产前和产后运动训练对DRAM的影响

产前和产后的运动干预对腹直肌分离的影响：一项系统回顾,汇报人：杨雪卉 中山大学医学院指导老师：郑停停 陈可迪,1,腹部相关解剖腹直肌分离系统回顾背景和目的 Background and Objectives方法 Methods结果 Results讨论 Discussion结论 Conclusion,2,腹部相关解剖,前外侧群 形成腹腔的前外侧壁，包括腹直肌、腹外斜肌、腹内斜肌和腹横肌等,3,腹部相关解剖,腹直肌鞘 包裹腹直肌，前层由腹外斜肌腱膜与腹内斜肌腱膜的前层愈合而成，后层由腹内斜肌腱膜后层与腹横肌腱膜愈合而成。,4,腹部相关解剖,腹筋膜 包括浅筋膜、深筋膜和腹内筋膜。 浅筋膜 在腹上部为一层，在脐以下分浅、深二层。浅层含有脂肪，称脂肪层；深层内有弹性纤维，称为膜性层。 深筋膜 可分数层，分别覆盖在前外侧群各肌的表面和深面。 腹内筋膜 附贴在腹腔各壁的内面。各部筋膜的名称和所覆盖的肌相同。白线 为两侧三层腹壁阔肌腱膜的纤维在正中线交织而成，其上方起自剑突，下抵耻骨联合，约在白线中部有-脐环。,5,腹部相关解剖,腹筋膜 包括浅筋膜、深筋膜和腹内筋膜。 浅筋膜 在腹上部为一层，在脐以下分浅、深二层。浅层含有脂肪，称脂肪层；深层内有弹性纤维，称为膜性层。 深筋膜 可分数层，分别覆盖在前外侧群各肌的表面和深面。 腹内筋膜 附贴在腹腔各壁的内面。各部筋膜的名称和所覆盖的肌相同。白线 为两侧三层腹壁阔肌腱膜的纤维在正中线交织而成，其上方起自剑突，下抵耻骨联合，约在白线中部有-脐环。,6,腹直肌分离 D R A M 概述,腹壁的前内侧由腹直肌覆盖，腹直肌中间被白线分离成左右两部分。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 pubic symphysis.It consists of the aponeuroses of the transverse abdominal, external and internal abdominal oblique muscles.获得性的腹直肌分离是一个复杂的情况，由于腹白线的张力减弱，最终导致腹部的膨出。Acquired rectus abdominis diastasis (RD) is a complication of conditions weakening the linea alba resulting in abdominal protrusion.,7,腹直肌分离 D R A M 病因,腹直肌分离的出现是由于激素水平的改变以至于连接组织弹性的改变、胎儿的增大以至于对腹壁的机械性压力的增大、或者腹腔脏器的移位导致的。腹内压的增大例如妊娠或者肥胖，或者先前的腹部手术都可以导致腹直肌分离。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 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,腹直肌分离 D R A M 流行病学,腹直肌分离通常出现在孕期的46月，并且研究者发现在孕期的79月发生的频率最高。腹直肌分离会在产后1天到8周内达到恢复的最大限度，之后会出现恢复的平台期。DRAM usually appears in the second trimester of pregnancy and 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%产后：53%,9,腹直肌分离 D R A M 不良影响,腹壁对于姿势，躯干和骨盆的稳定，躯干的移动和腹腔脏器的支撑有重要意义。腹直肌间距的增加对这些功能会造成不利影响，并且会削弱腹部肌肉，影响其功能。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 14,15. 这些会导致躯干生物力学的改变，降低骨盆稳定和姿势的改变，那么就会导致腰椎和骨盆的更易受伤。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,腹直肌分离 D R A M 诊断标准,J Plast Surg Hand Surg, 2014; 48: 163169 Informa Healthcare Rectus abdominis diastasis Javed Akram & Steen Henrik Matzen,测量150名初产妇白线的普遍宽度,尸体研究白线的宽度,11,系统回顾 - 背景和目的,手术法非手术法有氧运动 aerobic exercises姿势和背部护理教育 postural and back care education外部支撑：如束腹等 external support (e.g.tubigrip or corset) 因此这项review的目的就是确定非手术干预措施是否能预防或减少产前DRAM的发生，并且减少产后DRAM和与其相关的不利影响。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,系统回顾 - 方法 - 数据来源,电子数据库（涉及到非手术干预措施来预防或减少产前或产后DRAM的，出版的研究）Electronic 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)手动搜索（参考目录和引文）（不限制语言和研究设计）Manual searching of the reference lists of included studies and citation tracking were conducted to ensure that all relevant studies were found.No study design or language restrictions were applied.,13,系统回顾 - 方法 - 研究选入,回顾、专家意见、社论都被包括在内。