产后身体活动最佳证据研究

doi:10.3969/j.issn.1006-9771.2022.07.011

摘要/Abstract

摘要：

目的总结并评价产后体育活动和锻炼方案的最佳证据。

方法检索JBI、UpToDate、Cochrane Library、国际妇产科联盟、美国卫生保健政策研究所、英国皇家妇产科医师协会、美国妇产科医师协会、安大略注册护士协会、世界卫生组织、澳大利亚健身协会、英国国家卫生医疗质量标准署、Web of Science、PubMed、CINAHL、医脉通、中国知网、万方等与产后体育活动和锻炼方案相关的文献,检索时限至2021年10月。2名研究人员分别采用AGREE Ⅱ、AMSTAR、JBI循证卫生保健中心质量评价工具独立对文献进行质量评价。

结果共纳入15篇文献,包括4项随机对照试验、4项系统评价、1项横断面研究、1项证据总结、4项指南、1项专家共识。汇总28条证据,包括产后体育活动和锻炼的意义、障碍因素、评估、锻炼方式、强度与时间、注意事项6个方面。

结论产后获得正确的运动锻炼知识对于促进妇女的健康和生活质量非常重要。建议证据应用时结合具体情况进行筛选,制订个体化的体育活动和锻炼方案。

关键词: 产妇, 体育活动, 锻炼, 证据总结

Abstract:

Objective To summarize and evaluate the best evidence for postpartum physical activity and exercise regimens.

Methods Literatures of postpartum sports and exercise programs were searched from JBI, UpToDate, Cochrane Library, International Federation of Gynecology and Obstetrics (FIGO), The Agency for Healthcare Research and Quality(AHRQ), Royal College of Obstetricians and Gynaecologists (RCOG), American Collage of Obstetricians and Gynecologists (ACOG), Registered Nurses' Association of Ontario (RNAO), World Health Organization (WHO), Fitness Australia (FA), National Institute for Health and Care Excellence (NICE), Web of Science, PubMed, CINAHL, Medlive, CNKI, and Wanfang Data, from database inception to October, 2021. Two researchers independently evaluated the literature quality according to the tool of the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE Ⅱ), A Measurement Tool to Assess Systematic Reviews (AMSTAR), and Joanna Briggs Institute Critical Appraisal Checklist.

Results A total of 15 articles were selected, including four randomized controlled trials, four systematic reviews, one cross-sectional study, one evidence summary, four guidelines, and one expert consensus. A total of 28 pieces of evidence were summarized, including the significance of postpartum physical activity and exercise, obstacle factors, assessment, exercise style, intensity and timing, and precautions.

Conclusion Knowledge of exercise after delivery is important to promote women's health and quality of life. It is recommended that the evidence be screened on a case-by-case basis and that an individualized programme of physical activity and exercise be developed.

Key words: puerpera, physical activity, exercise, evidence summary

中图分类号:

R714.6

耿小婷,李淑英,张金燕,郭艳巍. 产后身体活动最佳证据研究[J]. 《中国康复理论与实践》, 2022, 28(7): 809-815.

GENG Xiaoting,LI Shuying,ZHANG Jinyan,GUO Yanwei. Research on postpartum physical activities based on the best evidence[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2022, 28(7): 809-815.

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产后体育活动和锻炼方案的最佳证据"

