would be prevented from developing DRAM.22第22頁，共37頁。兩項研究發(fā)現(xiàn)產(chǎn)前運動能有效減少產(chǎn)前和產(chǎn)后

28、出現(xiàn)的DRAM的寬度。跟蹤調查一個產(chǎn)前腹部力量訓練的6周課程發(fā)現(xiàn)，對比無運動組，干預組DRAM寬度明顯減少。在案例研究中參與產(chǎn)前運動課程的參與者，產(chǎn)后48小時測量的DRAM寬度減少。所有的研究均發(fā)現(xiàn)無運動控制的組中都有一個產(chǎn)后DRAM寬度增加的現(xiàn)象。Evidence from two studies (n = 20) demonstrated that antenatal exercise reduced DRAM width during the antenatal1,3 and postnatal periods 1 (Table 2). Following a 6-week course

29、 of antenatal abdominal strengthening exercises , DRAM width during the antenatal period was significantly smaller in the intervention group mean 1.14 standard deviation (SD) 0.38 cm compared with the non-exercising control group mean 5.95 (SD) 2.36 cm (mean difference4.81 cm, 95% CI 3.83 to 5.80) 3

30、 (Table 2). In the case study1, the participant who attended antenatal fitness classes had reduced DRAM 48 hours after delivery. Comparatively, both studies found that non-exercising controls had an increase in DRAM width after delivery (Table 2).23第23頁，共37頁。一項針對于DRAM發(fā)展的危險因素的回顧性研究發(fā)現(xiàn)，產(chǎn)前運動與加速DRAM恢復有關，

31、然而當同時考慮經(jīng)產(chǎn)情況和生產(chǎn)方式時，效果并不是很明顯。A retrospective study 4 (n = 55) that looked at risk factors associated with developing DRAM reported that antenatal exercise may have been associated with faster recovery of DRAM; however, when parity and mode of delivery were taken into account, the effect was not signif

32、icant.24第24頁，共37頁。三個文獻研究以減少DRAM寬度為目的的產(chǎn)后腹部運動。由于數(shù)據(jù)不充分則合并數(shù)據(jù)不太可能。隨機對照試驗評估了產(chǎn)后618小時即開始腹部和骨盆運動的效果。在產(chǎn)后618小時和干預后18小時測量。干預組DRAM寬度減少了0.44cm，控制組減少0.17cm。單個案例研究結合了產(chǎn)后腹部運動和束腹或者姿勢/背部教育來減少產(chǎn)后DRAM。都表明產(chǎn)后DRAM寬度的減少。Sheppard也證明了觸診時腹橫肌的活性增加與腹肌耐力的增加。束腹減少下腰痛的可能。Three studies 21,28,29 included postnatal abdominal exercise wit

33、h the aim of reducing DRAM width. Pooling of data was not possible due to insufficient data . The randomised controlled trial 28 evaluated individualised abdominal and pelvic floor exercises delivered in two one-on-one sessions with a physiotherapist 6 and 18 hours after delivery. Measurements were

34、taken 6 and 18 hours after delivery and 18 hours after the intervention. The interven-tion group had a mean decrease in DRAM width of 0.44 cm(13%), compared with 0.17 cm (5%) for the control group(Table 2). The single case studies 21,29 combined abdomi-nal exercises with a tubigrip/corset and or pos

35、ture/back careeducation to reduce DRAM in the postnatal period. Bothstudies showed a reduction in DRAM width after delivery(Table 2). Sheppard 21 also reported improved transver-sus abdominis muscle activation on palpation and abdominalmuscle endurance with the interventions, while Thornton andThorn

36、ton 29 claimed that the corset helped to reduce lowback pain.25第25頁，共37頁。系統(tǒng)回顧 -結果 建議在研究中大量的人力物力消耗在于受試者的不配合，對于運動的依從性差。兩個受試者由于高危妊娠退出試驗，一個屬于與糖尿病有關的頑固性DRAM，需要長期服藥的退出了實驗。Most of the attrition was due to non-compliance with appointments or exercise regimens. Chiarello et al. 3 reported that two participan

37、ts dropped out due to the development of high-risk pregnancies. Lo et al. 4 reported that one patient was excluded from the study due to persistent DRAM which was thought to be associated with diabetes needing medical intervention (Table 2).26第26頁，共37頁。系統(tǒng)回顧 討論運動幫助了維持腹部肌肉張力、力量及控制力，因此降低了白線的壓力exercise

38、helps to maintain tone, strength and control of the abdominal muscles 3,5, consequently reducing stress on the line alba. 在懷孕期間規(guī)律的運動的女性通常在懷孕前也有運動，因此相對于孕期不運動的女性來說擁有更健康且狀況更好的腹部肌肉。因此建議女性在孕前即開始規(guī)律的運動。women who exercise during pregnancy generally also exercise prior to pregnancy and , therefore, may be fi

39、tter and have better conditioned abdominal muscles compared with women who do not exercise during pregnancy 427第27頁，共37頁。系統(tǒng)回顧 討論腹橫肌是腹部深層的肌肉，與腹直肌和白線有強壯的筋膜連接。腹橫肌的運動訓練會必然會造成同時訓練了腹直肌，提高了白線的完整性和筋膜的張力，允許了有效地負荷轉移和扭矩的產(chǎn)生。可能的是，腹橫肌的激活能保護白線，可能幫助預防DRAM和加速DRAM的恢復。然而更多高質量的研究需要證明這個假說。The transversus abdominis muscl

40、e is the deepest abdominal muscle, and has strong fascial links with the rectus abdominis muscle and the linea alba 32. Activation and exercise of the transversus abdominis muscle draws the bellies of the rectus abdominus muscle together, improves the integrity of the linea alba and increases fascia

41、l tension, allowing efficient load transference and torque production 13. Potentially, transversus abdominis muscle activation could be protective of the linea alba and may help to prevent or reduce DRAM and speed up recovery.28第28頁，共37頁。系統(tǒng)回顧 討論除了運動干預，兩項案例研究使用了體外支具如束腹，意圖減少DRAM的發(fā)生。體外支具可能會為腹部提供一個壓縮和支撐

42、，對腰椎骨盆部分模仿了腹橫肌的表面張力，可能對腹橫肌能提供一個生物反饋來激活活性。這些體外支具可以在除運動外應用，但仍需要證據(jù)證明他對DRAM的有效作用。In addition to exercise, two case studies 21,29 used external support garments (i.e. tubigrip, corsets) with the aim of reducing DRAM. External support garments may provide compression and support to the abdominal and lumbo

43、pelvic region by mimicking facial tension of the transversus abdominis muscle, and may provide biofeedback for the transversusabdominis muscle to assist with its activation. These external supports could be used in addition to transversus abdominismuscle exercises, but evidence is lacking about their use in the management of DRAM and further research is required.29第29頁，共37頁。局限研究的設計多樣，方法學的質量多樣。定義DRAM和測量DRAM的方法在各個研究也很多樣導致回顧無法得出強有力的結論。Studies were of varying design (e.g. single case studies, retrospective), had inadequately powered sample sizes, and were of varying method