Effect of Pulmonary Rehabilitation on Balance in Persons With Chronic Obstructive Pulmonary Disease

doi:10.1016/j.apmr.2010.06.021

Archives of Physical Medicine and Rehabilitation

Volume 91, Issue 9, September 2010, Pages 1460-1465

Presented to the Ontario Thoracic Society/Ontario Respiratory Care Society, January 27–29, 2010, Toronto, Ontario, Canada and the Canadian Respiratory Health Professionals and Canadian Thoracic Society, April 29–May 1, 2010, Halifax, Nova Scotia, Canada.

https://doi.org/10.1016/j.apmr.2010.06.021 Get rights and content

Abstract

Beauchamp MK, O'Hoski S, Goldstein RS, Brooks D. Effect of pulmonary rehabilitation on balance in persons with chronic obstructive pulmonary disease.

Objectives

To describe within-subject effects of pulmonary rehabilitation (PR) on balance in persons with chronic obstructive pulmonary disease (COPD) and to determine whether any observed changes in balance were associated with change in exercise tolerance or health-related quality of life.

Design

Single-arm longitudinal study.

Setting

Inpatient PR center.

Participants

Subjects with COPD (N=29; mean ± SD age, 69.8±10.3y; forced expiratory volume in 1 second, 46.3%±22.3% predicted; 59% men [n=17]).

Interventions

A standardized 6-week multidisciplinary PR program (exercise training, breathing exercises, education, and psychologic support).

Main Outcome Measures

Balance was assessed using the Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and the Activities-Specific Balance Confidence (ABC) scale. Exercise tolerance was determined from the 6-minute walk test (6MWT), and health-related quality of life from the Chronic Respiratory Questionnaire (CRQ).

Results

Subjects showed small improvements in BBS (2.8±2.8 points; P<.001) and TUG (−1.5±2.4s; P=.003) scores, but not in ABC scores (4.8±15.4 points; P>.05). There was a weak relationship between change in BBS and change in CRQ scores (r=.40; P=.045) and no relationship with change in 6MWT.

Conclusions

PR contributed to minor improvements in balance and had no effect on balance confidence in subjects with COPD. Further work is warranted to determine the optimal intervention for improving balance in this population.

Section snippets

Participants

Consecutive patients (N=38) enrolled in PR were approached for inclusion in the study; 5 did not meet eligibility criteria and 4 patients did not complete the 6-week PR program and were excluded. Therefore, 29 older adults with moderate to severe COPD (FEV₁, 46.3%±22.3% predicted; age, 69.8±10.3y; 59% men [n=17]) completed the study. Subject characteristics are listed in table 1. Patients were eligible to participate in this study if they met the following inclusion criteria: (1) physician

Subjects

Of 29 patients who completed the study, 12 (41%) reported at least 1 fall in the preceding year (table 1). Eight (67%) of the 12 fallers had a score at the 46-point cutoff or lower for risk for falls on the BBS; 6 fallers (50%) had a score at the 16-second cutoff or higher for the TUG. Overall, 11 patients (38%) achieved a score at the 6-point cutoff or lower for risk for falls on the BBS and a score at the 16-second cutoff or higher for the TUG.

PR Outcomes

Statistically significant improvements were found

Discussion

Although reductions in balance constitute an important secondary impairment in patients with COPD,2, 7, 8, 9 to our knowledge, this is the first study to report the effects of PR on measures of balance and fall risk in this population. Although measures of balance showed modest improvements after rehabilitation, the clinical relevance of these improvements is uncertain. In addition, balance confidence, an increasingly measured and targeted construct in fall prevention programs, did not improve

Conclusions

PR was associated with minor changes in results of standard clinical tests of balance and had no effect on balance confidence in patients with COPD. Measures of exercise tolerance and health-related quality of life cannot be used as surrogate measures to derive balance information. These observations emphasize the value of including a balance assessment of patients with moderate and severe COPD, particularly if they have a history of falling. The role of incorporating specific balance training

Acknowledgements

We thank the West Park Healthcare Centre PR staff and patients.

