产后早期静力性收缩训练联合神经肌肉电刺激治疗产后腹直肌分离的疗效研究

Clinical effects of early postpartum static contraction training combined with neuromuscular electrical stimulation in the treatment of postpartum diastasis recti abdominis

目的探讨产后早期(产后4~6周)静力性收缩训练(SCT)联合神经肌肉电刺激(NES),对产后腹直肌分离(DRA)产妇的疗效。方法选择2018年1月至2021年10月,江苏淮安市妇幼保健院收治的90例产后DRA产妇为研究对象。采用随机数字表法,将其随机分为研究组(n=45)与对照组(n=45)。于产后早期,对研究组产妇DRA采取SCT联合NES治疗;而对照组产妇仅采取NES治疗。2组产妇治疗第2、4、6周时的腹围、双侧腹直肌间距(IRD),盆底Ⅰ、Ⅱ类肌纤维肌电压值,产妇腰、背部疼痛的视觉模拟评分量表(VAS)评分比较,采用重复测量资料方差分析,治疗不同时间点上述指标两两比较,采用最小显著性差异(LSD)-t检验。本研究遵循的程序获得江苏淮安市妇幼保健院医学伦理委员审核批准(审批文号:201806),征得受试者知情同意,并与其签署临床研究知情同意书。结果①2组产妇本次分娩孕龄、剖宫产术分娩比例、孕期体重增加值、第一与第二产程持续时间、新生儿出生体重≥4000 g占比,产次、剖宫产次数≥2次占比,以及治疗前人体质量指数(BMI)≥24 kg/m^(2)占比、腹围、双侧IRD等临床资料比较,差异均无统计学意义(P>0.05)。②对2组DRA产妇治疗第2、4、6周时,腹围和双侧IRD,经重复测量资料方差分析结果显示,不同治疗措施与时间因素交互效应,均无统计学意义(F_(治疗×时间)=4.214、2.193,P_(治疗×时间)=0.062、0.241)。进一步对DRA治疗措施的主效应分析结果显示,不同治疗措施对产后DRA产妇治疗不同时间点的腹围、双侧IRD的主效应,均有统计学意义(F_(治疗)=6.874、8.291,P_(治疗)=0.032、0.012),研究组产妇治疗不同时间点的腹围、双侧IRD总体较对照组分别偏小4.1 cm(95%CI:1.2~5.3 cm,P<0.05)与偏短0.17 cm(95%CI:0.06~0.31 cm,P<0.05)。对时间因素的主效应分析结果显示,时间因素对产后DRA产妇治疗不同时间点的腹围、双侧IRD的主效应均有统计学意义(F_(时间)=14.286、9.574,P_(时间)<0.001、=0.004)。对治疗不同时间点2组产妇腹围、双侧IRD分别两两比较结果显示,治疗第4、6周时的腹围和双侧IRD,均显著偏小和偏短于治疗第2周,治疗第6周时的腹围和双侧IRD,均显著偏小和偏短于治疗第4周,并且差异均有统计学意义(P<0.05)。③2组产妇治疗第2、4、6周时的盆底Ⅰ、Ⅱ类肌纤维肌电压值及产妇腰、背部疼痛的VAS评分,经重复测量资料方差分析结果显示,不同治疗措施与时间因素交互效应,均有统计学意义(F_(治疗×时间)=6.721、7.284、8.277,P_(治疗×时间)=0.024、0.017、0.012)。进一步对治疗措施的单独效应进行分析的结果显示,治疗第4、6周时,研究组产妇盆底Ⅰ类肌纤维肌电压值均显著高于对照组,治疗第6周时,研究组产妇盆底Ⅱ类肌纤维肌电压值亦显著高于对照组,并且差异均有统计学意义(t=2.075、4.336、7.798,P=0.008、<0.001、<0.001)。进一步对研究组与对照组中时间因素的单独效应分别进行分析的结果显示,研究组与对照组产妇治疗第2、4、6周时的盆底Ⅰ、Ⅱ类肌纤维肌电压值及产妇腰、背部疼痛的VAS评分分别组内总体比较,差异均有统计学意义(研究组:F=155.488、229.732、598.316,均为P<0.001;对照组:F=83.498、92.179、765.398,均为P<0.001)。对组内进一步两两比较结果显示,2组产妇治疗第4、6周时的盆底Ⅰ、Ⅱ类肌纤维肌电压值,均较组内治疗第2周显著增高,而产妇腰、背部疼痛的VAS评分,则较组内治疗第2周显著降低,治疗第6周时的盆底Ⅰ、Ⅱ类肌纤维肌电压值,均较组内治疗第4周显著增高,而产妇腰、背部疼痛的VAS评分,则较组内治疗第4周显著降低,并且差异均有统计意义(P<0.001)。结论产后早期,对DRA产妇采取SCT联合NES治疗,可促进腹围及双侧IRD恢复,提高盆底肌力,缓解其腰、背部疼痛。

