Análise da atividade eletromiográfica da interação dos músculos do assoalho pélvico e reto abdominal de gestantes com diabetes mellitus gestacional e incontinência urinária específica da gestação
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2022-08-29
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Nunes, Sthefanie Kenickel
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Universidade Estadual Paulista (Unesp)
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Introdução: Pesquisas clínicas identificaram que mulheres diabéticas gestacionais apresentam inter-relação entre a Incontinência Urinária (IU) gestacional e Disfunção Muscular do Assoalho Pélvico (DMAP). Os músculos do assoalho pélvico (MAP) representam elemento crítico na sustentação dos órgãos pélvicos, fornecendo suporte ativo tanto em repouso quanto durante a atividade. Os resultados das pesquisas experimentais originadas desse resultado clínico evidenciaram alterações nos músculos estriados uretrais e músculo reto abdominal (MRA) de ratas diabéticas prenhes que mostrou atrofia muscular com desorganização e rompimento de fibras, alteração na organização dos tipos de fibras slow e fast (Tipo I e II), com aumento das fibras fast, fibrose e aumento do colágeno I/III que caracterizam matriz extracelular rígida. Estes achados corroboram os da literatura sobre o fato da integridade da estrutura dos músculos abdominais e do assoalho pélvico sofrer alterações nas diferentes fases da vida da mulher, particularmente na gestação e parto, sendo que a gestação complicada pelo diabetes pode ter alterações ainda mais evidentes, causando impacto negativo na qualidade de vida. A contração coordenada e eficaz dos MAP está relacionada à manutenção das funções de micção, evacuação e sexualidade. A DMAP é distúrbio que afeta a capacidade de controlar e coordenar os MAP, está associada à incontinência urinária de esforço, síndrome da bexiga hiperativa, prolapso de órgão pélvico, incontinência anal, dor pélvica, disfunção sexual e constipação, resultando em impacto negativo na qualidade de vida. A IU também está associada a um padrão de ativação alterado dos MAP em relação aos músculos abdominais durante as atividades funcionais incluindo as atividades que geram aumento da pressão intra-abdominal (PIAb). Achados provenientes de nossas pesquisas associam o Diabetes Mellitus Gestacional (DMG) com a DMAP. O DMG é definido como distúrbio de tolerância à glicose com início durante a gravidez, relacionado com a deterioração da função muscular fisiológica e associado ao termo "miopatia diabética", que se refere a alterações funcionais, metabólicas e estruturais que são induzidas pelo diabetes mellitus (DM) no músculo esquelético. Tendo em vista a importante repercussão negativa da incontinência urinária específica da gestação (IUEG) e este seja um distúrbio amplamente investigado, não existe na literatura nacional e internacional instrumento construído e validado para identificar e avaliar especificamente a IUEG, demostrando ser necessária a construção e validação de um questionário inédito para identificar e avaliar a IUEG na população brasileira. Estudos clínicos demonstraram que o DMG impacta negativamente na atividade eletromiográfica dos MAP ao longo da gestação. Lesão que acomete o músculo reto abdominal durante a gestação também foi relacionada ao DMG. Estudos translacionais mostraram impactos prejudiciais tanto de hiperglicemia leve de longo prazo quanto de hiperglicemia severa de curto prazo no músculo uretral de ratas prenhes, como: atrofia, adelgaçamento, desorganização, ruptura das fibras musculares e perda de tipos específicos de fibras de localizações anatômicas normais, denotando conexão entre os níveis de glicemia e estrutura do MAP. Recentemente, protocolo de estudo clínico estabeleceu pesquisa de biomarcador bem desenvolvida em novo modelo conceitual do papel da integração da tríade DMG, IUEG e miopatia hiperglicêmica como preditora de IU de longo prazo e DMAP. A avaliação do desempenho dos MAP por meio da Eletromiografia de superfície (EMG) é capaz de, além de analisar sua funcionalidade, também identifica o exato momento em que determinado músculo entra em ação, e assim verificar se há co-contração entre os músculos. A avaliação deve incluir o desempenho dos MAP em repouso e em atividades dinâmicas. O emprego da EMG, que é utilizada como forma de avaliação em trabalhos que analisaram a função dos MAP durante a gestação, é pertinente para analisar o status muscular, pois é possível obter dados como o recrutamento de unidades motoras, velocidade de condução das fibras musculares e a fadiga muscular, variáveis importantes para identificar com eficácia