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Article(id=1322191041281765644, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322191025829953744, articleNumber=null, orderNo=null, doi=10.16016/j.2097-0927.202504065, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1744732800000, receivedDateStr=2025-04-16, revisedDate=1751817600000, revisedDateStr=2025-07-07, acceptedDate=null, acceptedDateStr=null, onlineDate=1793164509362, onlineDateStr=2026-10-28, pubDate=1753804800000, pubDateStr=2025-07-30, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793164509362, onlineIssueDateStr=2026-10-28, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793164509362, creator=13701087609, updateTime=1793164509362, updator=13701087609, issue=Issue{id=1322191025829953744, tenantId=1146029695717560320, journalId=1319373162502258839, year='2025', volume='47', issue='14', pageStart='1557', pageEnd='1684', issueExtLink='null', onlineDate='null', pubDate='1753804800000', pubDateStr='2025-07-30', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1793164505679, creator='13701087609', updateTime=1793164547848, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext={EN=IssueExt(id=1322191202804420934, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322191025829953744, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1322191202804420935, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322191025829953744, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null, downloadFileDto=null}, startPage=1660, endPage=1669, ext={EN=ArticleExt(id=1322191041504063757, articleId=1322191041281765644, tenantId=1146029695717560320, journalId=1319373162502258839, language=EN, title=Current status and influencing factors of pelvic floor muscle training adherence in rectal cancer patients with prophylactic ostomy, columnId=1320435174995772212, journalTitle=Journal of Army Medical University, columnName=Clinical Medicine, runingTitle=null, highlight=null, articleAbstract=
Objective‍

To investigate the current status of pelvic floor muscle training (PFMT) adherence for preventing low anterior resection syndrome (LARS) in rectal cancer patients with prophylactic ostomy and analyze its influencing factors.

Methods‍

A total of 247 patients who underwent preventive stoma reversal surgery after sphincter-preserving rectal cancer resection between January 2024 and February 2025 at 22 tertiary hospitals in the Beijing-Tianjin-Hebei region were recruited in this study. Their clinical data were collected through a general information questionnaire, a LARS Knowledge-Attitude-Practice and Needs questionnaire, a PFMT Self-Efficacy Scale, and a PFMT Adherence Questionnaire. Univariate analysis, correlation analysis, LASSO regression, and random forest importance ranking were applied to screen the variables, and multiple linear regression analysis was conducted to analyze the significant variables.

Results‍

The overall PFMT adherence score was 14.52±4.18 among the 247 patients. The random forest algorithm identified 7 key predictors when the minimum error was achieved at a λ value of 2.293. The top 7 variables in importance ranking were PFMT self-efficacy, total knowledge-attitude-practice (KAP) score, education level, primary caregiver, tumor location, stoma reversal time, and chemoradiotherapy. Multiple linear regression analysis revealed that PFMT self-efficacy (P<0.001, β=0.007, 95%CI: 0.004~0.009), total KAP score (P<0.001, β=0.052, 95%CI: 0.035~0.070), stoma reversal time (P<0.030, β=-0.539, 95%CI: -1.025~-0.053), and chemoradiotherapy (P<0.045, β=-0.451, 95%CI: 0.010~0.892) were significant related factors of PFMT adherence (P<0.05).

Conclusion‍

PFMT adherence for LARS prevention is at a moderate level in rectal cancer patients with prophylactic ostomy. Key factors such as PFMT self-efficacy, total KAP score, stoma reversal time, and chemoradiotherapy are significantly correlated with PFMT adherence.

, authors=Na LIU1, Hongying PI2, Na GAO1, Yuze SUN3, Tianze WANG3, authorsList=Na LIU, Hongying PI, Na GAO, Yuze SUN, Tianze WANG, authorCompany=null, correspAuthors=Hongying PI, authorNote=null, correspAuthorsNote=null, copyrightStatement=© 2025 Journal of Army Medical University, copyrightOwner=Editorial Office of Journal of Army Medical University, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1322191043966120212, articleId=1322191041281765644, tenantId=1146029695717560320, journalId=1319373162502258839, language=CN, title=直肠癌预防性造口患者盆底肌训练依从性现状及影响因素分析, columnId=1322185541475488183, journalTitle=陆军军医大学学报, columnName=临床医学, runingTitle=null, highlight=null, articleAbstract=
目的

调查直肠癌预防性造口患者预防低位前切除术综合征（low anterior resection syndrome，LARS）盆底肌训练依从性现状并分析其影响因素。

方法

选取2024年1月至2025年2月在京津冀地区22家三级甲等医院普外科或胃肠外科行直肠癌保肛手术后成功行预防性造口还纳手术的247例患者作为研究对象，采用一般资料问卷、LARS知信行及需求问卷、盆底肌训练自我效能量表、盆底肌训练依从性问卷进行横断面调查，通过单因素分析、相关性分析筛选变量，LASSO回归与随机森林重要性排序进行特征变量选择，再对有意义的变量进行多重线性回归分析。

结果

247例患者预防LARS盆底肌训练依从性总体均分为（14.52±4.18）分，随机森林算法结果显示，当λ值为2.293时误差最小，对应的影响因素数目为7个，重要性排序居前7位的自变量为盆底肌训练自我效能、知信行总分、文化程度、主要照护者、肿瘤位置、造口还纳时间、放化疗。多重线性回归分析结果显示，盆底肌训练自我效能（P<0.001，β=0.007，95%CI：0.004~0.009）、知信行总分（P<0.001，β=0.052，95%CI：0.035~0.070）、造口还纳时间（P<0.030，β=-0.539，95%CI：-1.025~-0.053）、放化疗（P<0.045，β=-0.451，95%CI：0.010~0.892）是直肠癌预防性造口患者盆底肌训练依从性的相关因素（P<0.05）。

