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研究生：	蔡依芳 Tsai, Yi-Fang
論文名稱：	成人便祕之物理治療 Physical therapy management of constipation in adults
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：	2022
畢業學年度：	110
語文別：	英文
論文頁數：	76
中文關鍵詞：	便祕、身體活動量、物理治療、骨盆底、成人
外文關鍵詞：	Constipation, Physical activity, Physical therapy, Pelvic floor, Adult
相關次數：	點閱：129 下載：9
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背景與目的：便祕是一種常見的消化系統疾病，全球成人患有便祕之盛行率約略為10%。生活型態因素，包含飲食不均衡和缺乏身體活動/運動，是便祕的潛在危險因子。便祕還可能因為長期給骨盆底壓力而導致骨盆底肌失能。推薦的便祕初步治療包括調整生活型態及使用瀉藥。規律身體活動/運動（例如：有氧、阻力訓練）已經被證實有益於成人生理和心理健康，但是運動訓練對患有便祕的成人其骨盆底肌功能的影響仍不清楚。骨盆底肌訓練輔以生物回饋已經被認為是一種有效的治療方式，並被強烈推薦給在初步治療中未成功緩解便祕的患者，不過，在臨床環境中，骨盆底肌訓練沒有廣泛應用於患有便祕的成人。由於便祕是一個多因素的問題，多模式介入計畫可能比單一療法更有效。然而，物理治療介入對患有便祕之成人骨盆底肌症狀和功能的可行性及影響仍未知。因此，本研究的目的包含（1）透過前導性隨機對照試驗探討對患有便祕之成人提供多模式物理治療介入的可行性，以及（2）探討為期八週的多模式物理治療介入計畫，包括運動、骨盆底肌訓練和生活型態改變，對成人便祕患者的症狀嚴重度、骨盆底肌功能、健康相關生活品質、以及身體活動量的影響。
研究方法：本前導性隨機對照試驗自2021年1月執行至2022年6月，符合條件患有功能性便祕（無特定原因引起的原發性便祕）的成人被納入並隨機分配至介入組或控制組。在介入組的受試者會接受多模式物理治療介入計畫，內容包括提供單次生活型態改變衛教，以及每週兩次為期八週的運動訓練（有氧及阻力運動和骨盆底肌訓練）。控制組的受試者僅於接受基準評估後接受單次生活型態改變衛教。所有受試者會在基準與八週計畫後接受評估。主要成果指標為可行性結果，包含轉介率、同意率、出席率、退出率、依從率、不良事件及治療滿意度。次要成果指標包括症狀嚴重度（使用便祕症狀患者自評問卷）、骨盆底肌功能（以骨盆底肌協調量表、直腸指診以及肛直腸壓力計的方式進行評測）、健康相關生活品質（使用便祕生活品質患者自評問卷）以及身體活動量（使用身體活動量調查短板問卷）。本研究使用意向分析將所有被隨機分配的受試者都納入最終分析以維持樣本數。可行性結果使用描述性統計分析。連續性資料和類別性資料分別使用Mann-Whitney U檢定以及卡方檢定比較兩組基準特徵。結果變量使用Wilcoxon符號等級檢定以及Mann-Whitney U檢定分別進行組內和組間比較。當p值小於0.05視為具有統計學意義。
結果：本研究共收錄27名患有便祕之成人（平均年齡：36.96 ± 14.13；89%為女性），其中介入組有14人，控制組有13人。轉介率為5%，同意率為54.5%。介入組中共有11位受試者完成訓練計畫，出席率達97.7%。整體退出率為14.8%，包含介入組有3人，控制組有1人。居家骨盆底肌運動和走路的依從率分別是59.6%和50.6%。計畫期間沒有任何不良事件發生，且介入組和控制組對治療有中等以上滿意的比例分別為100%和83.3%。兩組之間所有基準特徵都沒有顯著差異。經過八週介入後，介入組的症狀嚴重度（p = 0.003）、由骨盆底肌協調量表評估之骨盆底肌協調程度（p = 0.011）、透過直腸指診量測之恥骨直腸肌肌力（p = 0.025）與模擬排便時向外推出的力（p = 0.025）、使用肛直腸壓力計量測之最大自主收縮肌力（p = 0.007）與平均最大自主收縮肌力（p = 0.005）、健康相關生活品質（p = 0.013）及總身體活動水平（p = 0.037）在介入組中得到顯著改善。在控制組中，八週計畫後便祕症狀患者自評問卷的腹部分量表（p = 0.010）有顯著改變，然而在其他結果變項都沒有發現顯著變化。八週計畫後，所有結果變量在兩組之間的比較顯示都沒有顯著差異。
結論：前導性研究結果發現，為期八週的多模式物理治療介入計畫在改善便祕患者的症狀嚴重程度、骨盆底肌功能、健康相關生活品質和身體活動量方面可能是可行且有效的。本論文可提供臨床專業人員關於物理治療介入可能有正向益處並可以被視為一項對成人便祕的治療選擇的證據。

Background and purpose: Constipation is a common digestive complaint with a mean prevalence rate of 10% in global adults. Lifestyle factors, including unbalanced diet and insufficient physical activity (PA)/physical exercise, are potential risk factors for constipation. Constipation may also lead to pelvic floor muscle dysfunction due to prolonged stress on the pelvic floor. The recommended initial treatment for constipation includes lifestyle modifications and laxatives. Regular PA/physical exercise (e.g., aerobic exercise, resistance training) has been shown to be beneficial for physiological and psychological health in adults. However, the impact of physical exercise on pelvic floor muscle function in adult with constipation remain unclear. Pelvic floor muscle training (PFMT) with biofeedback has been recognized as an effective therapy for relieving constipation in patients who have failed initial treatment. As constipation is a multifactorial problem, a multimodal intervention program may be more effective than monotherapy. Nevertheless, the feasibility and effect of a multimodal physical therapy intervention on pelvic floor symptoms and function in adults with constipation remain unknown. Therefore, the aims of this study were (1) to investigate the feasibility of a multimodal physical therapy intervention for adults with constipation through conducting a pilot randomized controlled trial (RCT); and (2) to explore the effect of an eight-week multimodal physical therapy intervention including physical exercise, PFMT, and lifestyle modifications on symptom severity, pelvic floor muscle function, health-related quality of life (HRQOL), and PA levels in adults with constipation.
