Falls in people with chronic obstructive pulmonary disease: an observational cohort study

Validity of balance and mobility screening tests for assessing fall risk in COPD

People with chronic obstructive pulmonary disease (COPD) have balance impairments and an increased risk of falls. The psychometric properties of short balance tests to inform fall risk assessment in COPD are unknown. Our objective was to determine the validity (concurrent, convergent, and known-groups) of short balance and mobility tests for fall risk screening. Participants with COPD aged ≥ 60 years attended a single assessment. Correlation coefficients described the relationships between the Brief Balance Evaluation Systems Test (Brief BESTest), Single-Leg Stance (SLS), Timed Up and Go (TUG), and Timed Up and Go Dual-Task (TUG-DT) tests, with the comprehensive Berg Balance Scale (BBS), chair-stand test, and measures of exercise tolerance, functional limitation, disability, and prognosis. Independent t-tests or Mann-Whitney U tests were used to examine differences between groups with respect to fall risk. Receiver operating characteristic curves examined the ability of the screening tests to identify individuals with previous falls. A total of 86 patients with COPD completed the study (72.9 ± 6.8 years; forced expiratory volume in 1 second: 47.3 ± 20.3% predicted). The Brief BESTest identified individuals who reported a previous fall (area under the curve (AUC) = 0.715, p = 0.001), and the SLS showed borderline acceptable accuracy in identifying individuals with a fall history (AUC = 0.684, p = 0.004). The strongest correlations were found for the Brief BESTest and SLS with the BBS (r = 0.80 and r = 0.72, respectively) and between the TUG and TUG-DT with the chair-stands test (r = 0.73 and r = 0.70, respectively). The Brief BESTest and SLS show the most promise as balance screening tools for fall risk assessment in older adults with COPD. These tests should be further evaluated prospectively.

Correlation between the Charlson comorbidity index and skeletal muscle mass/physical performance in hospitalized older people potentially suffering from sarcopenia

Background

Sarcopenia is a decrease in skeletal muscle mass, physical performance, and muscle strength in older people. In this study, we aimed to explore the correlation between comorbidity and skeletal muscle mass and physical performance in older people.

Methods

This retrospective study included 168 subjects. Their medical history, physical function, computed tomography (CT) chest scans, and blood tests for nutrition were evaluated. The patients were divided into two groups: (1) a low muscle mass group and (2) a normal muscle mass group. Multivariate analysis of variance was used to compare multiple sets of mean vectors.

Results

Overall, 72.02% of the subjects had a low skeletal muscle index (SMI) and low gait speed. The patients with low skeletal muscle mass and physical performance were older, had more serious comorbidities, and had longer average hospitalization periods and lower albumin and hemoglobin levels. Subjects with a high Charlson comorbidity index (CCI) were more likely to be in the sarcopenic group than in the non-sarcopenic group. In addition, there was a linear correlation between the CCI and SMI (r = − 0.549, P < 0.05), and between the CCI and gait speed (r = − 0.614, P < 0.05). The area under the curve (AUC) value for low skeletal muscle mass with the CCI was 0.879.

Conclusions

We identified an independent association between comorbidity and skeletal muscle mass/physical performance by researching the correlation between the CCI and SMI/gait speed. Our results suggested that the CCI score may have important clinical diagnostic value for sarcopenia.

Subjects With COPD Walk With Less Consistent Organization of Movement Patterns of the Lower Extremity

BACKGROUND

The inherent stride-to-stride fluctuations during walking are altered in the aging population and could provide insight into gait impairments and falls in patients with COPD. Stride-to-stride fluctuations are quantified two ways: variability of the fluctuations (eg, standard deviation), and movement patterns within the fluctuations. Our objective was to investigate stride-to-stride fluctuations by evaluating the variability and movement patterns of lower limb joints in subjects with COPD compared to subjects without COPD as control subjects.

METHODS

In this cross-sectional study, 22 subjects with COPD (age 63 ± 9 y; FEV₁ 54 ± 19% predicted) and 22 control subjects (age 62 ± 9 y; FEV₁ 95 ± 18% predicted) walked for 3 min on a treadmill while their gait was recorded. The amount of variability (ie, standard deviation and coefficient of variation) and movement patterns (ie, predictability and consistency in organization) were quantified for the range of motion and joint angle of the hip, knee, and ankle, at 3 walking speeds (ie, self-selected, fast, and slow). General linear mixed models were used for analysis.