diversos aspectos do desempenho muscular da gestante. A técnica é de acesso fácil, sem radiação, com desconforto mínimo, tem boa confiabilidade inter-observador e interdisciplinar, além de permitir avaliação dinâmica. Justificativa: Aprofundar e preencher lacunas do conhecimento sobre a repercussão do DMG e da miopatia hiperglicêmica a longo prazo torna-se imprescindível. Nesse contexto, analisar o desempenho dos MAP com avaliações eletromiográficas confiáveis, objetivas, visíveis e em tempo real é método alternativo para orientar a prática clínica e científica nos cuidados preventivos e terapêuticos. Objetivos: 1) Construção e validação de um instrumento para avaliação da incontinência urinária específica da gestação em mulheres brasileiras. 2) Analisar o efeito do DMG na funcionalidade dos MAP durante a gestação pela avaliação eletromiográfica. Métodos: 1) Trata-se de estudo transversal realizado no Centro de Pesquisas em Diabetes Perinatal (CPDP) da Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Brasil. A ferramenta de guia STROBE foi usada como guia para relatar este estudo. Os dados foram coletados entre março/2018 a dezembro/2021. Este estudo foi aprovado pelo Comitê de Ética em Pesquisa (CAAE 31976620.1.0000.5411). As gestantes foram recrutadas para participar do estudo durante a rotina de rastreio do DMG no CPDP. Os critérios de inclusão foram gestantes entre 18-40 anos de idade, normoglicêmicas e com DMG em tratamento não medicamentoso. Foram excluídas as participantes com DM tipo I ou II, uso de hipoglicemiantes, triagem ou diagnóstico inadequado de DMG, tratamento farmacológico após falha no controle da glicose com modificação do estilo de vida e dieta, doença do tecido conjuntivo, distúrbios neurológicos, prolapso de órgão pélvico ou cirurgia de incontinência, distúrbio hipertensivo gestacional ou pré-existente e incapacidade de realizar a sequência de contração dos MAP. O diagnóstico do DMG foi realizado de acordo com os critérios da American Diabetes Association (ADA) e quando confirmado estas participantes foram alocadas no grupo DMG. As participantes com resultado negativo foram alocadas no grupo normoglicêmico (NG). As participantes foram submetidas a aplicação do questionário e avaliação dos MAP pela EMG considerando a área dos levantadores do ânus. Todas as participantes forneceram consentimento informado previamente ao início da coleta de dados. 2) Este estudo foi aprovado pelo Comitê de Ética em Pesquisa (CAAE 82225617.0.0000.5411). O modelo foi proposto para avaliar o desempenho dos MAP em suas diferentes atividades por meio da EMG e desenhado com base na importância de incluir, além da medida de repouso inicial, as medidas de repouso antes e depois de cada atividade realizada. Este conceito permitirá análise ampliada e detalhada do desempenho dos MAP e MRA entre os repousos, entre as atividades e repousos, bem como entre atividades semelhantes e/ou opostas. Resultados: 1) Na primeira etapa foi feita uma revisão bibliográfica e análise de entrevistas qualitativas. Após a retirada de detalhes sugeridos pelos especialistas, obtiveram-se 14 itens como versão final do questionário. A avaliação das propriedades psicométricas do instrumento foi feita em segundo lugar. Foram relatadas a análise das propriedades psicométricas do instrumento, incluindo validade de conteúdo, validade formal, validade de construto e confiabilidade (consistência interna). 2) Durante as contrações rápidas não houve diferenças na atividade eletromiográfica dos MAP entre os grupos. A ativação dos MAP superficiais das mulheres com DMG independente do status da continência urinária foram semelhantes, mas separadamente eles diferiram da ativação das mulheres do grupo normoglicêmico-incontinente (NG-IU) sendo assim, as mulheres do grupo diabético-continente (DMG-C) e diabético-incontinente (DMG-IU) ativaram 56,3% (p=,000) e 28,7% (p=,047) menos os MAP superficiais comparado com as NG-IU, respectivamente. Em relação a ativação sinérgica do MRA durante a tarefa de contração rápida do AP, a ativação do RA das mulheres com DMG independente do status da continência urinária foi semelhante, mas separadamente eles diferiram da ativação das mulheres do grupo NG-IU sendo assim, as mulheres DMG-C e as mulheres DMG-IU ativaram 39,1% (p=,001) e 34,8% (p=,005) menos o MRA comparado com as NG-IU, respectivamente. Conclusão: 1) O PSUI-Q é uma escala baseada em conteúdo, que permite que clínicos ou pesquisadores não apenas caracterizem os níveis de sobrecarga emocional, social, financeiro, profissional e sexual experimentados por mulheres grávidas, mas também oferece uma compreensão mais personalizada da sua angústia durante esse período específico. Portanto, o PSUI-Q é uma medida valiosa que pode ser usada como base para os profissionais de saúde desenvolverem cuidados adequados para atender às necessidades individuais das mulheres. Compreender a sobrecarga da gestante deve ser um componente fundamental para o desenvolvimento de um pré-natal adequado para auxiliar a mulher no enfrentamento de sua situação, evitando as consequências adversas da carga emocional materna. O PSUI-Q desenvolvido com 14 itens foi confirmado como tendo validade e confiabilidade satisfatórias. 2) Os resultados preliminares deste estudo indicam que mulheres que são DMG-C e DMG-IU ativam menos os MAP e RA quando comparadas com mulheres NG-C e NG-IU.