结论

直肠癌预防性造口患者盆底肌训练依从性处于中等水平，盆底肌训练自我效能、知信行总分、造口还纳时间、放化疗与盆底肌训练依从性密切相关。

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皮红英，E-mail：
PI Hongying，E-mail：
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Keyword(id=1322191048357556547, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=CN, orderNo=6, keyword=随机森林模型)], refs=[Reference(id=1322191050819613016, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, doi=10.1007/s10151-023-02872-5, pmid=null, pmcid=null, year=2023, volume=28, issue=1, pageStart=10, pageEnd=null, url=null, language=null, rfNumber=1, rfOrder=0, authorNames=BROCK H, LAMBRINEAS L, ONG H I, journalName=Tech Coloproctol, refType=null, unstructuredReference=BROCK H，LAMBRINEAS L，ONG H I，et al. 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Physiol Int，2022，109（2）：246-260., articleTitle=Effects of multimodal training program on muscle deoxygenation in women with breast cancer：a randomized controlled trial, refAbstract=null), Reference(id=1322191057434030461, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, doi=10.26355/eurrev_202311_34486, pmid=null, pmcid=null, year=2023, volume=27, issue=22, pageStart=11169, pageEnd=11179, url=null, language=null, rfNumber=35, rfOrder=37, authorNames=HIRAOUI M, BUSAFI M AL, AL-HADABI B, journalName=Eur Rev Med Pharmacol Sci, refType=null, unstructuredReference=HIRAOUI M，BUSAFI M AL，AL-HADABI B，et al. Effects of combined resistance and aerobic training program on myoelectric activity of Vastus Lateralis in patients with breast cancer during adjuvant chemotherapy period［J］. Eur Rev Med Pharmacol Sci，2023，27（22）：11169-11179., articleTitle=Effects of combined resistance and aerobic training program on myoelectric activity of Vastus Lateralis in patients with breast cancer during adjuvant chemotherapy period, refAbstract=null), Reference(id=1322191057501139326, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, doi=10.3748/wjg.v31.i8.102331, pmid=null, pmcid=null, year=2025, volume=31, issue=8, pageStart=102331, pageEnd=null, url=null, language=null, rfNumber=36, rfOrder=38, authorNames=YUAN C D, ZHOU B Z, WANG N Y, journalName=World J Gastroenterol, refType=null, unstructuredReference=YUAN C D，ZHOU B Z，WANG N Y，et al. Evidence-based control of stress response on intraoperative physiological indexes and recovery of patients undergoing gastrointestinal surgery［J］. World J Gastroenterol，2025，31（8）：102331., articleTitle=Evidence-based control of stress response on intraoperative physiological indexes and recovery of patients undergoing gastrointestinal surgery, refAbstract=null), Reference(id=1322191057580831103, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, doi=null, pmid=null, pmcid=null, year=2025, volume=44, issue=4, pageStart=26, pageEnd=31, url=null, language=null, rfNumber=37, rfOrder=39, authorNames=郭涛, 朱文韬, 李祥飞, journalName=中国卫生经济, refType=null, unstructuredReference=郭涛，朱文韬，李祥飞，等. 京津冀医疗一体化对医疗卫生资源影响的政策效应研究［J］. 中国卫生经济，2025，44（4）：26-31., articleTitle=京津冀医疗一体化对医疗卫生资源影响的政策效应研究, refAbstract=null), Reference(id=1322191057656328576, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, doi=null, pmid=null, pmcid=null, year=2025, volume=44, issue=4, pageStart=26, pageEnd=31, url=null, language=null, rfNumber=37, rfOrder=40, authorNames=GUO T, ZHU W T, LI X F, journalName=Chin Health Econ, refType=null, unstructuredReference=GUO T，ZHU W T，LI X F，et al. 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Chin Health Econ，2025，44（4）：26-31., articleTitle=Research on the policy effect of the Beijing-Tianjin-Hebei medical integration strategy on medical and health resources, refAbstract=null), Reference(id=1322191057727631745, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, doi=10.28326/n.cnki.nhbrb.2025.001118, pmid=null, pmcid=null, year=null, volume=null, issue=null, pageStart=null, pageEnd=null, url=null, language=null, rfNumber=38, rfOrder=41, authorNames=赵泽众, journalName=河北日报, refType=null, unstructuredReference=赵泽众. 全国人大代表马永平：推动优质医疗资源在京津冀流动起来［N］. 河北日报，2025-03-03., articleTitle=全国人大代表马永平：推动优质医疗资源在京津冀流动起来, refAbstract=null), Reference(id=1322191057790546306, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, doi=10.28326/n.cnki.nhbrb.2025.001118, pmid=null, pmcid=null, year=null, volume=null, issue=null, pageStart=null, pageEnd=null, url=null, language=null, rfNumber=38, rfOrder=42, authorNames=ZHAO Z Z, journalName=Hebei Daily, refType=null, unstructuredReference=ZHAO Z Z. 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项目例数依从性总分
得分（分，x¯±s）t/FP
性别男17314.64±4.070.5030.479
女7414.23±4.44
年龄18~59岁12315.24±4.293.3880.035
60~79岁11414.02±5.31
≥80岁1011.96±5.23
文化程度初中及以下11713.61±4.176.3030.002
高中/中专4314.70±4.25
大学及以上8715.65±3.89
婚姻状况已婚23714.43±4.212.3570.126
未婚/离异/丧偶1016.50±2.64
职业状态在职5513.53±4.421.6580.193
离退休14214.79±4.24
无业3414.47±3.99
其他1614.52±2.58
居住地城镇16214.89±5.633.8830.031
农村8513.02±4.65
主要照护者自己3215.01±3.425.5210.001
配偶11514.89±3.97
子女7014.37±3.68
其他3011.97±5.65
医疗费用医保21114.49±4.170.0520.949
新农合2614.77±4.55
其他1014.50±3.66
家庭月收入<5 000元6213.89±3.991.6160.201
5 000~10 000元14114.53±4.05
>10 000元4415.36±4.74
造口并发症无5413.85±4.822.2770.080
肠造口周围皮肤并发症13914.44±3.98
腹壁造口隧道并发症4315.88±3.22
造口处腹壁切口并发症1113.45±5.77
放化疗无放化疗7815.97±4.654.8870.007
术前放化疗2313.91±4.13
术后放化疗11612.43±5.62
术前术后放化疗3012.16±3.98
造口还纳时间<3个月7015.56±3.684.9790.002
3~6个月9514.81±4.18
7~12个月6413.67±4.34
>12个月1811.94±4.08
合并基础病无10314.98±4.312.9660.043
1种10013.08±4.46
2种以上4412.38±4.47
手术方式腹腔镜21014.37±4.250.9060.405
机器人1815.56±2.92
开腹1915.16±4.36
), ArticleFig(id=1322191049850728780, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=CN, label=表1, caption=