项目	证据描述	证据等级	推荐强度
活动和锻炼的意义	1.产后运动可以提高产后妇女的整体身体素质,改善心肺功能,增强上肢及腹部的肌力耐力,促进背部和大腿的肌肉伸展,有利于控制产后体质量,防治血栓栓塞性疾病及糖尿病等,增强抵抗力^[16,28]。	1c	A
	2.适宜运动可缓解疼痛,减轻尿失禁症状,改善睡眠,提高自信,调节情绪,减少产后抑郁^{[21,23,25-26,30]}。	1a	A
	3.产后恢复孕前锻炼或建立新的锻炼习惯对于健康非常重要,产后也是妇产科医师以及其他专业人员进行健康保健生活方式宣教的最佳时机^[28]。	5b	A
活动和锻炼的障碍因素	4.疲劳、睡眠不足、忙于家务、缺乏时间、不可预测的日常活动,缺乏家人、朋友、伴侣等支持,是阻碍产后妇女运动的因素^[22]。	2b	A
活动和锻炼的障碍因素	5.缺乏专业人士关于产后体育活动和锻炼方面的建议与鼓励,医疗保健提供者也很少将运动计划纳入到产后护理计划 ^[16,22]。	1c	A
活动和锻炼的评估	6.建议产后体育活动前,应根据分娩方式进行评估,评估是否存在医疗或手术并发症,身体是否安全,是否可以恢复体力活动^[28,30]。	5b	A
	7.建议在进行高强度运动之前,进行腹部和盆底肌肉测试。可以采用盆底肌肉电生理学检查、指压试验、影像学检测、三维体态评价等进行盆底功能测试,也可以采用症状问卷进行评价 ^[27,29]。	5a	A
	8.建议在运动期间或运动后,及时评估产妇是否存在背痛、腰部疼痛、尿失禁等现象,若存在,建议放慢或降低强度水平^[27]。	5a	A
活动和锻炼的方式	9.建议进行腹部强化练习,包括腹部紧缩练习和牵引练习,以此拉动腹壁肌肉来增加腹部压力,减少腹直肌分离的发生率^[28,30]。	4a	A
	10.建议产妇每周进行中等强度有氧运动,包括体操、肌力训练、游泳、固定式自行车、舞蹈等^[26-27]。	5b	A
	11.建议产妇进行普拉提家庭锻炼,包括架桥、卷起、单腿循环、双腿闭合摇杆、单直腿伸展、双腿伸展、脊柱向前伸展、单腿踢、上下侧踢等以深呼吸为重点的全身伸展和核心力量训练^[17]。	1c	A
	12.建议无阴道并发症的产妇,产后立即进行腹部训练和盆底肌训练^[27,29-30]。	4b	A
	13.习惯从事高强度有氧运动或孕前进行过体育活动的妇女,建议在孕期及产后可继续从事这些活动^[26]。	5b	A
	14.普拉提、低强度有氧运动和肌肉强化活动,对产妇来说方便可行^[17,24]。	1c	B
	15.集体锻炼形式优于个人锻炼形式,此方式能够提高产后锻炼的动机、运动量和自我效能^[23]。	1a	A
	16.稳定训练能改善骨盆疼痛患者的功能,建议作为产后腰部疼痛产妇的一线治疗选择^[19]。	1c	A
	17.建议产后前4周进行呼吸功能训练、肌力训练,产后3~8周进行行走、游泳(一旦出血停止)、腹部和盆底运动、低冲击有氧运动、低强度水上有氧运动(一旦出血停止)等^[27]。	5a	B
	18.建议产后8~12周增加运动强度和重量练习,强化产后核心力量、腹部和盆底锻炼^[27]。	5a	A
	19.建议产后16周评估产妇盆底肌肉和核心控制能力,无产前或产后并发症可恢复孕前活动^[27]。	5a	A
活动和锻炼的强度与时间	20.根据产妇的健康水平定制个性化运动强度,建议使用Borg量表(6~20分)进行监测,运动强度应控制在12~14分的中等强度^[16]。	1c	B
	21.建议产后立即开始盆底运动(Kegel运动),可每日2~3次,每次10~15 min^[28-29]。	5a	A
	22.建议产妇每周锻炼4~5次,每次锻炼持续时间30~40 min^[23]。	1a	A
	23.建议产后4~6周,每周进行至少150 min中等强度有氧运动^[26,29]。	5a	A
注意事项	24.建议正在哺乳的产妇锻炼前应排空乳汁,以免乳房肿胀。运动之前补充充足水分^[27,29]。	4b	A
	25.建议避免单次过长时间锻炼,以免造成产妇额外的疲劳和压力^[23]。	1a	A
	26.建议鼓励产妇穿着宽松、舒适的服装,佩戴具有支持性良好的运动内衣^[27]。	5a	A
	27.建议通过提升产妇健康知识水平和健康素养,调动产妇参加体育锻炼的积极性,进而提高产后体力活动水平^[18]。	1c	A
	28.建议采取饮食与运动相结合,进行自我监测,是产妇减轻体质量最有效的方法^[20]。	1b	B