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Effects of pulmonary rehabilitation on fear of falling in Chronic Obstructive Pulmonary Disease (COPD) patients: An observational study
2022, Respiratory Medicine and Research
Citation Excerpt :
The number of subjects needed was 75, but we could analyse only 72 patients, which limits the power of our results. Then, our program lasted only 4 weeks, this time is short compared to other pulmonary rehabilitation programs (Beauchamp,Cochrane Fear of falling) [16,17,18] . And we wonder if the effects obtained after 4 weeks persist over time.
COPD patients have more fear of falling (FOF) in comparison with control population. One major aim of pulmonary rehabilitation (PR) is to maintain physical activity. Studies show that FOF can limit physical activity. The aim of this study was to assess the impact of PR on FOF in patients with COPD.
From January to august 2019, COPD patients (stage 2 to 4) undergoing a 4-weeks PR Program (PRP) at Morlaix Hospital Centre were included in this prospective observational study. The objectives were to assess [1] the impact of PR on FOF, [2] the correlations between evolution of FOF and evolution of parameters usually used during PRP, [3] to determine a MID for FOF. The primary endpoint was the Fall Efficacy Scale-International (FES-I) questionnaire. The secondary endpoints were tests and questionnaires usually used to assess exercise capacity, quality of life, dyspnea, anxiety, depression, and balance.
80 patients were included and 72 were analysed. After the PRP, there was a significant decrease of FOF, with significative decrease of FES-I score (−3.36, p<0.001) CI 95% [−5.1; −1.6]). The evolution of FES-I score was moderately correlated to changes in quality of life (QOL) using CAT (Intra-class Correlation Coefficient (ICC)=0.340, p=0.005) and SGRQ (ICC=0.454, p<0.0001), dyspnea using MMRC (ICC=0.311, p=0.009) and LCADL (ICC=0.396, p=0.001); and weakly correlated to changes in balance (ICC=−0.280, p=0.026). Using the distribution-based analysis, we found a MID between −3.6 to –4.9.
We showed a significant decrease of fear of falling in COPD patients after PRP, correlated with improvement of QOL, balance and decrease of dyspnea. We propose a MID of −4.9 for FES-I.
ClinicalTrials.gov NCT03793452
Pulmonary rehabilitation outcomes in individuals with chronic obstructive pulmonary disease: A systematic review
2022, Annals of Physical and Rehabilitation Medicine
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The agreement for 10% of the abstracts (187 records) reviewed by the 2 independent researchers was almost perfect, with Cohen's kappa 0.866 (95% confidence interval [CI] 0.76–0.97). Of the 267 included studies, 99 were observational studies [4,11–108], 87 were randomized controlled trials [109–195], 66 were quasi-experimental studies [105, 196–260], 9 had experimental designs [51, 261–268], 5 were pilot studies [269–273] and 1 was a mixed-methods study [274]. A total of 43,153 individuals with COPD were included in the studies.
The magnitude of response to pulmonary rehabilitation (PR) is influenced by the selection of outcomes and measures.
This systematic review aimed to review all outcomes and measures used in clinical trials of PR for individuals with chronic obstructive pulmonary disease (COPD).
The review involved a search of Scopus, Web of Knowledge, Cochrane Library, EBSCO, Science Direct and PubMed databases for studies of stable individuals with COPD undergoing PR. Frequency of reporting for each domain, outcome and measure was synthesized by using Microsoft Excel.
We included 267 studies (43153 individuals with COPD). A broad range of domains (n = 22), outcomes (n = 163) and measures (n = 217) were reported. Several measures were used for the same outcome. The most reported outcomes were exercise capacity (n = 218) assessed with the 6-min walk test (n = 140), health-related quality of life (n = 204) assessed with the Saint George's respiratory questionnaire (n = 99), and symptoms (n = 158) assessed with the modified Medical Research Council dyspnoea scale (n = 56). The least reported outcomes were comorbidities, adverse events and knowledge.
This systematic review reinforces the need for a core outcome set for PR in individuals with COPD because of high heterogeneity in reported outcomes and measures. Future studies should assess the importance of each outcome for PR involving different stakeholders.
CRD42017079935
Physiotherapy during and after acute exacerbation of COPD
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Les exacerbations sont des évènements déterminants dans l’évolution et le pronostic de la BPCO. Au décours de ces épisodes, la récupération fonctionnelle n’est pas toujours complète, et le risque d’une nouvelle hospitalisation est élevé, nécessitant une prise en charge par anticipation.
Les conséquences pulmonaires et extrapulmonaires des exacerbations nécessitent une évaluation et une prise en charge globale et individualisée. Par ailleurs, la fonction musculaire et le statut nutritionnel sont des éléments clés de la prise en charge. La réadaptation respiratoire est une stratégie efficace pour prendre en charge ces éléments tout en permettant une approche globale du patient.
L’accès aux programmes de réadaptation est limité. L’identification des freins à l’accès aux programmes représente autant de leviers possibles à explorer. Les stratégies de maintien sur le long terme nécessitent également d’être évaluées.
Le masseur-kinésithérapeute est un acteur majeur dans la prise en charge de la BPCO en per- et post-exacerbation afin d’évaluer le patient, mettre en place un programme de réadaptation individualisé ainsi que pour accompagner le patient sur le long terme dans le maintien d’un style de vie actif et la gestion de sa pathologie chronique.
Exacerbations are major events in the course and prognosis of COPD. Following acute exacerbation of COPD (AECOPD), functional recovery is not always complete and the risk of relapse is high, requiring proactive management.
