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研究生：	李依庭 Li, Yi-Ting
論文名稱：	多模式運動對患有尿失禁之停經後婦女骨盆底肌功能的影響 The effect of a multimodal exercise program on pelvic floor muscle function in postmenopausal women with urinary incontinence
指導教授：	林冠吟 Lin, Kuan-Yin
學位類別：	碩士 Master
系所名稱：	醫學院 - 物理治療學系 Department of Physical Therapy
論文出版年：	2021
畢業學年度：	109
語文別：	英文
論文頁數：	77
中文關鍵詞：	尿失禁、停經後婦女、運動、骨盆底肌功能
外文關鍵詞：	urinary incontinence, postmenopausal women, physical exercise, pelvic floor muscle function
相關次數：	點閱：166 下載：18
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背景
在台灣，停經後婦女患有尿失禁的盛行率高達29.8%，過去的文獻顯示更年期可能與尿失禁的發展是相關的，由於骨盆底有許多雌激素的受器，因此停經後體內雌激素的下降可能會導致骨盆底肌失能，進而造成尿失禁的發生；針對女性尿失禁的治療，骨盆底肌訓練目前已被國際失禁協會列為第一線的保守性治療。除了賀爾蒙改變與更年期後尿失禁的高盛行率相關之外，許多女性在經歷更年期轉變後更傾向於靜態的生活模式，過去已有文獻證實靜態的生活模式與尿失禁在老年女性中是高度相關的，並且也提出身體活動對於預防失禁的重要性。規律的身體活動包括有氧運動以及阻力訓練已被證實可以改善停經後婦女的骨質密度、壓力管理以及自律神經功能，但是身體活動加上骨盆底肌訓練對於此族群骨盆底肌功能的影響仍是未知的，因此本研究之目的為探討一多模式運動結合有氧運動、阻力運動以及骨盆底肌訓練對於患有尿失禁之停經後婦女骨盆底肌功能的影響。
方法
此篇研究為平行設計之前導性隨機控制試驗，從2020年3月執行至2021年6月。招募對象為患有尿失禁並且為靜態生活的停經後婦女，符合條件的受試者被隨機分配至介入組或控制組，分配到介入組的受試者會接受多模式運動訓練，內容包括有氧運動、阻力運動以及骨盆底肌訓練，而控制組的受試者只接受骨盆底肌訓練，介入總共為期8週，每週兩次。前、後測評估在首次訓練前以及8週介入完成後執行，主要成果指標為骨盆底肌功能，此評估使用陰道壓力計以及陰道內診的方式測量，次要成果指標包含症狀嚴重程度、健康相關生活品質以及身體活動量，評估皆使用相關問卷進行評估，分別是尿失禁症狀調查問卷、國際尿失禁諮詢委員會問卷之下尿路症狀對生活品質影響、身體活動量調查短版問卷，另外受試者亦須填寫3日排尿日誌的紀錄。所有資料使用SPSS第22版進行統計分析，連續性資料分別使用配對t檢定以及共變數分析檢定進行組內以及組間比較，類別性資料則分別使用麥內瑪檢定以及卡方檢定進行組內以及組間比較，顯著水準設在p值小於0.05。
結果
本篇研究共收錄26位停經後患有尿失禁之女性，其中介入組跟控制組各有13人。兩組在介入前之所有基本資料皆無顯著的差異。在八週的介入後，兩組在由陰道指診所測得之骨盆底肌功能皆有顯著的進步(介入組：肌力p=0.002，維持收縮時間p=0.018，重複最大肌力收縮次數 p=0.005；控制組：肌力p=0.027，維持收縮時間p=0.03，重複最大肌力收縮次數 p=0.001)，但是陰道壓力計的數值並沒有測得任何顯著的改變，兩組間也沒有顯著的差異。在次要成果指標方面，症狀嚴重程度在介入組及控制組都有達到顯著的改善 (介入組：p=0.001; 控制組：p=0.049)，且兩組間有顯著的差異 (p=0.045)，而健康相關生活品質只有介入組有顯著的進步 (p=0.011)，且其分數之改變有達到顯著的組間差異 (p=0.018)。兩組在身體活動量上則無顯著的改變。
結論
八週的多模式運動訓練對於停經後患有尿失禁之婦女在骨盆底肌功能、症狀嚴重程度以及健康相關生活品質上可能是有正向的影響，且其在改善失禁嚴重程度與健康相關生活品質之幅度可能比只做骨盆底肌訓練大。建議未來研究納入更多的樣本數證實本篇研究之發現。

Background
In Taiwan, the prevalence of urinary incontinence (UI) in postmenopausal women was 29.8%. Previous studies have indicated that menopause may be associated with developing UI. As there are many estrogen receptors in pelvic floor, the estrogen decline after menopausal transition may lead to pelvic floor muscle dysfunction, and the subsequent development of UI. Pelvic floor muscle training (PFMT) has been recommended by the International Continence Society as the first‐line conservative treatment for women with UI. In addition to the prevalent incontinence associated with postmenopausal status, many women tend to have a more sedentary lifestyle after menopausal transition. Previous studies have shown that a sedentary lifestyle is related to UI in older women and indicated the importance of physical activity on preventing incontinence. Regular physical exercise including aerobic exercise and resistance training has been proved to improve bone mineral density, stress management and autonomic functions in postmenopausal women. However, the effect of physical exercise adding to PFMT on pelvic floor muscle function in postmenopausal women with UI remains unknown. Therefore, the aim of this study was to investigate the effect of a multimodal exercise program incorporating aerobic exercise, resistance exercise, and PFMT on pelvic floor muscle function in postmenopausal women with UI.