Introduction: Clinical research has identified that women with gestational diabetes have an interrelationship between gestational urinary incontinence (UI) and pelvic floor muscular dysfunction (PFMD). The pelvic floor muscles (PFM) are critical to supporting the pelvic organs, providing active support both at rest and during activity. The experimental research from this clinical result showed altered striated urethral muscles and rectus abdominis muscle (RAM) in pregnant diabetic rats. Those had muscle atrophy with fiber disorganization and disruption, altered organization of slow and fast fiber types (type I and II), increased fast fibers and fibrosis as well collagen I/III, leading to a rigid extracellular matrix. These findings corroborate the literature on the integrity of the structure of the abdominal muscles and the pelvic floor changes throughout women’s lives, particularly during pregnancy and childbirth. Besides, diabetes-complicated pregnancies may have even more evident changes, hurting the quality of life. The coordinated and effective contraction of PFM is related to the maintenance of urination, evacuation, and sexual functioning. PFMD is a disorder that affects the ability to control and coordinate PFM associated with stress urinary incontinence, overactive bladder syndrome, pelvic organ prolapses, anal incontinence, pelvic pain, and sexual dysfunction and constipation, thus negatively impacting the quality of life. UI is also associated with altered PFM activation patterns in abdominal muscles during functional activities, including those that increase intra-abdominal pressure (PIAb). Findings from our research associate gestational diabetes mellitus (GDM) with DMAP. GDM is defined as a glucose tolerance disorder with onset during pregnancy. It is related to physiological muscle function deterioration and associated with the term "diabetic myopathy," which refers to functional, metabolic, and structural changes that diabetes mellitus (DM) induces in the skeletal muscles. Given the strong negative impact of pregnancy-specific urinary incontinence (PSUI) and how it is a widely investigated disorder, no built, validated instruments exist in the national and international literature to specifically identify and evaluate PSUI. That shows the need to develop and validate an unprecedented questionnaire to identify and assess the SUI in the Brazilian population. Clinical studies have shown that DMG negatively impacts the electromyographic activity of PFM throughout pregnancy. An injury affecting the rectus abdominis muscle during pregnancy was also related to GDM. Translational studies have shown harmful impacts of both mild long-term hyperglycemia and severe short-term hyperglycemia on the urethral muscle of pregnant rats. These include atrophy, thinning, disorganization, muscle fiber rupture, and loss of specific types of fibers from normal anatomical locations, denoting a connection between blood glucose levels and PFM structure. Recently, a clinical trial protocol established well-developed biomarker research in a new conceptual model of the role of integrating the triad GDM, PSUI, and hyperglycemic myopathy as a predictor of long-term UI and PFMD. In addition to analyzing muscle functionality, PFM performance evaluation via electromyography (EMG) can identify the exact moment when a particular muscle acts and thus checks for co-contraction between the muscles. The assessment should include PFM performance at rest and in dynamic activities. Studies that analyze PMF function during pregnancy use EMG as an assessment. It is relevant to analyze muscle status as it can obtain data such as the recruitment of motor units, the conduction velocity of muscle fibers, and muscle fatigue, which are essential variables to efficiently identify different aspects of pregnant women's muscle performance. In addition, the technique is easily accessible, does not require radiation, has minimal discomfort and good inter-observer and interdisciplinary reliability, and allows dynamic evaluation. Justification: Deepening and filling knowledge gaps about the long-term repercussion of GDM and hyperglycemic myopathy becomes essential. In this context, analyzing PFM performance with reliable, objective, visible, and real-time electromyographic assessments is an alternative method to guide clinical and scientific practice in preventive and therapeutic care. Objectives: 1) To build and validate an instrument to assess pregnancy-specific urinary incontinence in Brazilian women. 