RESULTS

Control subjects had more consistent organization of the hip and knee joint movement patterns compared to subjects with COPD (P = .02 and P = .02, respectively). Further, control subjects adapted to speed changes by demonstrating more consistent organization of movement patterns with faster speeds, whereas subjects with COPD did not. At the fast walking speed, subjects with COPD demonstrated less consistent organization of knee and hip joint movement patterns as compared to control subjects without COPD (P = .03 and P = .005, respectively). The amount of variability did not differ between groups.

CONCLUSIONS

Although subjects with COPD did not demonstrate decreased amount of variability, their hip and knee joint movement patterns were less consistent in organization during walking. Reduced consistency in organization of movement patterns may be a contributing factor to falls and mobility problems experienced by patients with COPD.

Exercise Training Modalities for People with Chronic Obstructive Pulmonary Disease

Exercise training confers health benefits for people with chronic obstructive pulmonary disease (COPD). This article reviews the evidence for several exercise training modalities shown to be beneficial among individuals with COPD. These modalities include aerobic, resistance, nonlinear periodized, upper limb and balance training, as well as yoga, Tai Chi, inspiratory muscle training, whole body vibration training and neuromuscular electrical stimulation. The literature pertaining to each modality was critically reviewed, and information on the rationale, mechanism(s) of action (where known), benefits, and exercise prescription is described to facilitate easy implementation into clinical practice.

A TUG Value Longer Than 11 s Predicts Fall Risk at 6-Month in Individuals with COPD

Risk of a fall is increased in individuals with chronic obstructive pulmonary disease (COPD), and is usually evaluated using the Berg Balance Scale (BBS), but this is difficult to perform in everyday clinical practice. We aimed to prospectively predict short-term fall recurrence in COPD patients using a predetermined cut-off value of the Timed Up and Go test (TUG). In stable COPD patients, we collected self-reported records of the number of falls in the previous year, and measured TUG and BBS scores for each individual. Records of fall recurrence were obtained prospectively at 6-months after the initial evaluation. Among the 50 patients recruited, 23 (46%) had at least one fall during the past year. The optimal diagnosis value for the TUG to detect a fall was 10.9 s with a sensitivity of 100% and a specificity of 97%. A cut-off of 11 s predicted fall recurrence with high sensitivity and specificity (93% and 74%, respectively). The TUG as well as the BBS score detected fallers, and a cut-off value of 11 s predicted fall recurrence. TUG could be easily incorporated into the scheduled functional evaluations of COPD patients, could predict the risk of a fall and when appropriate, could guide specific balance training exercises to prevent fall.

Epidemiology of falls and fall-related injuries among middle-aged adults with kidney disease

PURPOSE

Comorbidities, such as kidney disease (CKD), increase the likelihood of falls and fall-related injuries. Despite the focus of most research in this population on older adults, falls are a significant cause of injury throughout adulthood. Therefore, we aimed to describe the epidemiology of falls in middle-aged adults with kidney diseases.

METHODS

We analyzed falls and fall-related injuries among middle-aged adults (45-65 years old) with and without CKD included in the 2014 Behavioral Risk Factor Surveillance System (BRFSS) utilizing multivariate logistic regression and complex sample survey data analysis procedures.

RESULTS

Middle-aged adults with CKD were more likely to suffer a fall (2.30, 95% CI 2.07-2.55) and a fall-related injury (1.54, 95% CI 1.32-1.80) compared to those without CKD. However, only the increased likelihood for falls remained significant after correction for multiple demographic, health, lifestyle, and comorbid conditions (AOR 1.22, 95% CI 1.08-1.39). Among adults with CKD, general health status, smoking, and total comorbidity scores were significant predictors of falls and fall-related injuries (p < 0.05 for all). Furthermore, individual comorbidities such as COPD, asthma, depressive disorders, stroke, and arthritis also predicted falls and fall-related injuries (p < 0.05 for all).

CONCLUSION

Middle-aged adults with CKD were more likely than those without CKD to fall and suffer a fall-related injury. However, injury risk did not remain elevated after accounting for differences between groups. The presence of comorbidities, especially depressive disorders, was associated with increased odds for falls and fall-related injuries. Given the high prevalence of depression among adults with CKD, the relationship between depression and falls warrants further examination.