Methods: This pilot RCT was conducted from January 2021 to June 2022. Adults with functional constipation (idiopathic constipation without a specific cause) were enrolled and randomly allocated to either the intervention group (IG) or the control group (CG). Participants in the IG received a multimodal physical therapy intervention program comprising of a lifestyle modifications brochure and an exercise program (physical exercise and PFMT) twice weekly for eight weeks. Participants in the CG only received the lifestyle modifications brochure after baseline assessment. Assessments were performed at baseline and after eight-week program. The primary outcome was feasibility measures including referral, consent, attendance, withdrawals, and adherence rates, adverse events, and treatment satisfaction. The secondary outcomes were symptom severity measured using the Patient Assessment of Constipation Symptoms Questionnaire (PACSYM); pelvic floor muscle function assessed through the Pelvic Floor Muscle Coordination Scale (PFMCS), digital rectal examination (DRE), and anorectal manometry; HRQOL measured by the Patient Assessment of Constipation Quality of Life Questionnaire (PACQOL); and PA levels measured using the International Physical Activity Questionnaire (IPAQ). Intention-to-treat analysis was performed to preserve the sample size and original randomization. Feasibility outcomes were evaluated using descriptive statistics. Mann-Whitney U test and Chi-square test were used for continuous data and categorical data to compare the baseline characteristics between two groups. Wilcoxon signed rank test and the Mann-Whitney U test were used for intragroup and intergroup comparison of outcome variables. The p-value of < 0.05 was considered as statistically significant.
Results: Twenty-seven participants (mean age: 36.96 ± 14.13 years; 89% female) were included in the study (IG n=14, CG n=13). The referral rate was 5%, and the consent rate was 54.5%. Eleven participants in the IG completed the program with an attendance rate of 97.7%. The overall withdrawal rate was 14.8% (IG n=3, CG n=1). Adherence rates to home pelvic floor exercise and walking were 59.6% and 50.6%, respectively. No adverse events were reported, and the treatment satisfaction was ‘moderately satisfied’ in both IG (100%) and CG (83.3%). No significant difference was found in baseline characteristics between two groups. After eight-week intervention, significant improvements were found in the symptom severity (p = 0.003), pelvic floor muscle coordination (p = 0.011) assessed by PFMCS, strength of puborectalis muscle (p = 0.025) and push effort during attempted defecation (p = 0.025) measured through DRE, maximal voluntary contraction (MVC) of pelvic floor muscles ([MVC] p = 0.007, [average MVC] p = 0.005) measured by manometry, HRQOL (p = 0.013), and the total PA level (p = 0.037) in the IG. In the CG, the abdominal subscale of PACSYM (p = 0.010) showed a significant change after eight weeks of the program, while no significant changes were found in other outcome variables. The comparisons between two groups showed no significant differences in all outcome variables after eight-week program.