直肠癌预防性造口患者一般情况及其对LARS盆底肌训练依从性影响的单因素分析

, figureFileSmall=null, figureFileBig=null, tableContent=
项目例数依从性总分
得分（分，x¯±s）t/FP
性别男17314.64±4.070.5030.479
女7414.23±4.44
年龄18~59岁12315.24±4.293.3880.035
60~79岁11414.02±5.31
≥80岁1011.96±5.23
文化程度初中及以下11713.61±4.176.3030.002
高中/中专4314.70±4.25
大学及以上8715.65±3.89
婚姻状况已婚23714.43±4.212.3570.126
未婚/离异/丧偶1016.50±2.64
职业状态在职5513.53±4.421.6580.193
离退休14214.79±4.24
无业3414.47±3.99
其他1614.52±2.58
居住地城镇16214.89±5.633.8830.031
农村8513.02±4.65
主要照护者自己3215.01±3.425.5210.001
配偶11514.89±3.97
子女7014.37±3.68
其他3011.97±5.65
医疗费用医保21114.49±4.170.0520.949
新农合2614.77±4.55
其他1014.50±3.66
家庭月收入<5 000元6213.89±3.991.6160.201
5 000~10 000元14114.53±4.05
>10 000元4415.36±4.74
造口并发症无5413.85±4.822.2770.080
肠造口周围皮肤并发症13914.44±3.98
腹壁造口隧道并发症4315.88±3.22
造口处腹壁切口并发症1113.45±5.77
放化疗无放化疗7815.97±4.654.8870.007
术前放化疗2313.91±4.13
术后放化疗11612.43±5.62
术前术后放化疗3012.16±3.98
造口还纳时间<3个月7015.56±3.684.9790.002
3~6个月9514.81±4.18
7~12个月6413.67±4.34
>12个月1811.94±4.08
合并基础病无10314.98±4.312.9660.043
1种10013.08±4.46
2种以上4412.38±4.47
手术方式腹腔镜21014.37±4.250.9060.405
机器人1815.56±2.92
开腹1915.16±4.36
), ArticleFig(id=1322191049959780685, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
项目例数依从性总分
得分（分，x¯±s）t/FP
肿瘤位置<5 cm7213.42±4.902.6880.047
5~<8 cm11616.84±4.04
8~<10 cm5415.35±3.24
≥10 cm514.00±2.12
肿瘤分期T11514.93±3.751.8160.123
T215514.09±3.76
T36413.05±4.96
T41314.38±3.81
), ArticleFig(id=1322191050081415503, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=CN, label=续表1, caption=

直肠癌预防性造口患者一般情况及其对LARS盆底肌训练依从性影响的单因素分析　(x¯±s)

, figureFileSmall=null, figureFileBig=null, tableContent=
项目例数依从性总分
得分（分，x¯±s）t/FP
肿瘤位置<5 cm7213.42±4.902.6880.047
5~<8 cm11616.84±4.04
8~<10 cm5415.35±3.24
≥10 cm514.00±2.12
肿瘤分期T11514.93±3.751.8160.123
T215514.09±3.76
T36413.05±4.96
T41314.38±3.81
), ArticleFig(id=1322191050152718672, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
变量知信行总分盆底肌训练自我效能依从性评分
知信行总分1
盆底肌训练自我效能0.290a1
依从性评分0.389a0.467a1
), ArticleFig(id=1322191050228216145, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=CN, label=表2, caption=

预防LARS知信行水平、盆底肌训练自我效能与盆底肌训练依从性的相关性分析

, figureFileSmall=null, figureFileBig=null, tableContent=
变量知信行总分盆底肌训练自我效能依从性评分
知信行总分1
盆底肌训练自我效能0.290a1
依从性评分0.389a0.467a1
), ArticleFig(id=1322191050291130706, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
变量赋值方式
年龄18~59岁=1，60~79岁=2，80岁以上=3
文化程度初中及以下=1，高中/中专=2，大学及以上=3
居住地城市=1，乡镇或农村=2
主要照护者自己=1，配偶=2，子女=3，其他=4
造口还纳时间3个月以内=1，3~6个月=2，7~12个月=3，12个月以上=4
合并基础疾病无基础疾病=1，合并1种基础疾病=2，合并2种以上基础疾病=3
肿瘤位置<5 cm=1，5~<8 cm=2，8~10 cm=3，>10 cm=4
放化疗无放化疗=1，术前放化疗=2，术后放化疗=3，术前术后均放化疗=4
KAP总分原值输入
盆底肌训练自我效能原值输入
), ArticleFig(id=1322191050358239571, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=CN, label=表3, caption=