Exercise Performance as a Predictor for Balance Impairment in COPD Patients

Background and objective: Six-minute walk test (6-MWT) is a widely used test for assessing exercise performance in chronic obstructive pulmonary (COPD). However, the association between reduced walking distance and balance impairment in COPD has not been directly investigated. Therefore, the aim of this study was to identify exercise performance as a predictor for balance impairment in COPD. Materials and Methods: The cross-sectional study was conducted at a single visit involving stable COPD patients in Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand from November 2015 to October 2017. The 6-MWT was measured for in all subjects. The prognostic confounding factors were also collected for all subjects. Balance test was measured using the Berg Balance Scale (BBS) and the Timed Up and Go (TUG) test. A cut-off score of BBS < 46 and/or the TUG ≥ 13.5 s was classified as balance impairment. Multivariable logistic regressions were performed to identify the six-minute walk distance (6-MWD) as a predictor for balance impairment in COPD. Results: Of the 176 COPD subjects assessed for eligibility, 118 COPD patients were enrolled including 86 males (72.9%) with a mean age of 73.5 ± 8.1 years. Thirty-three (28.0%) cases were classified with a balance impairment. The 6-MWD < 300 m was the predictor of balance impairment in COPD with an adjusted risk ratio of 10.10 (95%CI; 2.87, 35.61, p-value < 0.001). Conclusions: The 6-MWT is not only useful for evaluation of exercise performance, but also for prediction of balance impairment in patients with COPD. Our study suggests that the 6-MWD < 300 m is an important risk factor for balance impairment in COPD.

Pulmonary Rehabilitation in the Management of Chronic Lung Disease

Pulmonary rehabilitation is a core component of management of patients with chronic lung disease that have exercise or functional limitations. Causes of these limitations are manifold but include loss of skeletal muscle mass, power and endurance, diminished respiratory capacity owing to respiratory muscle weakness, inefficient gas exchange, and increased work of breathing, and impaired cardiovascular functioning. Besides physical limitations, patients with chronic lung disease have high rates of depression and anxiety leading to social isolation and increased health care use. Pulmonary rehabilitation uses a comprehensive and holistic approach that has been shown to ameliorate most effects of chronic lung disease.

Balance Measures Over 12 Months in Individuals With Chronic Obstructive Pulmonary Disease

PURPOSE

To describe balance for 12 mo in people with chronic obstructive pulmonary disease (COPD).

METHODS

Individuals with COPD completed the Berg Balance Scale (BBS), the Balance Evaluation Systems Test (BEST), and the Activities-Specific Balance Confidence (ABC) scale before pulmonary rehabilitation (PR), post-PR and at 3, 6, and 12 mo. If an acute exacerbation of COPD (AECOPD) occurred, balance measures were repeated after 7 d and 1 mo. Descriptive data are displayed for balance measures at 5 time-points (pre-PR, post-PR, 3 mo, 6 mo, and 12 mo) in those without exacerbations. The outcome score at 7 d and 1 mo post-AECOPD was compared with the assessment closest to the AECOPD.

RESULTS

A total of 42 patients were recruited and 32 patients (17 male; mean age ± standard deviation = 68.5 ± 9.9 yr; FEV1 % predicted =38 ± 15%) completed balance measures post-PR. Seventeen, 11, and 6 patients, who did not exacerbate, completed balance measures at 3, 6, and 12 mo, respectively, with no overall change in balance measures over time. Of 32 patients, 15 experienced an AECOPD and of these, 8 and 11 completed measures at 7 d and 1 mo, respectively. Balance declined from baseline to 7 d (BBS, P = .010; BEST, P = .002) and to 1 mo post-AECOPD (BBS, P = .035). Balance recovered from 7 d to 1 mo post-AECOPD but did not return to baseline levels (BBS, P = .045; BEST, P = .006). There were no changes in balance confidence post-AECOPD.

CONCLUSIONS

Balance remained stable over 12 mo after completion of PR in those who remained exacerbation-free. The impact of an AECOPD on measures of balance persisted after 1 mo.

New evaluation of trunk movement and balance during walking in COPD patients by a triaxial accelerometer

Background

Individuals with COPD may experience ambulatory difficulty due to both effort intolerance arising from respiratory dysfunction and impaired balance control during walking. However, the trunk movement during walking has not been evaluated or adjusted for patients with COPD. The Lissajous index (LI) visually and numerically evaluates the left–right symmetry of the trunk movement during walking and is useful in clinical practice. In COPD patients, the LI is used as an indicator of the left–right symmetry of the trunk during walking. Here, we used the LI to evaluate the symmetry of COPD patients based on bilateral differences in mediolateral and vertical accelerations, and we investigated the correlation between the patients’ symmetry evaluation results and their physical function.

