Effects of body awareness therapy on balance and fear of falling in patients with chronic obstructive pulmonary disease: a randomized controlled trial

Chronic Obstructive Pulmonary Disease (COPD) is an avoidable and manageable respiratory disease that causes ongoing breathing difficulties and limitations in the airways and/or air sacs of the lungs, often due to prolonged exposure to harmful gases or particles [1, 2]. COPD treatment aims to manage the disease, prevent disease progression, and exercise tolerance [2]. The GOLD (Global Initiative for Obstructive Lung Diseases) and other treatment guidelines for chronic lung diseases emphasize that COPD is a systemic disease accompanied by extrapulmonary involvement. These factors adversely affect both the severity of the disease and the prognosis [1‐3]. The most common extrapulmonary comorbidities in COPD are muscle weakness, balance disorders, and an increased risk of falls. [4, 5]. Peripheral muscle weakness, systemic inflammation, physical inactivity, and decreased exercise capacity affect balance in patients with COPD [6‐8]. Clinical studies have shown that patients with COPD have limitations in functional capacity and balance compared to healthy individuals [7, 9, 10]. It has been reported that patients with COPD often experience functional performance deficits that affect their postural stability and balance due to lower extremity muscle weakness, an inability to manage symptoms, a worsening ability to adapt to the disease, and reduced physical activity levels [7, 9, 11]. In a study by Beauchamp et al., it was found that COPD patients had decreased responses to postural perturbations compared to healthy individuals [11]. In a comprehensive study characterizing proprioceptive postural control in COPD, it was found that patients used more ankle muscle proprioceptive signals and less back muscle proprioceptive signals during balance control [12]. Furthermore, achieving successful balance depends not only on motor performance but also on mental awareness, the individual's ability to harmonize with the environment and space, and the effective use of proprioceptive inputs [8, 11, 12]. Increased loss of balance may constitute a potential risk factor for the possibility of falls in patients with COPD [13]. Lower extremity muscle weakness and loss of balance ability are the two main factors that cause falls in COPD patients [13, 14].

Pulmonary rehabilitation (PR) provides minimal gains for extrapulmonary comorbidities such as balance in COPD [15, 16]. Therefore, alternative treatment modalities are needed to increase balance skills and prevent falls. Body Awareness Therapy (BAT) is an alternative method that treats patients holistically and attaches importance to the quality, coordination, and rhythm of movement [17, 18]. Jacques Dropsy, a French exercise instructor and psychotherapist, developed BAT as an alternative method in the early 1970s [19]. It was later adapted to rehabilitation programs by Swedish and Norwegian physiotherapists. The treatment includes proprioceptive exercises that aim to improve movement quality, rhythm, and coordination by focusing on the senses [17]. This holistic approach addresses the physical, psychological, and social aspects of the individual. The treatment program is tailored to the patient's needs and focuses on the body's movements [19, 20]. It includes exercises that enhance body awareness, carefulness, and sense of position. BAT builds upon traditional physiotherapy methods [21]. Breathing exercises, relaxation exercises, sensory awareness development, positioning, body stabilization, rhythm and coordination development, and techniques related to the ability to perform quality exercise with maximum awareness are among the physiotherapy methods used in BAT [21, 22]. Upon reviewing the literature, it is evident that BAT can alleviate pain, fatigue, eating, and sleep issues in various patient groups [17, 19, 20]. Additionally, it can improve exercise quality, coordination, balance, postural control, quality of life, and mind–body integration. BAT has become increasingly popular among health professionals, particularly physiotherapists, in recent years. [19, 22, 23]. It has been widely used and has been shown to have many benefits in the treatment of various medical conditions such as chronic pain, fibromyalgia, osteoarthritis, eating disorders, sexual traumas, coronary artery diseases, congestive heart failure, falls in old age, anxiety, and depression [18‐23].

COPD is a multisystemic disease that can lead to musculoskeletal, cardiac, metabolic, and psychological comorbidities [1]. Comorbid conditions can have a negative impact on the severity of the disease and the prognosis [1, 3]. Recent studies have shown that loss of balance is one of the comorbid conditions in these patients [9, 11, 15]. The incidence of falls is higher in COPD patients, with a 55% increase compared to non-COPD patients [14]. Fear of falling can lead to limitations in daily life, self-care activities, social isolation, introversion, and depression, which can seriously deteriorate the quality of life and negatively affect the disease prognosis [14, 24].