Reviews, editorials, opinions and theses were excluded. 两个研究者(DB和CP）根据标题和摘要，独立的运用纳入标准，完成所有研究的检索。对于潜在合格的研究，会进行再定标准下的全文检索和审查。Two reviewers (DB and CP) 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,系统回顾 - 方法 - 数据摘取,the Cochrane Consumers and Communication Review Groupdata extraction template先是通过选择一个研究的过程来测试这种选择模式是否合适，之后对其进行精确调整。The form was pilot tested on a selection of studies and subsequently refined.从每个研究中摘取出指定的数据，例如受试者特征（年龄，经产状况，生产方式），干预（类型，持续时间，频率，变化，设置），结局（首要和次要，方法和评估时间），结果和不利的事件。Data were extracted from each study 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,系统回顾 - 方法 - 结局,最基本的结局指标是是否出现DRAM或DRAM的宽度。其次的结局指标是背痛，腹部力量，完成日常生活的能力和生活质量。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. 超声检查是诊断腹直肌分离的金指标，测量标准误为0.050.2cm。其他测量方法比如测径器（测量标准误0.010.41cm）或触诊（指宽法）也可以应用在测量腹直肌分离上，但是可能会降低精确性。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 DRAM, but may be less valid to measure the exact inter-recti distance3,23.,16,系统回顾 - 方法 -质量控制,the modified Downs and Black checklist总得分从028分。分数在2628分的被评价为极好的，2025分的为好的，1519分的为一般的，分数为14分或更少的被评价为低级的。Total scores ranged from 0 to 28 points. Studies were rated as excellent if they scored 26 to 28, 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,系统回顾 - 方法 - 数据分析,单独分析产前运动干预和产后运动干预对DRAM的作用的研究数据。Analysis was performed separately for interventions to prevent DRAM during the antenatal period and for interventions to treat DRAM during the postnatal period.对于有相似的干预措施及相似的结局的研究进行META分析：当存在充分合适的数据能相互结合时，META分析能为初步的结果（DRAM的发生与否）提供一个合适的有效的模型，利用倒方差法来产生一个拥有95%置信区间的风险率。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 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,系统回顾 - 方法 - 数据分析,统计学的异质性通过I2 统计，超过50%代表比较高的异质性。Statistical heterogeneity was assessed using the I2 statistic, with values of more than 50% representing substantial levels of heterogeneity 27. 若实验缺少明显的异质性的话，将对合并后的数据进行META分析。若无法合并数据的话，将采取描述性总结的形式来完成。Fixed effects meta-analysis was applied to combine data in the absence of significant heterogeneity between the trials. Where it was not possible to pool data, an arrative summary of the studies was completed.,19,系统回顾 -结果,1682个潜在的相关研究根据题目和摘要筛选剔除1362篇，并且剔除重复性的研究300篇，剩余的20篇研究进行全文阅读的审查剔除不符合要求的12篇（包括无干预办法的研究7篇，无DRAM预后报道的研究4篇和出版物类型不符的1篇）最终剩余8篇满意度高的研究,Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review D.R. Benjamina, A.T.M. Van de Waterb, C.L. Peirisa,b,20,系统回顾 -结果,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 two-finger separation on sit-up.Thornton and Thornton 29 did not provide a definition of DRAM.,21,在三个研究中对比无运动干预的小组，产前的运动干预对于DRAM的出现频率减少了35%，每三个通过运动干预的怀孕女性中，就有一个能有效预防DRAM的发展。