Methods
This was a parallel group, pilot randomized controlled trial (RCT) conducted from March 2020 to June 2021. Postmenopausal women with UI and a sedentary lifestyle were recruited. Eligible participants were randomly allocated to either the intervention group (IG) to receive a multimodal exercise program incorporating aerobic exercise, resistance exercise and PFMT, or the control group (CG) to receive only PFMT. The intervention was provided twice weekly for eight weeks. The assessments were conducted at baseline and after 8-week intervention. The primary outcome was pelvic floor muscle function measured by manometry and through digital palpation. The secondary outcomes were symptom severity measured using the International Consultation on Incontinence Questionnaire －Urinary Incontinence Short Form (ICIQ-UI SF), health-related quality of life (HRQoL) measured using the International Consultation on Incontinence Questionnaire Lower Urinary Tract Symptoms Quality of Life Module (ICIQ-LUTSqol), and physical activity levels measured by the International Physical Activity Questionnaire (IPAQ). In addition, the participants were asked to complete a 3-day bladder diary. Data analysis was performed using Statistical Product and Service Solutions (SPSS) version 22.0. For continuous data, paired-t tests and analysis of covariance tests were used for within-group and between-group comparisons, respectively. For categorical data, McNemar’s tests and chi-square tests were used for within-group and between-group comparisons. The significant level was set at p-value < 0.05.
Results
A total of 26 postmenopausal women with UI were recruited in the study (IG n=13, CG n=13), and baseline characteristics showed no significant difference between two groups. After 8-week intervention, the pelvic floor muscle function measured via digital palpation were significantly increased in IG and CG (IG muscle strength: p=0.002, holding time: p=0.018, number of maximal voluntary contraction [MVC]: p=0.005; CG muscle strength: p=0.027, holding time: p=0.03, number of MVC: p=0.001); however, no significant changes were found in the parameters measured by manometry, and no significant differences were found between IG and CG. For the secondary outcome measures, the symptom severity was improved significantly in both IG and CG (IG p=0.001; CG p=0.049), and significant difference was found between two groups after intervention (p=0.045). The HRQoL was improved significantly only in IG after intervention (p=0.011), and the improvement was significantly greater in IG than in CG (p=0.018). The physical activity levels did not change in both groups after intervention.
Conclusion
An 8-week multimodal exercise program may have a positive effect on pelvic floor muscle function, symptom severity, and HRQoL in postmenopausal women with UI, and it may be more effective than PFMT alone in improving symptom severity and HRQoL. Future studies with large sample size are needed to confirm the findings of this study.