预防LARS盆底肌训练依从性影响因素随机森林模型的自变量赋值情况

, figureFileSmall=null, figureFileBig=null, tableContent=
变量赋值方式
年龄18~59岁=1，60~79岁=2，80岁以上=3
文化程度初中及以下=1，高中/中专=2，大学及以上=3
居住地城市=1，乡镇或农村=2
主要照护者自己=1，配偶=2，子女=3，其他=4
造口还纳时间3个月以内=1，3~6个月=2，7~12个月=3，12个月以上=4
合并基础疾病无基础疾病=1，合并1种基础疾病=2，合并2种以上基础疾病=3
肿瘤位置<5 cm=1，5~<8 cm=2，8~10 cm=3，>10 cm=4
放化疗无放化疗=1，术前放化疗=2，术后放化疗=3，术前术后均放化疗=4
KAP总分原值输入
盆底肌训练自我效能原值输入
), ArticleFig(id=1322191050446319956, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
自变量共线性诊断
容差VIF
常量--
文化程度0.7901.266
主要照护者0.8181.222
造口还纳时间0.9171.091
肿瘤位置0.9241.082
放化疗0.8181.222
KAP总分0.7211.387
盆底肌训练自我效能0.8411.190
), ArticleFig(id=1322191050530206037, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=CN, label=表4, caption=

直肠癌预防性造口患者预防LARS盆底肌训练依从性影响因素各变量的共线性诊断

, figureFileSmall=null, figureFileBig=null, tableContent=
自变量共线性诊断
容差VIF
常量--
文化程度0.7901.266
主要照护者0.8181.222
造口还纳时间0.9171.091
肿瘤位置0.9241.082
放化疗0.8181.222
KAP总分0.7211.387
盆底肌训练自我效能0.8411.190
), ArticleFig(id=1322191050609897814, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
自变量偏回归系数标准误标准化回归系数tP95%CI
常量2.5601.6501.5520.122-0.690~5.810
文化程度0.3780.2670.0821.4140.159-0.148~0.904
主要照护者-0.4660.275-0.096-1.6980.091-1.007~0.075
造口还纳时间-0.5390.247-0.117-2.1870.030-1.025~-0.053
肿瘤位置0.0410.2900.0070.1400.889-0.530~0.611
放化疗0.4510.2240.1142.0130.0450.010~0.892
知信行总分0.0520.0090.3565.900<0.0010.035~0.070
盆底肌训练自我效能0.0070.0010.3215.743<0.0010.004~0.009
), ArticleFig(id=1322191050697978199, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322191041281765644, language=CN, label=表5, caption=

直肠癌预防性造口患者预防LARS盆底肌训练依从性影响因素的多重线性回归分析

, figureFileSmall=null, figureFileBig=null, tableContent=
自变量偏回归系数标准误标准化回归系数tP95%CI
常量2.5601.6501.5520.122-0.690~5.810
文化程度0.3780.2670.0821.4140.159-0.148~0.904
主要照护者-0.4660.275-0.096-1.6980.091-1.007~0.075
造口还纳时间-0.5390.247-0.117-2.1870.030-1.025~-0.053
肿瘤位置0.0410.2900.0070.1400.889-0.530~0.611
放化疗0.4510.2240.1142.0130.0450.010~0.892
知信行总分0.0520.0090.3565.900<0.0010.035~0.070
盆底肌训练自我效能0.0070.0010.3215.743<0.0010.004~0.009
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直肠癌预防性造口患者盆底肌训练依从性现状及影响因素分析
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刘娜 1 , 皮红英 2 , 高娜 1 , 孙瑜泽 3 , 王天择 3
陆军军医大学学报 | 临床医学 2025,47(14): 1660-1669
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陆军军医大学学报 |临床医学 2025 , 47 (14) : 1660 -1669
直肠癌预防性造口患者盆底肌训练依从性现状及影响因素分析
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刘娜1, 皮红英2 , 高娜1, 孙瑜泽3, 王天择3
作者信息
  • 1解放军总医院：第一医学中心普通外科医学部，北京
  • 2解放军总医院：卫勤训练中心，北京
  • 3解放军医学院，北京
通讯作者:
皮红英，E-mail：
PI Hongying，E-mail：
Current status and influencing factors of pelvic floor muscle training adherence in rectal cancer patients with prophylactic ostomy
Na LIU1, Hongying PI2 , Na GAO1, Yuze SUN3, Tianze WANG3
Affiliations
  • 1Department of General Surgery，First Medical Center，Chinese PLA General Hospital，Beijing, Beijing，China
  • 2Medical Service Training Center of Chinese PLA General Hospital，Beijing, Beijing，China
  • 3PLA Medical College, Beijing，China
出版时间: 2025-07-30 doi: 10.16016/j.2097-0927.202504065
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摘要
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目的

调查直肠癌预防性造口患者预防低位前切除术综合征（low anterior resection syndrome，LARS）盆底肌训练依从性现状并分析其影响因素。

方法

选取2024年1月至2025年2月在京津冀地区22家三级甲等医院普外科或胃肠外科行直肠癌保肛手术后成功行预防性造口还纳手术的247例患者作为研究对象，采用一般资料问卷、LARS知信行及需求问卷、盆底肌训练自我效能量表、盆底肌训练依从性问卷进行横断面调查，通过单因素分析、相关性分析筛选变量，LASSO回归与随机森林重要性排序进行特征变量选择，再对有意义的变量进行多重线性回归分析。