Pulmonary and extrapulmonary consequences of AECOPD require comprehensive and individualized care. Muscle function and nutritional status are key elements to target. Pulmonary rehabilitation is an effective strategy designed to deal with these aspects and to facilitate a comprehensive, patient-centered approach.
Access to pulmonary rehabilitation programs is limited, and existing barriers need to be more precisely identified as a first step toward their possible removal. Long-term exercise maintenance strategies likewise warrant further study.
The physiotherapist has a major role to assume in per- and post-exacerbation management of people with COPD; it is up to him to assess the patient and to put into place an individualized pulmonary rehabilitation program; it is also up to him to provide long-term support, helping the patient to maintain an active lifestyle while coping with a chronic pathology.
Falls prevalence and risk factors in people with chronic obstructive pulmonary disease: A systematic review
2021, Respiratory Medicine
Falls are frequent in people with chronic obstructive pulmonary disease (COPD) and related to increased morbidity, mortality, and health care costs in older adults. This systematic review aims to synthesise the falls outcomes and to examine risk factors for falls in the COPD literature.
The protocol was registered in the Prospective Register of Systematic Reviews (PROSPERO: CRD42015017257). Searches were updated and operated in five electronic databases in December 2019 for studies reporting falls outcomes and risk factors in people with COPD. Meta-analyses were conducted on the prevalence of fallers and frequent fallers. Quality assessment appraised the risk of bias of included articles.
Twenty-three studies met the eligibility criteria and were retained after the full-text review. In the meta-analyses, the pooled prevalence of COPD fallers was 30% (95%CI 19%–42%), and the pooled prevalence of frequent fallers (≥2 falls in the analysed period of occurrence) was 24% (95%CI 2%–56%). The falls incidence rate in stable COPD varied from 1.17 to 1.49 falls/person-year. Different study methodologies were identified. Age, female gender, falls history, the number of medications, comorbidities, coronary heart disease, use of supplemental oxygen, impaired balance performance and smoking history were risk factors for falls identified in stable COPD.
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2020, Archives of Physical Medicine and Rehabilitation
To systematically review the evidence for balance impairment and effectiveness of interventions on balance in people with chronic obstructive pulmonary disease (COPD).
Four electronic databases (Scopus, CINAHL, PubMed, Cochrane Library databases) were searched from inception until June 30, 2019.
Two reviewers independently searched with keywords focusing on COPD, postural control, and exercise. Cross-sectional studies related to balance and randomized controlled trials (RCTs) related to the effectiveness of exercise intervention on balance outcomes were included.
Two reviewers independently extracted data of balance impairment on participants, exercise training on balance outcome measures. Methodological quality of cross-sectional studies was assessed using the National Institutes of Health (NIH) Quality Assessment Tool. Methodological quality of RCTs was assessed using the Physiotherapy Evidence Database (PEDro) scale and bias was analyzed using the Cochrane risk of bias.
A narrative review with descriptive synthesis was used. Fifteen cross-sectional studies and 4 RCTs met the final inclusion criteria. The quality of 10 cross-sectional studies were rated as moderate to high (NIH score≥7). Most studies demonstrated impaired balance in people with COPD than in people without COPD. The quality of all included RCTs was good to excellent (PEDro score=6-9). One RCT had a low risk of bias. Generally, pulmonary rehabilitation program combined with balance training, Tai Chi, and cycling exercise showed significant improvement in balance in people with COPD.
Impaired balance is evident in people with COPD. Available RCTs suggest that exercise interventions may improve balance performance in COPD patients. However, more research on the effect of exercise interventions on balance in COPD patients is still required.
Effects of land- and water-based exercise programmes on postural balance in individuals with COPD: additional results from a randomised clinical trial
2020, Physiotherapy (United Kingdom)
To investigate the effects of water-based exercise training on postural balance in individuals with chronic obstructive pulmonary disease (COPD), and compare the effects of two similar protocols of land- and water-based exercise programmes on postural balance in this population.
Randomised clinical trial.
University-based, outpatient, physical therapy clinic.
Fifty individuals with COPD.
Participants were assigned at random to the land group (LG; n = 27) or the water group (WG; n = 23), and underwent high-intensity endurance and strength training three times per week for 3 months.
Functional balance was assessed by the timed up and go test (TUG), and static balance was assessed with a force platform in the following conditions: standing with feet hip-width apart and eyes open; standing with feet hip-width apart and eyes closed; standing on a short base; and one-legged stance.
Seventeen subjects completed the intervention in the LG {nine males, mean age 64 [standard deviation (SD) 8] years, mean forced expiratory volume in 1 second (FEV₁) 48 (SD 17) %predicted} compared with 14 subjects in the WG [nine males, mean age 65 (SD 8) years, FEV₁ 51 (SD 15) %predicted]. Water-based exercise training had a positive effect on functional balance [TUG: mean difference −1.17 (−1.93 to −0.41 95% confidence interval) seconds; P = 0.006], whereas static balance remained unaltered for both groups. There was no between-group difference in postural balance after exercise training; however, a higher proportion of participants who had a clinically relevant improvement in the TUG were in the WG (LG 35%, WG 64%; P < 0.001).
Functional balance improved after 3 months of high-intensity exercise training performed in water. Despite the environment, non-specific training seems to be insufficient to improve static balance.
clinicalTrials.gov NCT01691131.