In clinic BAT applications, maintaining postural stability, relaxed breathing, and awareness are crucial for achieving dynamic balance and reducing fear of movement. The exercises and training included in the program focus on how individuals manage their balance and relate to the ground and vertical axis in their environment [21, 22]. Although BAT comprises simple, repetitive movements that preserve the ability to use stability limits, one of its main components is to enable the participant to experience their body and its limits through multiple slow, repetitive movements. This is made possible thanks to the neuroplasticity of the brain. Movement awareness develops through the cortical processing of movement-related information in the brain and the facilitation of proprioceptives [17]. It can improve postural control, balance, and coordination while reducing fear of movement [19, 22]. Increasing awareness of body responses, movement limits, and environmental inputs may reduce the fear of falling in individuals who are confident in their balance ability.

BAT is a method that aims to normalize posture, balance, muscular tension, and stiffness in many conditions. It is a principled movement training technique that emphasizes sensory-motor awareness and movement teaching based on cognitive perception of movement [17, 18]. It can liberate the individual both psychologically and physically by providing awareness. It is anticipated that patients will improve their mind–body-behavior interaction through learned experiences [19]. This may contribute to less energy consumption, higher participation and performance in daily life, and the ability to manage dyspnea, fear of movement, and postural control.

With these features, BAT can improve the ability of patients with COPD to perform their daily living activities with less energy consumption and develop their ability to cope with their disease. This study aimed to investigate the effect of BAT on balance and fear of falling in patients with COPD.

Forty-three patients completed the study. According to the baseline values, while 45.55% of the patients in the BAT + PR group participating in the study were female, this ratio was 38.09% in the PR group (p = 0.625). The mean age of the BAT + PR group was 52.59 ± 7.03 years, and that of the PR group was 53.38 ± 7.17 years (p = 0.717). The severity of the disease examined by the CAT score was found to be 23.95 ± 9.96 in the BAT + PR group. The CAT score of the PR group was found to be 25.14 ± 9.03 (p = 0.685). Information on other demographic characteristics is shown in Table 1.

The primary outcomes of the study are Limits of the Stability (LOS), Modified Clinical Test of Sensory (mCTS), and Fear of Fall (FoF). The groups had no significant difference in any parameter according to the baseline values except muscle strength (p = 0.036) (Table 2).

When the post-treatment values were compared, improvements were observed in all subscales of LOS except Directional Control (DC) (p = 0.956) in the BAT + PR group. There was a significant interaction effect for the groups by time in Reaction Time (RT) (η² = 0.777, large), Movement Velocity (MVL) (η² = 0.789, large), Endpoint Excursion (EPE) (η² = 0.687, large), and Maximal Excursion (ME) (η² = 0.887, large) (Table 3).

When the mCTS scores were examined after the treatment, improvements were observed in static posture skills with eyes open (p < 0.001, η² = 0.679, large) and closed (p < 0.001, η² = 0.705, large) on firm ground in the BAT + PR group. In contrast, improvements that could not be detected in posture skills were observed with eyes open (p = 0.097) and eyes closed (p = 0.500) on foam ground in the BAT + PR group. There was a significant interaction effect for the groups by time in Fear of Fall (FoF) (η² = 0.331, large) (Table 4).

According to the results of the secondary outcomes, the baseline quadriceps strength score was higher in favor of the PR group (Table 2). However, at the end of the study, the muscle strength of the patients in the BAT + PR group increased more and differed from that of the control group (p < 0.001). There was a significant interaction effect for the groups by time in muscle strength (η² = 0.803, large), 6MWT (η² = 0.859, large), and BDS (η² = 0.546, large) (Table 5).

This study is the first randomized controlled study in which BAT was used as an exercise modality in patients with COPD. The most clinically important finding is that BAT combined with PR is superior to PR alone to improve balance, fear of falling, dyspnea, functional capacity, and muscle strength parameters in patients with COPD.

Much of the available literature suggests that BAT is a creative and enjoyable activity, making rehabilitation more interesting for patients; therefore, it increases the motivation of the patients to continue the program [18]. During exercise, the awareness of movement and the interaction between the mind, body, and behavior can be beneficial in regulating the emotional, mental, social, and behavioral factors that impact health. When we look at the literature, although there are various application protocols of BAT; to allow the patient to experience his/her own body reactions, symptoms, and learned movements, it is recommended to be applied one day a week, 1 h a day [18, 20]. BAT was applied to the BAT + PR group once a week for 1 h in this study.