结果

247例患者预防LARS盆底肌训练依从性总体均分为（14.52±4.18）分，随机森林算法结果显示，当λ值为2.293时误差最小，对应的影响因素数目为7个，重要性排序居前7位的自变量为盆底肌训练自我效能、知信行总分、文化程度、主要照护者、肿瘤位置、造口还纳时间、放化疗。多重线性回归分析结果显示，盆底肌训练自我效能（P<0.001，β=0.007，95%CI：0.004~0.009）、知信行总分（P<0.001，β=0.052，95%CI：0.035~0.070）、造口还纳时间（P<0.030，β=-0.539，95%CI：-1.025~-0.053）、放化疗（P<0.045，β=-0.451，95%CI：0.010~0.892）是直肠癌预防性造口患者盆底肌训练依从性的相关因素（P<0.05）。

结论

直肠癌预防性造口患者盆底肌训练依从性处于中等水平，盆底肌训练自我效能、知信行总分、造口还纳时间、放化疗与盆底肌训练依从性密切相关。

直肠癌  /  预防性造口  /  低位前切除术综合征  /  盆底肌训练  /  依从性  /  随机森林模型
Objective‍

To investigate the current status of pelvic floor muscle training (PFMT) adherence for preventing low anterior resection syndrome (LARS) in rectal cancer patients with prophylactic ostomy and analyze its influencing factors.

Methods‍

A total of 247 patients who underwent preventive stoma reversal surgery after sphincter-preserving rectal cancer resection between January 2024 and February 2025 at 22 tertiary hospitals in the Beijing-Tianjin-Hebei region were recruited in this study. Their clinical data were collected through a general information questionnaire, a LARS Knowledge-Attitude-Practice and Needs questionnaire, a PFMT Self-Efficacy Scale, and a PFMT Adherence Questionnaire. Univariate analysis, correlation analysis, LASSO regression, and random forest importance ranking were applied to screen the variables, and multiple linear regression analysis was conducted to analyze the significant variables.

Results‍

The overall PFMT adherence score was 14.52±4.18 among the 247 patients. The random forest algorithm identified 7 key predictors when the minimum error was achieved at a λ value of 2.293. The top 7 variables in importance ranking were PFMT self-efficacy, total knowledge-attitude-practice (KAP) score, education level, primary caregiver, tumor location, stoma reversal time, and chemoradiotherapy. Multiple linear regression analysis revealed that PFMT self-efficacy (P<0.001, β=0.007, 95%CI: 0.004~0.009), total KAP score (P<0.001, β=0.052, 95%CI: 0.035~0.070), stoma reversal time (P<0.030, β=-0.539, 95%CI: -1.025~-0.053), and chemoradiotherapy (P<0.045, β=-0.451, 95%CI: 0.010~0.892) were significant related factors of PFMT adherence (P<0.05).

Conclusion‍

PFMT adherence for LARS prevention is at a moderate level in rectal cancer patients with prophylactic ostomy. Key factors such as PFMT self-efficacy, total KAP score, stoma reversal time, and chemoradiotherapy are significantly correlated with PFMT adherence.