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: Supported by the Ontario Respiratory Care Society; a Canada Research Chair; Canadian Respiratory Health Professionals; the Canadian Institutes of Health Research; and the University of Toronto National Sanitarium Association Chair in Respiratory Rehabilitation Research.

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

: Reprints are not available from the author.

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Original articleEffect of Pulmonary Rehabilitation on Balance in Persons With Chronic Obstructive Pulmonary Disease

Abstract

Objectives

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Participants

Subjects

PR Outcomes

Discussion

Conclusions

Acknowledgements

Chest

Am J Med

Clin Chest Med

Respir Med

Chest

Lancet

Arch Gerontol Geriatr

Chest

Respir Med

Chest

Skeletal muscle dysfunction in chronic obstructive pulmonary diseaseA statement of the American Thoracic Society and European Respiratory Society

Am J Respir Crit Care Med

Measurement of initial N-acetyl aspartate concentration by magnetic resonance spectroscopy and initial infarct volume by MRI predicts outcome in patients with middle cerebral artery territory infarction

Stroke

Self-selected walking velocity for functional ambulation in patients with end-stage emphysema

J Cardiopulm Rehabil

Reductions in functional balance, coordination, and mobility measures among patients with stable chronic obstructive pulmonary disease

J Cardiopulm Rehabil

Static balance is affected following an exercise task in chronic obstructive pulmonary disease

J Cardiopulm Rehabil Prev

Guideline for the prevention of falls in older personsAmerican Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on falls prevention

J Am Geriatr Soc

Interventions for preventing falls in older people living in the community

Cochrane Database Syst Rev

Exercise for improving balance in older people

Cochrane Database Syst Rev

Effective exercise for the prevention of falls: a systematic review and meta-analysis

J Am Geriatr Soc

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: Gold executive summary

Am J Respir Crit Care Med

Validation of a fall-risk screening test, the Elderly Fall Screening Test (EFST), for community-dwelling elderly

Disabil Rehabil

Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease

Thorax

Psychophysical bases of perceived exertion

Med Sci Sports Exerc

Measuring balance in the elderly: validation of an instrument

Can J Public Health

Original article
Effect of Pulmonary Rehabilitation on Balance in Persons With Chronic Obstructive Pulmonary Disease