表4

参考文献 33

[1]	程琳, 尚会超, 郭一辰, 等. 多轨迹产后康复训练仪的设计与运动规划仿真[J]. 中原工学院学报, 2020, 31(4): 15-21.
	CHENG L, SHANG H C, GUO Y C, et al. Design and motion planning simnlation of multi-rack postpartum rehabilitation training instrument[J]. J Zhongyuan Univ Technol, 2020, 31(4): 15-21.
[2]	GEBREGZIABHER N K, NETSEREAB T B, FESSAHA Y G, et al. Prevalence and associated factors of postpartum depression among postpartum mothers in central region, Eritrea: a health facility based survey[J]. BMC Public Health, 2020, 20(1): 1614. doi: 10.1186/s12889-020-09676-4
[3]	AKSU S, VAROL F G, HOTUN S N. Long-term postpartum health problems in Turkish women: prevalence and associations with self-rated health[J]. Contemp Nurse, 2017, 53(2): 167-181. doi: 10.1080/10376178.2016.1258315
[4]	LÍNDAL E, HAUKSSON A, ARNARDÓTTIR S, et al. Low back pain, smoking and employment during pregnancy and after delivery: a 3-month follow-up study[J]. J Obstet Gynaecol, 2000, 20: 263-266. doi: 10.1080/01443610050009575
[5]	马立苹. 盆底生物反馈训练联合针灸对产后尿失禁患者疗效的影响[J]. 河北医药, 2017, 39(15): 2362-2364, 2368.
	MA L P. Effect of pelvic floor biofeedback training combined with acupuncture on the efficacy of postpartum urinary incontinence[J]. Hebei Med J, 2017, 39(15): 2362-2364, 2368.
[6]	Physical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804[J]. Obstet Gynecol, 2020, 135(4): e178-e188. doi: 10.1097/AOG.0000000000003772
[7]	王杰, 杨振宇, 庞学红, 等. 2013年中国乳母产后体重滞留状况及其影响因素[J]. 中华预防医学杂志, 2016, 50(12): 1067-1073.
	WANG J, YANG Z Y, PANG X H, et al. The status of postpartum weight retention and its associated factors among Chinese lactating women in 2013[J]. Chin J Prev Med, 2016, 50(12): 1067-1073.
[8]	Committee Opinion No. 650 Summary: Physical Activity and Exercise During Pregnancy and the Postpartum Period[J]. Obstet Gynecol, 2015, 126(6): 1326-1327. doi: 10.1097/AOG.0000000000001209
[9]	POYATOS-LEÓN R, GARCÍA-HERMOSO A, SANABRIA-MARTÍNEZ G, et al. Effects of exercise-based interventions on postpartum depression: a meta-analysis of randomized controlled trials[J]. Birth, 2017, 44(3): 200-208. doi: 10.1111/birt.12294
[10]	VAN DER PLIGT P, OLANDER E K, BALL K, et al. Maternal dietary intake and physical activity habits during the postpartum period: associations with clinician advice in a sample of Australian first time mothers[J]. BMC Pregnancy Childbirth, 2016, 16: 27. doi: 10.1186/s12884-016-0812-4
[11]	BERNABE-ORTIZ A, DIEZ-CANSECO F, VASQUEZ A, et al. Disability, caregiver's dependency and patterns of access to rehabilitation care: results from a national representative study in Peru[J]. Disabil Rehabil, 2016, 38(6): 582-588. doi: 10.3109/09638288.2015.1051246
[12]	周芬, 郝玉芳, 丛雪, 等. 指南研究与评价工具AGREE Ⅱ及各领域分值的补充解释及思考[J]. 护理学报, 2018, 25(18): 56-58.
	ZHOU F, HAO Y F, CONG X, et al. Guidance research and evaluation tool AGREE Ⅱ and supplementary explanations and reflections on the scores of various fields[J]. J Nurs, 2018, 25(18): 56-58.
[13]	胡雁, 郝玉芳. 循证护理学[M]. 2版. 北京: 人民卫生出版社, 2018: 56-93.
	HU Y, HAO Y F. Evidence-base Nursing[M]. 2nd ed. Beijing: People's Medical Publishing House, 2018: 56-93.
[14]	邢唯杰, 胡雁, 周英凤, 等. 推动证据向临床转化(六):证据总结的制作与撰写[J]. 护士进修杂志, 2020, 35(12): 1129-1132.
	XING W J, HU Y, ZHOU Y F, et al. Promoting the transformation of evidence into clinical practice: making and writing evidence summary[J]. J Nurs Training, 2020, 35(12): 1129-1132.
[15]	王春青, 胡雁. JBI证据预分级及证据推荐级别系统(2014版)[J]. 护士进修杂志, 2015, 30(11): 964-967.
	WANG C Q, HU Y. JBI Evidence Pre-Classification and Evidence Rank System (2014 ed)[J]. J Nurs Training, 2015, 30(11): 964-967.
[16]	ZOURLADANI A, ZAFRAKAS M, CHATZIGIANNIS B, et al. The effect of physical exercise on postpartum fitness, hormone and lipid levels: a randomized controlled trial in primiparous, lactating women[J]. Arch Gynecol Obstet, 2015, 291(3): 525-530. doi: 10.1007/s00404-014-3418-y