Patients and methods

Sixteen stable COPD patients (all males; age 71.3±9.2 years) and 26 healthy control subjects (15 males; age 68.2±6.9 years) participated in this study. They performed the 10-minute walk test at a comfortable gait speed wearing a triaxial accelerometer, and we measured their trunk acceleration for the evaluation of symmetry. Motor functions were also evaluated in the patients with COPD.

Results

The average mediolateral bilateral difference and LI values of the COPD patients were significantly larger than those of the healthy subjects. The COPD patients’ LI values were significantly correlated with their static balance.

Conclusion

The LI measured using a triaxial accelerometer during walking is useful in balance assessments of patients with COPD.

Inter-rater and intra-rater reliability of the Brief-BESTest in people with chronic obstructive pulmonary disease

Objective:

To investigate the inter-rater and intra-rater reliability of the Brief Balance Evaluation System Test (Brief-BESTest) in people with chronic obstructive pulmonary disease and its correlation between the Brief-BESTest score and lung function, functional exercise capacity, functional lower limb strength, and fear of falling.

Design:

Prospective, single-group, observational study.

Setting:

Outpatient pulmonary rehabilitation program.

Subjects:

People with chronic obstructive pulmonary disease who were attending a pulmonary rehabilitation program.

Intervention:

Participants performed three Brief-BESTests on two separate days, assessed by two independent physiotherapists. Participants also performed a lung function test, two 6-minute walk tests, the five sit-to-stand test and completed the Fall Efficacy Scale International questionnaire.

Results:

Thirty participants (mean (SD) age was 72 (7), forced expiratory volume in 1 second % predicted was 47 (16%), and baseline 6-minute walk distance was 427 (90) meters) completed the study. The interclass coefficients of the inter-rater and intra-rater reliability were 0.86 and 0.96, respectively. The Brief-BESTest score was moderately correlated with the 6-minute walk distance ( r = 0.49, P < 0.01) and the five sit-to-stand test time ( r =−0.54, P < 0.01). No adverse events were reported after the completion of 90 tests in this study.

Conclusion:

The Brief-BESTest was shown to have good inter- and intra-rater reliability for measuring balance in people with chronic obstructive pulmonary disease. A moderate correlation was demonstrated between the Brief-BESTest balance score with functional exercise capacity and functional lower limb strength in this population.

Effect of adding neuromuscular electrical stimulation training to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: randomized clinical trial

OBJECTIVE:

To investigate the effectiveness of neuromuscular electrical stimulation added to pulmonary rehabilitation on walking tolerance and balance in patients with chronic obstructive pulmonary disease (COPD).

DESIGN:

Randomized clinical trial.

SETTING:

Outpatient, Faculty of Medicine of Sousse, Tunisia.

SUBJECTS:

A total of 45 patients with COPD were assigned to an intervention group ( n = 25) or a control group ( n = 20).

INTERVENTIONS:

The intervention group underwent a neuromuscular electrical stimulation added to pulmonary rehabilitation, and the control group underwent only a pulmonary rehabilitation, three times per week during six months.

MAIN MEASURES:

Measures were taken at baseline and after six months of training. A stabilometric platform, time up and go, Berg balance scale tests, 6 minute walking test, and the maximal voluntary contraction were measured.

RESULTS:

In the intervention group, an increase in an exercise tolerance manifested by a longer distance walked in 6 minute walking test 619.5 (39.6) m was observed in comparison to the control group 576.3 (31.5) m. The values of the time up and go, Berg balance scale, and maximal voluntary contraction in the intervention group at follow-up were significantly higher than those in the control group ( P  = 0.02, P  = 0.01, P  = 0.0002, respectively). The center of pressure in the mediolateral and in the anteroposterior directions, as well as the center of pressure area was significantly more improved in open eyes and closed eyes in the intervention group compared to the control group ( P < 0.001).

CONCLUSION:

The neuromuscular electrical stimulation added to pulmonary rehabilitation group benefited from better walking tolerance and greater balance improvement than the only pulmonary rehabilitation.