2) To analyze the effect of DMG on PFM functionality during pregnancy via electromyographic assessment. Methods: 1) This is a cross-sectional study performed at São Paulo State University's Botucatu Medical School's Research Center on Perinatal Diabetes (RCPD UNESP), Brazil. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guide tool was used as a guide to report this study. Data were collected between March 2018 and December 2021. This study was approved by the Research Ethics Committee (CAAE 31976620.1.0000.5411). The study recruited pregnant women to participate in the routine GDM screening at the RCPD. Inclusion criteria were pregnant women between 18-40 years of age who were normoglycemic and had GDM on a non-drug treatment. Participants with type I or II DM, using hypoglycemic agents, with inadequate screening or diagnosis of GDM, pharmacological treatment after failure of glucose control with lifestyle and diet modification, connective tissue disease, neurological disorders, and organ prolapse were excluded. GDM was diagnosed according to the American Diabetes Association (ADA) criteria, and when confirmed, these participants were allocated to the GDM group. Participants with a negative result were assigned to the normoglycemic (NG) group. The participants were submitted to filling out a questionnaire and were assessed for PFM by the EMG considering the levator ani area. All participants provided informed consent before data collection. 2) This study was approved by the Research Ethics Committee (CAAE 82225617.0.0000.5411). The model proposed to evaluate the performance of PFMs in their different activities through EMG was designed based on the importance of including rest measures before and after each activity performed besides the initial rest measure. This concept will allow for an extended, detailed PFM and RAM performance analysis between rests, between activities and rests, and between similar or opposite activities. Results: 1) The first stage included a bibliographic review and analysis of qualitative interviews. After removing details suggested by the experts, 14 items were included in the final version of the questionnaire. The assessment of the instrument's psychometric properties was performed afterward. Finally, the analysis of the instrument's psychometric properties, including content validity, formal validity, construct validity, and reliability (internal consistency), were reported. 2) There were no differences in PFM electromyographic activity between groups during rapid contractions. Superficial PFM activation in women with GDM regardless of urinary continence status was similar, but separately they differed from activation of women in the normoglycemic-incontinent (NG-UI) group. Thus, women in the diabetic-continent (GDM-C) and diabetic-incontinent (DMG-UI) groups activated 56.3% (p=.000) and 28.7% (p=.047) less superficial PFM compared to NG-UI, respectively. Regarding the synergistic activation of the RAM during the rapid contraction task of the PF, the activation of the RAM of the women with GDM regardless of their urinary continence status was similar, but separately they differed from the activation of the women in the NG-UI group. GDM-C and GDM-UI women activated 39.1% (p=.001) and 34.8% (p=.005) fewer MRA than NG-UI, respectively. Conclusion: 1) The PSUI-Q is a content-based scale clinicians and researchers use to define emotional, social, financial, professional, and sexual burden levels pregnant women experience, as well as provide a more tailored understanding of their distress during that period. Therefore, the PSUI-Q is a valuable measure health care professionals can use to develop appropriate care to meet women's individual needs. Understanding the burden of pregnant women should be fundamental to developing proper prenatal care to help women cope with their situation and avoid the adverse consequences of the maternal emotional burden. The 14-item PSUI-Q had satisfactory validity and reliability. 2) The preliminary results in this study indicate that women who are GDM-C and GDM-UI activate less PFM and RAM when compared to NG-C and NG-UI women.