Conclusions: The pilot study found that an eight-week multimodal physical therapy intervention program may be feasible and effective in improving symptom severity, pelvic floor muscle function, HRQOL, and PA levels in patients with constipation. The available evidence from this thesis informs clinical professionals that physical therapy management may have positive benefits and can be considered a treatment option for constipation in adults.

ABSTRACT  I
摘要  IV
致謝  VI
TABLE OF CONTENTS  VII
ABBREVIATION  X
CHAPTER 1 INTRODUCTION  1
1.1 Background  1
1.2 Purpose of the study  2
CHAPTER 2 LITERATURE REVIEW  4
2.1 Constipation  4
2.1.1 Epidemiology and diagnosis  4
2.1.2 Pathophysiology  5
2.1.3 Risk factors  6
2.2 Impacts of constipation  8
2.2.1 Pelvic floor muscle function  8
2.2.1.1 Role of pelvic floor muscle in defecation  8
2.2.1.2 Constipation and pelvic floor muscle dysfunction  8
2.2.2 Health-related quality of life  9
2.3 Managements of constipation  9
2.3.1 Clinical management guidelines  10
2.3.2 Conservative treatments for constipation  11
2.3.2.1 Lifestyle modifications  11
2.3.2.2 Pelvic floor muscle training  12
2.4 Multimodal physical therapy intervention for adults with constipation  13
CHAPTER 3 MATERIALS AND METHODS  15
3.1 Research design  15
3.2 Study participants  15
3.2.1 Inclusion and exclusion criteria  15
3.2.2 Sample size  15
3.3 Procedures  16
3.4 Outcome measures  16
3.4.1 Primary outcome  17
3.4.2 Secondary outcomes  17
3.5 Intervention  21
3.5.1 Physical therapy intervention group  21
3.5.2 Control group  24
3.6 Statistical analysis  24
CHAPTER 4 RESULTS  25
4.1 Demographic characteristics and feasibility outcomes  25
4.2 Symptom severity  26
4.3 Pelvic floor muscle function  26
4.4 Health-related quality of life  27
4.5 Physical activity levels  27
CHAPTER 5 DISCUSSION  28
5.1 Feasibility  28
5.2 Symptom severity  29
5.3 Pelvic floor muscle function  31
5.4 Health-related quality of life  32
5.5 Physical activity levels  33
5.6 Strengths and limitations  33
CHAPTER 6 CONCLUSIONS  35
REFERENCES  36
TABLES  46
Table 1. Feasibility outcomes of the participants  46
Table 2. Demographics and baseline characteristics of the intervention group and the control group  47
Table 3. The comparison of symptom severity and bowel diary between the intervention group and the control group  49
Table 4. The comparison of pelvic floor muscle function between the intervention group and the control group  51
Table 5. The comparison of health-related quality of life between the intervention group and the control group  53
Table 6. The comparison of physical activity levels between the intervention group and the control group  54
FIGURES  55
Figure 1. LABORIE biofeedback and the anal probe  55
Figure 2. Equipment for aerobic and resistance exercise training  55
Figure 3. CONSORT flow diagram  56
APPENDICES  57
Appendix 1. Human study approval  57
Appendix 2. Approval of ethics midterm report  58
Appendix 3. Questionnaires for baseline characteristics, symptoms severity, health-related quality of life, physical activity levels, and data recording form for assessment of pelvic floor muscle function  59
Appendix 4. Seven-day bowel diary  70
Appendix 5. Lifestyle modification brochure  72
Appendix 6. Training protocols of physical therapy intervention  73
Appendix 7. Physical Activity Readiness Questionnaire  75
Appendix 8. Rating of Perceived Exertion  76
                                    

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