Patients with Chronic Obstructive Pulmonary Disease Walk with Altered Step Time and Step Width Variability as Compared with Healthy Control Subjects

RATIONALE

Compared with control subjects, patients with chronic obstructive pulmonary disease (COPD) have an increased incidence of falls and demonstrate balance deficits and alterations in mediolateral trunk acceleration while walking. Measures of gait variability have been implicated as indicators of fall risk, fear of falling, and future falls.

OBJECTIVES

To investigate whether alterations in gait variability are found in patients with COPD as compared with healthy control subjects.

METHODS

Twenty patients with COPD (16 males; mean age, 63.6 ± 9.7 yr; FEV₁/FVC, 0.52 ± 0.12) and 20 control subjects (9 males; mean age, 62.5 ± 8.2 yr) walked for 3 minutes on a treadmill while their gait was recorded. The amount (SD and coefficient of variation) and structure of variability (sample entropy, a measure of regularity) were quantified for step length, time, and width at three walking speeds (self-selected and ±20% of self-selected speed). Generalized linear mixed models were used to compare dependent variables.

RESULTS

Patients with COPD demonstrated increased mean and SD step time across all speed conditions as compared with control subjects. They also walked with a narrower step width that increased with increasing speed, whereas the healthy control subjects walked with a wider step width that decreased as speed increased. Further, patients with COPD demonstrated less variability in step width, with decreased SD, compared with control subjects at all three speed conditions. No differences in regularity of gait patterns were found between groups.

CONCLUSIONS

Patients with COPD walk with increased duration of time between steps, and this timing is more variable than that of control subjects. They also walk with a narrower step width in which the variability of the step widths from step to step is decreased. Changes in these parameters have been related to increased risk of falling in aging research. This provides a mechanism that could explain the increased prevalence of falls in patients with COPD.

Fall-Risk-Increasing Drugs: A Systematic Review and Meta-analysis: III. Others

BACKGROUND AND OBJECTIVE

The use of psychotropic medication and cardiovascular medication has been associated with an increased risk of falling. However, other frequently prescribed medication classes are still under debate as potential risk factors for falls in the older population. The aim of this systematic review and meta-analysis is to evaluate the associations between fall risk and nonpsychotropic and noncardiovascular medications.

METHODS AND DESIGN

A systematic review and meta-analysis. A search was conducted in Medline, PsycINFO, and Embase. Key search concepts were "falls," "aged," "medication," and "causality." Studies were included that investigated nonpsychotropic and noncardiovascular medications as risk factors for falls in participants ≥60 years or participants with a mean age ≥70 years. A meta-analysis was performed using the generic inverse variance method, pooling unadjusted and adjusted odds ratio (OR) estimates separately.

RESULTS

In a qualitative synthesis, 281 studies were included. The results of meta-analysis using adjusted data were as follows (a pooled OR [95% confidence interval]): analgesics, 1.42 (0.91-2.23); nonsteroidal anti-inflammatory drugs (NSAIDs), 1.09 (0.96-1.23); opioids, 1.60 (1.35-1.91); anti-Parkinson drugs, 1.54 (0.99-2.39); antiepileptics, 1.55 (1.25-1.92); and polypharmacy, 1.75 (1.27-2.41). Most of the meta-analyses resulted in substantial heterogeneity that did not disappear after stratification for population and setting in most cases. In a descriptive synthesis, consistent associations with falls were observed for long-term proton pump inhibitor use and opioid initiation. Laxatives showed inconsistent associations with falls (7/20 studies showing a positive association).

CONCLUSION

Opioid and antiepileptic use and polypharmacy were significantly associated with increased risk of falling in the meta-analyses. Long-term use of proton pump inhibitors and opioid initiation might increase the fall risk. Future research is necessary because the causal role of some medication classes as fall-risk-increasing drugs remains unclear, and the existing literature contains significant limitations.

Spatiotemporal gait characteristics in patients with COPD during the Gait Real-time Analysis Interactive Lab-based 6-minute walk test

Background and aim

Overground gait assessment is limited by the analysis of multiple strides or both spatiotemporal gait characteristics, while fixed speed treadmill walking restricts natural gait speed variations. The Gait Real-time Analysis Interactive Lab (GRAIL)-based 6-minute walk test (6MWT) enables 3D motion analysis and self-paced treadmill walking, and could provide insight in gait alterations in patients with chronic obstructive pulmonary disease (COPD). The aim of this study is to compare spatiotemporal gait characteristics between patients with COPD and healthy elderly during the GRAIL-based 6MWT.