[17]	ASHRAFINIA F, MIRMOHAMMADALI M, RAJABI H, et al. Effect of pilates exercises on postpartum maternal fatigue[J]. Singap Med J, 2015, 56(3): 169-173. doi: 10.11622/smedj.2015042
[18]	ABDOLLAHI M, PEYMAN N. The Effect of an educational program based on health literacy strategies on physical activity in postpartum women[J]. J Mid Reprod Health, 2017, 5(4): 1059-1065.
[19]	WANG H, FENG X, LIU Z, et al. A rehabilitation programme focussing on pelvic floor muscle training for persistent lumbopelvic pain after childbirth: a randomized controlled trial[J]. J Rehabil Med, 2021, 53(4): 1-6. doi: 10.2340/16501977-2835
[20]	LIM S, O'REILLY S, BEHRENS H, et al. Effective strategies for weight loss in post-partum women: a systematic review and meta-analysis[J]. Obes Rev, 2015, 16(11): 972-987. doi: 10.1111/obr.12312
[21]	CARTER T, BASTOUNIS A, GUO B, et al. The effectiveness of exercise-based interventions for preventing or treating postpartum depression: a systematic review and meta-analysis[J]. Arch Womens Ment Health, 2019, 22(1): 37-53. doi: 10.1007/s00737-018-0869-3
[22]	EDIE R, LACEWELL A, STREISEL C, et al. Barriers to exercise in postpartumwomen: a mixed-methods systematic review[J]. J Women Health Phys Ther, 2021, 45(2): 83-92.
[23]	姜霞, 谭珍科, 聂应军. 运动锻炼对产妇抑郁干预效果的Meta分析[J]. 武汉体育学院学报, 2021, 55(8): 71-78.
	JIANG X, TAN Z K, NIE Y J. A meta-analysis of effect of exercise on postpartum depression symptoms[J]. J Wuhan Inst Phys Educ, 2021, 55(8): 71-78.
[24]	WOLPERN A E, BARDSLEY T R, BRUSSEAU T A, et al. Physical activity in the early postpartum period in primiparous women[J]. J Sci Med Sport, 2021, 24(11): 1149-1154. doi: 10.1016/j.jsams.2021.06.009
[25]	EUSTIS E H, ERNST S, SUTTON K, et al. Innovations in the treatment of perinatal depression: the role of yoga and physical activity interventions during pregnancy and postpartum[J]. Curr Psychiatry Rep, 2019, 21(12): 133. doi: 10.1007/s11920-019-1121-1
[26]	PIERCY K L, TROIANO R P, BALLARD R M, et al. The Physical Activity Guidelines for Americans[J]. JAMA, 2018, 320(19): 2020-2028. doi: 10.1001/jama.2018.14854
[27]	Fitness Australia. Pre- and Post-Natal Exercise Guidelines. (2013-09-18). https://bp-fitnessaustralia-production.s3.amazonaws.com/uploads/uploaded_file/file/219/Pre-and-Post-Natal-Exercise-Guidelines.pdf.
[28]	SYED H, SLAYMAN T, DUCHENE THOMA K. ACOG Committee Opinion No. 804: Physical Activity and Exercise During Pregnancy and the Postpartum Period[J]. Obstet Gynecol, 2021, 137(2): 375-376.
[29]	中华预防医学会妇女保健分会. 产后保健服务指南[J]. 中国妇幼健究, 2021, 32(6): 767-781.
	Branch of Women's Health Care, Chinese Preventive Medicine Association. Guideline to Postpartum Health Services[J]. Chin J Women Child Health Res, 2021, 32(6): 767-781.
[30]	LEE R, THAIN S, TAN L K, et al. Asia-Pacific Consensuson Physical Activity and Exercise in Pregnancy and the Postpartum Period[J]. BMJ Open Sport Exerc Med, 2021, 7(2): e000967. doi: 10.1136/bmjsem-2020-000967
[31]	PRITCHETT R V, DALEY A J, JOLLY K. Does aerobic exercise reduce postpartum depressive symptoms? A systematic review and meta-analysis[J]. Br J Gen Pract, 2017, 67(663): e684-e691. doi: 10.3399/bjgp17X692525
[32]	李丽, 郜琳瑜. 瑜伽运动结合心理辅导对初产妇产后抑郁患者心理健康及体型、盆底功能恢复的影响[J]. 中国健康心理学杂志, 2019, 27(1): 118-123.
	LI L, GAO L Y. Effects of yoga combined with psychological counseling on mental health, body type and pelvic floor function recovery of primiparas with postpartum depression[J]. Chin J Health Phys, 2019, 27(1): 118-123.
[33]	DAVIS K, GOODMAN S H, LEIFERMAN J, et al. A randomized controlled trial of yoga for pregnant women with symptoms of depression and anxiety[J]. Complem Ther Clin Pract, 2015, 21(3): 166-172.

指南	各领域标准化得分/%						≥ 60%领域数	≥ 30%领域数	推荐级别
指南	范围和目的	参与人员	严谨性	清晰性	适用性	编辑独立性	≥ 60%领域数	≥ 30%领域数	推荐级别
Piercy等^[26]	100	72.2	67.7	88.8	64.5	100	6	6	A
FA^[27]	100	61.1	67	86.1	52	79.1	5	6	B
ACOG^[28]	94.4	69.4	61.4	83.3	50	58.3	4	6	B
中华预防医学会妇女保健分会^[29]	83.3	75	69.7	83.3	66.6	87.5	6	6	A