rectal cancer  /  prophylactic ostomy  /  low anterior resection syndrome  /  pelvic floor muscle training  /  adherence  /  random forest model
刘娜, 皮红英, 高娜, 孙瑜泽, 王天择. 直肠癌预防性造口患者盆底肌训练依从性现状及影响因素分析. 陆军军医大学学报, 2025 , 47 (14) : 1660 -1669 . DOI: 10.16016/j.2097-0927.202504065
Na LIU, Hongying PI, Na GAO, Yuze SUN, Tianze WANG. Current status and influencing factors of pelvic floor muscle training adherence in rectal cancer patients with prophylactic ostomy[J]. Journal of Army Medical University, 2025 , 47 (14) : 1660 -1669 . DOI: 10.16016/j.2097-0927.202504065
正文
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低位前切除术综合征（low anterior resection syndrome，LARS）是直肠癌保肛手术后常见的并发症，以大便失禁、尿急、排便习惯改变等症状为特征，严重影响患者的生活质量［1-4］。中低位直肠癌保肛行预防性造口的患者，在手术后由于存在造口，改变了排便途径，因此LARS的症状往往会被掩饰，但在造口还纳后则会表现出LARS相关症状。这一系列症状不仅限制了他们的日常身体活动，而且对他们的情绪和心理健康产生了削弱作用，破坏了他们身心社会系统的整合和整体心理健康。有研究表明，盆底肌训练已被证明可显著改善LARS的症状［5］，尤其是在无失禁但至少有中度症状的患者中［6-7］。BROCK等［1］的研究表明，尽管目前有一些预防措施如经肛门灌洗和盆底肌肉训练显示出一定的效果，但其有效性受到患者依从性的限制。在临床上康复行为的可行性和依从性往往被低估，但却有着至关重要的价值，因为患者的依从性决定了许多治疗的成功。既往对康复锻炼依从性影响因素的研究，缺少对各个相关因素重要性的对比且影响因素不够精简［5］。随机森林是一种机器学习集成算法，具有抗过拟合能力强、不易受变量间共线性影响，以及能较精确地对众多影响因素做出重要性排序等优点［7］。本研究采用随机森林模型与LASSO回归进行重要性排序及特征变量筛选，再结合多重线性回归，分析直肠癌预防性造口患者预防LARS盆底肌训练依从性的影响因素，为提高患者盆底肌训练锻炼依从性，改善LARS症状提供依据。
1　资料与方法
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1.1　研究对象
本研究采用横断面研究设计，于2025年3月回溯北京、天津、河北地区22家三级甲等医院因直肠癌保肛预防性造口术后再次行还纳手术的患者电子病历，数据采集窗口设定为2024年1月1日至2025年2月28日，经便利抽样法初筛确定符合纳排标准的286例患者，其中12人无法取得联系，27人明确拒绝随访，最终247例患者纳入研究。纳入标准：①年龄>18岁，认知力正常；②病例确诊为直肠恶性肿瘤；③行直肠前切除保肛手术且行预防性造口的患者；④造口成功还纳术后的患者；⑤造口还纳前医嘱开展盆底肌训练的患者。排除标准：①造口还纳失败；②由于其他原因引起的排便失禁情况；③手术后出现吻合口漏等并发症不适合进行盆底肌训练者。本研究通过解放军总医院伦理委员会审核（伦审第S2023-574-01号）。
1.2　调查工具
1.2.1　一般资料调查表
自行设计的问卷调查表，包括患者年龄、性别、文化程度、婚姻状况、职业状态、居住地、合并基础疾病、医疗费用方式、家庭收入、主要照护者、造口并发症、手术方式、肿瘤位置、肿瘤分期、造口还纳时间、放化疗情况等。
1.2.2　盆底肌训练依从性问卷
该问卷由CHEN等［8］设计，用于描述患者每天盆底肌训练的情况。该量表包括3个问题：①平均每天花多少时间进行盆底肌训练（没有=1分，<5 min=2分，5~<10 min=3分，10~20 min=4分，>20 min=5分）；②平均每天进行盆底肌训练收缩的次数（没有=1分，<30次=2分，30~<60次=3分，60~<90次=4分，90~<120次=5分，120~200次=6分）；③盆底肌训练依从性视觉模拟量表，从0~10选取最能反映依从性的数字，该量表的总分2~21分，可以测量患者盆底肌训练的依从性，分数越高依从性越好。该量表的Cronbach’s α系数为0.81。该量表条目简单，易于理解，已被我国学者广泛使用。
1.2.3　盆底肌训练自我效能量表
该量表是由巴西博士SACOMORI等［9］利用自我效能理论于2013年研发，2019年由我国学者谷瑞芮等［10］汉化，采用分级计分的方式，用来评估盆底肌训练的自我效能。由17个条目组成，每个条目为10级评分、每10分一个等级，每个条目的分数为0~100分，所有条目均为正向计分，总分为0~1 700分，总分越高，说明盆底肌训练的自我效能越好。汉化的量表选取了176人，包括105名压力性尿失禁产妇，71名正常产妇，共提取3个因子，累积方差贡献率为79.76%，每个条目在其公因子上的载荷值均>0.5；对45名产妇的重测信度为0.939，总量表的Cronbach’s α系数为0.956。
1.2.4　LARS知信行问卷
该问卷以2017年设计的产褥期妇女盆底肌功能锻炼知信行及需求问卷为参考［11］，经过2轮的专家讨论修订而成，包括知识维度（12个条目）、信念维度（10个条目）、行为维度（10个条目），共32个条目。问卷总的Cronbach’s α系数为0.925，各维度的Cronbach’s α系数为：知识维度为0.944，态度维度为0.840，行为维度为0.920。折半信度为0.894，重测信度为0.756，问卷的总体内容效度评估结果为0.920，各条目的内容效度为0.933~1.000；聚敛效度理想，区分效度理想。问卷采用Likert 5级评分法，知识维度全部为正向评分，从“完全不同意”至“完全同意”对应1~5分，总分12~60分；信念维度设有正向评分和反向评分，正向评分从“完全不同意”到“完全同意”计1~5分，反向评分从“完全不同意”到“完全同意”计5~1分，总分10~50分；行为维度全部为正向评分，从“完全不同意”至“完全同意”对应1~5分，总分10~50分。问卷总分为32~160分，分数越高，说明患者对LARS知信行水平越好［12-13］。