摘要  I
ABSTRACT  III
致謝  VI
ABBREVIATION  VII
TABLE OF CONTENTS  IX
CHAPTER I  INTRODUCTION  1
I.1  Background and significance  1
I.2  Purpose  2
CHAPTER II  LITERATURE REVIEW  4
II.1  Urinary incontinence  4
II.1.1  Definition and prevalence  4
II.1.2  Etiology  4
II.1.3  Risk factors  5
II.1.4  Diagnosis  6
II.1.5  Management  8
II.1.6  Variables associated with urinary incontinence  10
II.1.6.1  Pelvic floor muscle function  10
II.1.6.2  Health-related quality of life  10
II.1.6.3  Physical activity levels  11
II.2  Postmenopausal and urinary incontinence  11
II.2.1  Hormone decline  11
II.2.2  Lifestyle change  12
II.2.2.1  Physically active lifestyle and urinary incontinence	12
II.2.2.2  Sedentary lifestyle and urinary incontinence	13
II.3  Effects of a multimodal exercise program for patients with urinary incontinence  14
II.3.1  Aerobic exercise with pelvic floor muscle training  14
II.3.2  Resistance exercise with pelvic floor muscle training  15
CHAPTER III  MATERIALS AND METHODS  16
III.1  Research design  16
III.2  Participants  16
III.3  Procedures  17
III.4  Intervention  17
III.4.1  Physical exercise training  17
III.4.2  Pelvic floor muscle training  18
III.5  Outcome measures  19
III.5.1  Primary outcome  19
III.5.1.1  Pelvic floor muscle function  19
III.5.2  Secondary outcomes  21
III.5.2.1  Symptom severity  21
III.5.2.2  Health-related quality of life  22
III.5.2.3  Physical activity levels  22
III.5.2.4  Satisfaction with program  23
III.6  Sample size determination  24
III.7  Statistical analysis  24
CHAPTER IV  RESULTS  26
IV.1  Demographic characteristics  26
IV.2  Pelvic floor muscle function  26
IV.3  Symptom severity  27
IV.4  Health-related quality of life  28
IV.5  Physical activity levels  28
IV.6  Satisfaction with program  28
CHAPTER V  DISCUSSION  30
V.1  Pelvic floor muscle function  30
V.2  Symptom severity  31
V.3  Health-related quality of life  32
V.4  Physical activity levels  33
V.5  Strengths and limitations  33
CHAPTER VI  CONCLUSION  36
CHAPTER VII  REFERENCES  37
TABLES  44
Table 1.  Baseline characteristics of intervention group and control group  44
Table 2.  Comparison of pelvic floor muscle function, symptom severity, and health-related quality of life between intervention group and control group  46
Table 3.  Comparison of symptom severity and physical activity levels between intervention group and control group  47
Table 4.  Comparison of bladder diary between intervention group and control group  48
Table 5.  Comparison of physical activity levels between intervention group and control group  49
FIGURES  50
Figure 1.  Study flow diagram  50
Figure 2.  Comparison of health-related quality of life between intervention group and control group  51
Figure 3.  Satisfaction with the program in intervention group and control group  52
Figure 4.  Cycle ergometer for aerobic exercise  53
Figure 5.  Dumbbell, thera-band, sandbag, and swiss ball for resistance exercise  53
Figure 6.  Digital palpation  54
Figure 7.  Laborie® Biofeedback and Stimulation System  54
Figure 8.  Manometry probe  54
APPENDICES  55
Appendices 1.  Human study approval  55
Appendices 2.  Approval of ethics midterm report  56
Appendices 3.  Training protocol of intervention  57
Appendices 4.  Data recording form for pelvic floor muscle assessment  59
Appendices 5.  Physical Activity Readiness Questionnaire  62
Appendices 6.  The Questionnaire for Urinary Incontinence Diagnosis  63
Appendices 7.  Bladder diary  64
Appendices 8.  Questionnaires for baseline characteristics, symptom severity, health-related quality of life, and physical activity levels  65
                                    

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