Objective To explore therapeutic effects of early postpartum(4-6 weeks postpartum)static contraction training(SCT)combined with neuromuscular electrical stimulation(NES)in the treatment of parturients with postpartum diastasis recti abdominis(DRA).Methods A total of 90 cases of postpartum DRA parturients who were admitted to Huai'an Maternal and Child Health Care Hospital from January 2018 to October 2021 were selected into this study.They were randomly divided into study group(n=45)and control group(n=45)by random number table method.At 4-6 weeks of early postpartum,parturients in study group were treated with SCT combined with NES,while parturients in control group were only treated with NES.Abdominal circumference,bilateral inter-recti distance(IRD),voltage values of type Ⅰ and Ⅱ muscle fiber of pelvic floor and visual analogue scale(VAS)scores of waist and back pain in two groups at the 2nd,4th and 6th week of treatment were compared by variance of repeated measurement data method.Least significant difference(LSD)-t test was used for pairwise comparison of the above indicators at different time points.This study was approved by the ethics committee of Huai'an Maternal and Child Health Care Hospital(Approval No.201806),and informed consent for clinical research was signed with all subjects.Results①There were no significant differences between two groups in general clinical data,such as gestational age of delivery,proportion of cesarean section,weight gain during pregnancy,duration of the first and second stage of labor,proportion of neonatal birth weight≥4000 g,parity,proportion of cesarean section more than twice,and proportion of body mass index(BMI)≥24 kg/m^(2),abdominal circumference and bilateral IRD before treatment(P>0.05).②Analysis of variance of repeated measurement data of abdominal circumference and bilateral IRD of two groups at the 4th and 6th weeks of treatment showed that there were no statistical difference in interaction effects between different treatment measures and time factors(F_(treatment×time)=4.214,2.193,P_(treatment×time)=0.062,0.241).Further analysis of main effect of DRA treatment measures showed that main effects of different DRA treatment measures on abdominal circumference and bilateral IRD at different treatment time points of postpartum DRA parturients were statistically significant(F_(treatment)=6.874,8.291;P_(treatment)=0.032,0.012).Abdominal circumference and bilateral IRD in study group were 4.1 cm(95%CI:1.2-5.3 cm,P<0.05)and 0.17 cm(95%CI:0.06-0.31 cm,P<0.05)smaller and shorter than those in control group,respectively.Main effect analysis results of time factors showed that main effects of time factors on abdominal circumference and bilateral IRD of postpartum DRA parturients at different treatment time points were statistically significant(F_(time)=14.286,9.574;P<0.001,=0.004).Further pairwise analysis showed that abdominal circumference and bilateral IRD at the 4th and 6th week of treatment were significantly smaller and shorter than those at the 2nd week of treatment,and abdominal circumference and bilateral IRD at the 6th week of treatment were also significantly smaller and shorter than those at the 4th week of treatment,all differences were statistically significant(P<0.05).③Analysis of variance of repeated measurement data of voltage values of type Ⅰ and Ⅱ muscle fiber of pelvic floor and VAS scores of waist and back pain in two groups at the 2nd,4th and 6th weeks of treatment showed that there were statistical difference in interactive effects between different treatment measures and time factors(F_(treatment×time)=6.721,7.284,8.277;P_(treatment×time)=0.024,0.017,0.012).Further analysis of individual effects of treatment measures showed that voltage values of typeⅠmuscle fiber of pelvic floor at the 4th and 6th weeks of treatment in study group were higher than those in control group,and voltage value of type Ⅱ muscle fiber of pelvic floor in study group was significantly higher than that in control group,and all differences were statistically significant(t=2.075,4.336,7.798;P=0.008,<0.001,<0.001).Further analysis of individual effects of time factors in study group and control group respectively showed that there were statistical differences in voltage values of typeⅠmuscle fiber of pelvic floor at the 2nd,4th and 6th week of treatment both of study group and control group(study group:F=155.488,229.732,598.316,all P<0.001;control group:F=83.498,92.179,765.398,all P<0.001).Further pairwise comparison within study group and control group showed that voltage values of type Ⅰ muscle fiber of pelvic floor at the 4th and 6th week of treatment of two groups were statistically higher than those at the 2nd week of treatment within group,VAS scores of waist and back pain were statistically lower than those at the 2nd week of treatment within group,and voltage values of typeⅠmuscle fiber of pelvic floor at the 6th week of treatment of two groups were statistically higher than those at the 4th week of treatment within group,VAS scores of waist and back pain were statistically lower than those at the 4th week of treatment within group,and all differences were statistically significant(P<0.001).Conclusions Early postpartum SCT combined with NES in the treatment of postpartum DRA parturients can promote recovery of abdominal circumference and bilateral IRD,improve pelvic floor muscle strength and relieve lumbar and back pain.