The role of BAT in the development of balance function has been associated with perturbation training, coordinating movement, strengthening muscles, using different sensory systems, and sudden changes in the center of gravity during exercises performed in different positions [27, 32]. The BAT + PR group showed significant improvements in the eyes open parameters of static balance and in all parameters of dynamic balance. Furthermore, the significant interaction effects between groups according to time were high in reaction time, movement velocity, end-point excursion and maximal excursion.

It was observed that BAT provided significantly more improvement in dynamic balance than in static balance. This may be because BAT exercises include exercises with both eyes open and eyes closed in dynamic positions on different surfaces. In the BAT + PR group, there was no significant difference before and after the treatment in the both mCTS test results performed on a foam surface; there was a significant improvement in the results performed on the firm floor. The Partial eta squared results also proved the large interaction effects over time. Kaya et al. showed that dance movement therapy, and Leung et al. showed that Tai Chi increased balance and functional capacity in patients with COPD [33, 34]. Considering the literature, studies showing the effect of alternative treatment methods on extrapulmonary symptoms in COPD are quite limited, and they appear to be effective when applied with PR.

Many studies have determined that the risk of falls is more common in older patients with COPD [13, 14, 24, 35]. Our findings clearly showed that BAT applied together with PR provided a statistically significant and large-effect improvement in fear of falling compared to the PR group. Beauchamp et al. stated that a standardized 6-week multidisciplinary PR program had no effect on balance confidence in individuals with COPD [36]. On the other hand, Berriet et al. reported that Cognitive Behavioral Therapy given with 4-week PR significantly reduced the fear of falling in COPD patients. Interventions lasted six weeks to 12 months and included muscle strengthening, balance, exercise, stretching, walking, relaxation, and cognitive behavioral therapy [37]. Within the scope of our 8-week program, some similar activities were performed, and at the end of our study; balance gains were achieved and the fear of falling was reduced. In this context, our result is compatible with the literature. We think that this decrease is related to the ease of management of the disease with alternative treatments, the reduction of the stress and emotionally negative components caused by the disease by considering not only the physical but also the psychological dimension.

The number of patients did not allow us to make a comparison between balance and fear of falling levels according to COPD stages. We think that future studies can focus on this issue. Our findings may raise the awareness that pulmonary and extrapulmonary outputs are correlated with each other. Additionally, extrapulmonary functions, as well as pulmonary functions, should be evaluated and included in the treatment plan, and alternative therapies for balance impairments and the fear of falling should be added to rehabilitation programs in COPD.

Patients in both the BAT + PR group and PR groups showed a significant improvement in 6MWT distance improvement. When the distance improvements between the groups were compared, the difference was significantly greater and had a large effect in the BAT + PR group. Since body awareness exercises created an aerobic effort, it is not surprising that the experimental group in our study achieved greater improvement in the 6MWT distance. Improving the 6MWT distance with conventional exercise training in COPD is already known and frequently reported in the literature [38‐40].

One of our results showed a significant improvement in the Modified Borg Dyspnea Scale results measured after the 6MWT in both groups. The results of the BAT + PR group were statistically more significant and had a larger effect than those of the PR group. Combining movements with breathing in BAT, learning to perform activities with less energy expenditure with breathing training, and energy conservation techniques may have helped to improve postexercise dyspnea value. Considering the studies examining the effect of alternative treatments applied to patients with chronic obstructive or respiratory pulmonary diseases on dyspnea, practices such as Tai Chi, Yoga, and Mindful Based Therapy integrated into PR significantly improve dyspnea compared to PR alone [34, 41‐43].

Failure to evaluate respiratory functions in this study can be considered a limitation. Spirometric evaluations were not included in this study since the study was carried out during the pandemic period and the risk of transmission.

To our knowledge, this is the first study to evaluate the effect of BAT on balance and fear of falling in patients with COPD. The results of this study show that BAT, in addition to traditional PR, was safe and had significantly clear benefits to increase balance and reduce fear of falling in patients with COPD. We suggest that BAT, an alternative intervention with various exercises appealing to individuals of all ages, should be presented as an alternative option for pulmonary rehabilitation program content for those who find it more enjoyable or motivating than other aerobic exercises and meditative exercise types.