Introduction: Clinical research has identified that women with gestational diabetes have an interrelationship between gestational urinary incontinence (UI) and pelvic floor muscular dysfunction (PFMD). The pelvic floor muscles (PFM) are critical to supporting the pelvic organs, providing active support both at rest and during activity. The experimental research from this clinical result showed altered striated urethral muscles and rectus abdominis muscle (RAM) in pregnant diabetic rats. Those had muscle atrophy with fiber disorganization and disruption, altered organization of slow and fast fiber types (type I and II), increased fast fibers and fibrosis as well collagen I/III, leading to a rigid extracellular matrix. These findings corroborate the literature on the integrity of the structure of the abdominal muscles and the pelvic floor changes throughout women’s lives, particularly during pregnancy and childbirth. Besides, diabetes-complicated pregnancies may have even more evident changes, hurting the quality of life. The coordinated and effective contraction of PFM is related to the maintenance of urination, evacuation, and sexual functioning. PFMD is a disorder that affects the ability to control and coordinate PFM associated with stress urinary incontinence, overactive bladder syndrome, pelvic organ prolapses, anal incontinence, pelvic pain, and sexual dysfunction and constipation, thus negatively impacting the quality of life. UI is also associated with altered PFM activation patterns in abdominal muscles during functional activities, including those that increase intra-abdominal pressure (PIAb). Findings from our research associate gestational diabetes mellitus (GDM) with DMAP. GDM is defined as a glucose tolerance disorder with onset during pregnancy. It is related to physiological muscle function deterioration and associated with the term "diabetic myopathy," which refers to functional, metabolic, and structural changes that diabetes mellitus (DM) induces in the skeletal muscles. Given the strong negative impact of pregnancy-specific urinary incontinence (PSUI) and how it is a widely investigated disorder, no built, validated instruments exist in the national and international literature to specifically identify and evaluate PSUI. That shows the need to develop and validate an unprecedented questionnaire to identify and assess the SUI in the Brazilian population. Clinical studies have shown that DMG negatively impacts the electromyographic activity of PFM throughout pregnancy. An injury affecting the rectus abdominis muscle during pregnancy was also related to GDM. Translational studies have shown harmful impacts of both mild long-term hyperglycemia and severe short-term hyperglycemia on the urethral muscle of pregnant rats. These include atrophy, thinning, disorganization, muscle fiber rupture, and loss of specific types of fibers from normal anatomical locations, denoting a connection between blood glucose levels and PFM structure. Recently, a clinical trial protocol established well-developed biomarker research in a new conceptual model of the role of integrating the triad GDM, PSUI, and hyperglycemic myopathy as a predictor of long-term UI and PFMD. In addition to analyzing muscle functionality, PFM performance evaluation via electromyography (EMG) can identify the exact moment when a particular muscle acts and thus checks for co-contraction between the muscles. The assessment should include PFM performance at rest and in dynamic activities. Studies that analyze PMF function during pregnancy use EMG as an assessment. It is relevant to analyze muscle status as it can obtain data such as the recruitment of motor units, the conduction velocity of muscle fibers, and muscle fatigue, which are essential variables to efficiently identify different aspects of pregnant women's muscle performance. In addition, the technique is easily accessible, does not require radiation, has minimal discomfort and good inter-observer and interdisciplinary reliability, and allows dynamic evaluation. Justification: Deepening and filling knowledge gaps about the long-term repercussion of GDM and hyperglycemic myopathy becomes essential. In this context, analyzing PFM performance with reliable, objective, visible, and real-time electromyographic assessments is an alternative method to guide clinical and scientific practice in preventive and therapeutic care. Objectives: 1) To build and validate an instrument to assess pregnancy-specific urinary incontinence in Brazilian women. 