1.3　调查方法
本研究采用问卷收集法，选取符合纳排标准的患者进行沟通，取得配合并签署知情同意书后进行问卷收集。对参与数据收集的研究人员进行统一培训，模拟访问和预调查访问，使其熟悉调查流程和问卷内容，掌握正确的调查方法和数据记录方式，提高数据收集的准确性和一致性，培训合格后进入正式问卷调查。因本研究问卷中涉及的问卷内容较为专业，为保证问卷回收质量，本研究中疾病诊断的相关信息来自病历系统收集，患者一般情况资料、主观感受评价内容等由患者本人或直接照护者提供，由研究小组成员通过电话访问获取，所有问卷内容一次电话访问即可完成，时间在10~15 min内。研究者采用统一的指导语，一对一进行收集，每个问题复述答案确认无误、检查无漏项后当场回收，确保问卷真实有效。共发放问卷274例，其中27例患者明确拒绝本研究问卷随访，最终247例患者随访成功，问卷随访回收率为90.15%。
1.4　统计学方法
采用SPSS 26.0软件进行统计分析。服从正态分布的计量资料采用x¯±s描述，组间比较采用独立样本t检验或单因素方差分析；计数资料用例（%）表示，组间比较采用χ2检验；相关性分析采用Pearson相关分析；采用R Studio软件进行随机森林模型分析，以依从性评分作为因变量，将单因素分析和相关性分析中差异有统计学意义的变量纳入随机森林模型，得到变量的重要性排序结果，采用LASSO回归获得最佳惩罚参数λ值所在的最优影响因素进行变量筛选，将筛选出的变量运用多重线性回归进行多因素分析。以P<0.05为差异有统计学意义。
2　结果
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2.1　247名患者预防LARS盆底肌训练依从性、知信行水平、自我效能评分情况
247名直肠癌预防性造口患者预防LARS盆底肌训练依从性总分为（14.52±4.18）分；盆底肌训练自我效能总分为（1 034.13±196.27）分、条目均分为（60.82±11.53）分；预防LARS知信行总分为（100.89±28.55）分，其中知识维度为（35.51±10.92）分、条目均分为（2.96±0.91）分，信念维度为（37.51±9.28）分、条目均分为（3.75±0.93）分，行为维度为（27.87±12.26）分、条目均分为（2.77±1.23）分。
2.2　预防LARS盆底肌训练依从性评分的单因素分析
247名直肠癌预防性造口患者预防LARS盆底肌训练依从性总分比较：单因素分析结果显示，不同年龄、居住地、合并基础疾病、主要照护者、文化程度、肿瘤位置、造口还纳时间、放化疗的患者预防LARS盆底肌训练依从性得分比较差异有统计学意义（P<0.05），见表1。
2.3　盆底肌训练依从性、知信行水平、自我效能评分的相关性分析
Pearson相关性分析结果显示，盆底肌训练依从性得分与盆底肌训练自我效能、预防LARS知信行总分均呈正相关（P<0.01），见表2。
2.4　盆底肌训练依从性影响因素的筛选
2.4.1　变量重要性排序
以依从性得分作为因变量，将单因素分析和相关性分析中有统计学意义的变量作为自变量纳入随机森林模型，随机森林模型的变量赋值情况见表3。结果显示，变量重要性由高到低依次为盆底肌训练自我效能、知信行总分、文化程度、主要照护者、肿瘤位置、造口还纳时间、放化疗、年龄、合并其他慢性疾病、居住地（图1）。
2.4.2　变量筛选
根据变量重要性排序结果，利用R软件中的glmnet函数对单因素分析和相关性分析中有统计学意义的10个变量进行LASSO回归（图2、3）。结果显示，当λ值为2.293时误差最小，所对应的影响因素数目为7个。因此，将排名居前7位的变量（盆底肌训练自我效能、知信行总分、文化程度、主要照护者、肿瘤位置、造口还纳时间、放化疗）纳入多重线性回归分析。
2.5　直肠癌预防性造口患者盆底肌训练依从性影响因素的多重线性回归分析
以依从性得分作为因变量，以随机森林模型筛选出的重要性居前7位的变量为自变量，进行多重线性回归分析，自变量赋值情况和随机森林模型自变量赋值情况一致。为确保模型稳定性，先进行共线性诊断，计算自变量间的相关系数矩阵，共线性诊断结果显示，所有自变量的方差膨胀因子（variance inflation factor，VIF）值均<5，表示7个变量不存在多重共线性问题，模型结果可靠（表4）。多重线性回归分析结果显示，盆底肌训练自我效能、知信行总分、造口还纳时间、放化疗是直肠癌预防性造口患者盆底肌训练依从性的独立影响因素（P<0.05，表5）。
3　讨论
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3.1　直肠癌预防性造口患者对于预防LARS盆底肌训练的依从性较低
本研究结果显示，247名直肠癌预防性造口患者预防LARS盆底肌训练依从性总分整体处于中等水平。这一结果反映了虽然患者对术后康复训练具备基本认知，但临床实践中仍存在显著的依从性提升空间。从分值特征分析，均值14.52分与标准差4.18分，表明不同患者的依从性呈现两极分化趋势，一些患者能够积极配合训练方案，但仍有部分患者存在不同程度的执行障碍。值得注意的是，中等水平的依从性可能对预防LARS的效果形成限制。LARS的发生与盆底肌肉功能损伤密切相关，规律的盆底肌训练可通过增强肌肉收缩力、改善控便能力降低发病风险［5-7］。但依从性不足可能导致训练强度、频率或持续时间未达干预标准，难以实现预期的康复目标［1］。结合临床实践，直肠癌预防性造口患者常面临生理与心理的双重挑战，造口导致的躯体不适、排便习惯改变、自我形象认同障碍等，均可能削弱患者坚持盆底肌训练的动力。此外，盆底肌训练本身具有长期性、隐蔽性特点，缺乏实时监督与反馈，容易因短期效果不显著或训练疲劳而产生懈怠，常与患者对训练必要性的认知不足、医疗指导不充分、家庭支持薄弱等因素相关［14］。
3.2　预防LARS盆底肌训练的依从性受到多种因素的影响