Compared with non-exercising controls in three studies(n = 228), antenatal exercise reduced the presence of DRAM by 35% (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.,22,两项研究发现产前运动能有效减少产前和产后出现的DRAM的宽度。跟踪调查一个产前腹部力量训练的6周课程发现，对比无运动组，干预组DRAM宽度明显减少。在案例研究中参与产前运动课程的参与者，产后48小时测量的DRAM宽度减少。所有的研究均发现无运动控制的组中都有一个产后DRAM宽度增加的现象。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 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 (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).,23,一项针对于DRAM发展的危险因素的回顾性研究发现，产前运动与加速DRAM恢复有关，然而当同时考虑经产情况和生产方式时，效果并不是很明显。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 significant.,24,三个文献研究以减少DRAM宽度为目的的产后腹部运动。由于数据不充分则合并数据不太可能。随机对照试验评估了产后618小时即开始腹部和骨盆运动的效果。在产后618小时和干预后18小时测量。干预组DRAM宽度减少了0.44cm，控制组减少0.17cm。单个案例研究结合了产后腹部运动和束腹或者姿势/背部教育来减少产后DRAM。都表明产后DRAM宽度的减少。Sheppard也证明了触诊时腹横肌的活性增加与腹肌耐力的增加。束腹减少下腰痛的可能。Three studies 21,28,29 included postnatal abdominal exercise with 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 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 posture/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 andThornton 29 claimed that the corset helped to reduce lowback pain.,25,系统回顾 -结果 建议,在研究中大量的人力物力消耗在于受试者的不配合，对于运动的依从性差。两个受试者由于高危妊娠退出试验，一个属于与糖尿病有关的顽固性DRAM，需要长期服药的退出了实验。Most of the attrition was due to non-compliance with appointments or exercise regimens. Chiarello et al. 3 reported that two participants 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,系统回顾 讨论,运动帮助了维持腹部肌肉张力、力量及控制力，因此降低了白线的压力exercise helps to maintain tone, strength and control of the abdominal muscles 3,5, consequently reducing stress on the line alba. 在怀孕期间规律的运动的女性通常在怀孕前也有运动，因此相对于孕期不运动的女性来说拥有更健康且状况更好的腹部肌肉。因此建议女性在孕前即开始规律的运动。women who exercise during pregnancy generally also exercise prior to pregnancy and , therefore, may be fitter and have better conditioned abdominal muscles compared with women who do not exercise during pregnancy 4,27,系统回顾 讨论,腹横肌是腹部深层的肌肉，与腹直肌和白线有强壮的筋膜连接。腹横肌的运动训练会必然会造成同时训练了腹直肌，提高了白线的完整性和筋膜的张力，允许了有效地负荷转移和扭矩的产生。可能的是，腹横肌的激活能保护白线，可能帮助预防DRAM和加速DRAM的恢复。然而更多高质量的研究需要证明这个假说。The transversus abdominis muscle 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 fascial 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,系统回顾 讨论,除了运动干预，两项案例研究使用了体外支具如束腹，意图减少DRAM的发生。体外支具可能会为腹部提供一个压缩和支撑，对腰椎骨盆部分模仿了腹横肌的表面张力，可能对腹横肌能提供一个生物反馈来激活活性。这些体外支具可以在除运动外应用，但仍需要证据证明他对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 lumbopelvic 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,局限,研究的设计多样，方法学的质量多样。定义DRAM和测量DRAM的方法在各个研究也很多样导致回顾无法得出强有力的结论。Studies were of varying design (e.g. single case studies, retrospective), had inadequately powered