2) To analyze the effect of DMG on PFM functionality during pregnancy via electromyographic assessment. Methods: 1) This is a cross-sectional study performed at São Paulo State University's Botucatu Medical School's Research Center on Perinatal Diabetes (RCPD UNESP), Brazil. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guide tool was used as a guide to report this study. Data were collected between March 2018 and December 2021. This study was approved by the Research Ethics Committee (CAAE 31976620.1.0000.5411). The study recruited pregnant women to participate in the routine GDM screening at the RCPD. Inclusion criteria were pregnant women between 18-40 years of age who were normoglycemic and had GDM on a non-drug treatment. Participants with type I or II DM, using hypoglycemic agents, with inadequate screening or diagnosis of GDM, pharmacological treatment after failure of glucose control with lifestyle and diet modification, connective tissue disease, neurological disorders, and organ prolapse were excluded. GDM was diagnosed according to the American Diabetes Association (ADA) criteria, and when confirmed, these participants were allocated to the GDM group. Participants with a negative result were assigned to the normoglycemic (NG) group. The participants were submitted to filling out a questionnaire and were assessed for PFM by the EMG considering the levator ani area. All participants provided informed consent before data collection. 2) This study was approved by the Research Ethics Committee (CAAE 82225617.0.0000.5411). The model proposed to evaluate the performance of PFMs in their different activities through EMG was designed based on the importance of including rest measures before and after each activity performed besides the initial rest measure. This concept will allow for an extended, detailed PFM and RAM performance analysis between rests, between activities and rests, and between similar or opposite activities. Results: 1) The first stage included a bibliographic review and analysis of qualitative interviews. After removing details suggested by the experts, 14 items were included in the final version of the questionnaire. The assessment of the instrument's psychometric properties was performed afterward. Finally, the analysis of the instrument's psychometric properties, including content validity, formal validity, construct validity, and reliability (internal consistency), were reported. 2) There were no differences in PFM electromyographic activity between groups during rapid contractions. Superficial PFM activation in women with GDM regardless of urinary continence status was similar, but separately they differed from activation of women in the normoglycemic-incontinent (NG-UI) group. Thus, women in the diabetic-continent (GDM-C) and diabetic-incontinent (DMG-UI) groups activated 56.3% (p=.000) and 28.7% (p=.047) less superficial PFM compared to NG-UI, respectively. Regarding the synergistic activation of the RAM during the rapid contraction task of the PF, the activation of the RAM of the women with GDM regardless of their urinary continence status was similar, but separately they differed from the activation of the women in the NG-UI group. GDM-C and GDM-UI women activated 39.1% (p=.001) and 34.8% (p=.005) fewer MRA than NG-UI, respectively. Conclusion: 1) The PSUI-Q is a content-based scale clinicians and researchers use to define emotional, social, financial, professional, and sexual burden levels pregnant women experience, as well as provide a more tailored understanding of their distress during that period. Therefore, the PSUI-Q is a valuable measure health care professionals can use to develop appropriate care to meet women's individual needs. Understanding the burden of pregnant women should be fundamental to developing proper prenatal care to help women cope with their situation and avoid the adverse consequences of the maternal emotional burden. The 14-item PSUI-Q had satisfactory validity and reliability. 2) The preliminary results in this study indicate that women who are GDM-C and GDM-UI activate less PFM and RAM when compared to NG-C and NG-UI women.
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Palavras-chave
Assoalho pélvico, Eletromiografia, Gravidez, Questionário, Diabetes mellitus gestacional, Músculo do assoalho pélvico, Incontinência urinária, Pelvic floor, Gestational diabetes mellitus, Pelvic floor muscle, Pregnancy, Urinary incontinence, Questionnaire, Electromyography