本研究显示，直肠癌预防性造口患者盆底肌训练自我效能整体处于中等水平，结合依从性的关联性分析，可推断自我效能的个体差异是影响依从性的核心心理因素［15］。这一结论符合社会认知理论中“效能信念驱动行为”的机制［16］。高自我效能患者更善于将训练任务内化为可掌控目标，通过制定计划、利用工具支持和建立反馈循环来维持训练持续性；而低效能者易受躯体不适和短期效果滞后的干扰，产生行为退缩，在一些特殊情境下出现执行困境，如时间管理、动力维持等具体场景的信心不足。因此，可以基于患者知识赋权理论［17］，采用分阶段目标设定降低行为启动门槛、生物反馈技术提供可视化动作矫正、同伴支持强化成功经验积累等方法，利用“微成功”累积模式弥合患者的执行信心缺口，促进健康行为的长期维持。
本研究基于知信行理论，证实了预防LARS的知信行水平与盆底肌训练依从性呈显著正相关。研究发现，知识维度短板明显，患者对LARS机制和盆底肌训练相关认知不足导致在行动上的偏差［18-19］；信念转化存在阈值效应，高信念者能将训练内化为日常优先事项，而低信念者易陷入“无症状即无效”的认知误区［20］；行为执行断层突出，反映出知而不行的普遍困境，患者延续护理的居家监督缺失和短期效果延迟可能是主要障碍。这些发现提示可以通过精准化知识宣教填补认知空白，采取动机性访谈促进信念内化［21］，以及借助智能化行为支持等方法破解执行惰性。本研究结果为构建“知识赋能-信念固着-行为落地”的阶梯式干预策略提供了实证依据［22-24］，未来需进一步验证各维度的中介效应及动态干预的长期效果。
本研究结果显示，造口还纳时间作为直肠癌预防性造口患者术后康复的关键节点［25］，与盆底肌训练依从性也呈现显著正向关联，即还纳时间越短，患者依从性越好。从生理层面来看，尽早还纳造口的患者肠道功能恢复快、并发症少，躯体疼痛、造口渗漏等训练干扰因素减少。在心理层面上，患者对恢复生理常态的迫切期待形成其明确的行为驱动力，而延迟还纳造口容易诱发训练无效的认知惰性。对于医护人员从目标管理角度来说，将训练与造口还纳前功能储备需求绑定，通过短期可见性目标可以增强患者的执行承诺，据此优化临床路径，强化早期训练介入，结合造口还纳节点制定阶梯式目标［26-27］，并通过定期随访强化生理恢复与训练效果的正向关联［28-30］，对延迟还纳者则需针对性开展认知干预，重塑训练价值认知，降低负性心理对依从性的影响。
本研究结果显示，合并放化疗作为直肠癌综合治疗的重要组成部分［31］，对盆底肌训练依从性产生显著负向影响，这可能是由于放疗所致的盆底组织水肿、纤维化及放射性肠炎，加剧训练时的局部酸痛或排便异常［32］，而化疗引发的乏力、恶心、骨髓抑制等全身反应，直接降低患者体能储备，导致训练频率与强度下降［33］。长周期治疗带来的频繁医疗接触打乱生活节奏，叠加“治疗优先”认知偏差，形成“副作用-放弃-信心衰减”负向循环。提示医护人员在干预时需结合治疗阶段动态调整，化疗间期采用短时高频训练维持肌耐力，放疗期聚焦功能性动作（如咳嗽时自主收缩），同步整合营养支持、心理干预，纠正“训练加重不适”误区［34-36］，将训练嵌入治疗日程，基于训练周期建立依从性模型，优化精准康复方案。
3.3　京津冀区域医疗资源配置对依从性模式的潜在影响
本研究作为率先聚焦京津冀地区直肠癌保肛术后患者盆底肌训练依从性的多中心研究，尽管缺乏其他区域的直接对照数据，但其发现仍具有一定提示意义。一方面是优质医疗资源集聚效应：京津冀地区三甲医院集中度居全国前列，其规范化诊疗流程可能提升患者对康复训练的认知水平［37］，但同时也可能产生患者过度依赖院内指导而缺乏居家自主管理能力，这或可解释本研究观察到的“高认知、低执行”现象。京津冀地区虽具备医疗技术优势，但患者自我管理能力未同步提升，提示单纯增加硬件投入无法改善康复结局，需依据患者个体不同背景、不同治疗阶段等因素，制定科学有效的个性化康复训练方案，并且同步构建“医院-社区-家庭”三级行为支持网络以提高训练有效性和依从性。另一方面是跨区域就医流动性差异，北京作为国家医学中心接收大量周边省市复杂病例，可能导致研究队列中晚期肿瘤及多次手术史患者比例高于本地居民基线，此类人群因治疗负担加重更易出现训练中断［38］。可借助京津冀医疗协同发展平台，试点建立跨机构依从性监测系统，为全国性推广提供模式范本［37］。
本研究存在若干方法学局限需予以阐明。便利抽样法虽保障了数据采集效率，但可能引入三级医疗中心选择偏倚，所有病例均来自京津冀地区三甲医院，其收治患者通常具有更高并发症风险与更复杂临床特征，可能导致研究结果难以外推至基层医疗机构或低资源地区。数据时间窗口可能未充分纳入超远期（>1年）造口还纳患者的功能预后数据。纳入标准中“遵医嘱开展盆底肌训练”的要求，已经把未行康复锻炼或未接受到该方面健康教育的群体排除，可能产生依从性选择偏倚［39］。尽管如此，本研究系统描绘了区域范围内三甲医院场景下直肠癌保肛术后造口还纳患者的规范化康复路径，其建立的康复训练衔接模型仍可为区域性诊疗共识提供实证依据。
综上所述，直肠癌预防性造口患者盆底肌训练依从性处于中等水平，医护人员应建立基于提升盆底肌训练自我效能强化行为韧性，依托知信行理论，执行精准性的健康教育干预方案，以造口还纳时间为节点优化康复训练目标管理，并针对放化疗患者实施动态训练适配方案，以提高患者预防LARS盆底肌训练依从性。未来可进一步通过纵向队列研究验证因果关系，结合生物行为学指标开发精准化策略，以切实提升盆底肌训练效果，降低LARS发生风险，优化患者术后康复管理。

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2025年第47卷第14期
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doi: 10.16016/j.2097-0927.202504065
  • 接收时间：2025-04-16
  • 首发时间：2026-10-28
  • 出版时间：2025-07-30
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  • 收稿日期：2025-04-16
  • 修回日期：2025-07-07
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    1解放军总医院：第一医学中心普通外科医学部，北京
    2解放军总医院：卫勤训练中心，北京
    3解放军医学院，北京

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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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