Materials and methods

Eighty COPD patients (60% male; 62±7 years; FEV₁:56±19% predicted) and 38 healthy elderly (63% male; 62±6 years; FEV₁:119±17% predicted) performed two GRAIL-based 6MWTs. Mean differences and coefficient of variation of spatiotemporal gait characteristics were calculated using the trial with the largest walk distance. Sub-analyses were conducted to account for walking speed differences between groups, and muscle strength and COPD severity within the patient group.

Results

COPD patients showed increased temporal gait characteristics, decreased stride and step lengths, and increased gait variability compared to healthy elderly (p<0.01). Stride length variability remained increased in COPD after correction for walking speed (MD:0.98%, CI:0.36–1.61, p = 0.003). Reduced quadriceps strength did not translate into altered gait characteristics, while COPD severity is associated with stride time (left MD:-0.02s, CI:-0.04–0.01, p = 0.003; right MD:-0.02s, CI:-0.04–0.01, p = 0.003).

Discussion

COPD patients performed the GRAIL-based 6MWT differently compared to healthy elderly. Further research should use other variability measures to investigate gait characteristics in COPD, to assess subtle alterations in gait and to enable development of rehabilitation strategies to improve gait, and possibly balance and fall risk in COPD. Other lower limb muscle groups should be considered when investigating gait alterations in COPD.

Conclusion

COPD patients have different gait characteristics compared to healthy elderly. Independent of walking speed, COPD patients demonstrate increased stride length variability during the GRAIL-based 6MWT compared to healthy elderly.

Pulmonary Rehabilitation With Balance Training for Fall Reduction in Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Controlled Trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. A growing body of evidence shows that individuals with COPD have important deficits in balance control that may be associated with an increased risk of falls. Pulmonary rehabilitation (PR) is a key therapeutic intervention for individuals with COPD; however, current international guidelines do not include balance training and fall prevention strategies.

OBJECTIVE

The primary aim of this trial is to determine the effects of PR with balance training compared to PR with no balance training on the 12-month rate of falls in individuals with COPD. Secondary aims are to determine the effects of the intervention on balance, balance confidence, and functional lower body strength, and to estimate the cost-effectiveness of the program.

METHODS

A total of 400 individuals from nine PR centers across Canada, Europe, and Australia will be recruited to participate in a randomized controlled trial. Individuals with COPD who have a self-reported decline in balance, a fall in the last 2 years, or recent near fall will be randomly assigned to an intervention or control group. The intervention group will undergo tailored balance training in addition to PR and will receive a personalized home-based balance program. The control group will receive usual PR and a home program that does not include balance training. All participants will receive monthly phone calls to provide support and collect health care utilization and loss of productivity data. Both groups will receive home visits at 3, 6, and 9 months to ensure proper technique and progression of home exercise programs. The primary outcome will be incidence of falls at 12-month follow-up. Falls will be measured using a standardized definition and recorded using monthly self-report fall diary calendars. Participants will be asked to record falls and time spent performing their home exercise program on the fall diary calendars. Completed calendars will be returned to the research centers in prepaid envelopes each month. Secondary measures collected by a blinded assessor at baseline (pre-PR), post-PR, and 12-month follow-up will include clinical measures of balance, balance confidence, functional lower body strength, and health status. The cost-effectiveness of the intervention group compared with the control group will be evaluated using the incremental cost per number of falls averted and the incremental cost per quality-adjusted life years gained.

RESULTS

Recruitment for the study began in January 2017 and is anticipated to be complete by December 2019. Results are expected to be available in 2020.

CONCLUSIONS

Findings from this study will improve our understanding of the effectiveness and resource uses of tailored balance training for reducing falls in individuals with COPD. If effective, the intervention represents an opportunity to inform international guidelines and health policy for PR in individuals with COPD who are at risk of falling.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02995681; https://clinicaltrials.gov/ct2/show/NCT02995681 (Archived by WebCite at http://www.webcitation.org/6ukhxgAsg).

Association between asthma and falls: A nationwide population-based study

OBJECTIVES

We evaluated the relationship between asthma and falls in Koreans using data from a large population-based cross-sectional survey.

METHODS

Data were obtained from 228,642 participants, of whom 6,372 had asthma, who participated in the 2013 Korean Community Health Survey. We explored the risk of falls after adjusting for sociodemographic factors and comorbidities. Logistic regression was used to identify risk factors for falls in asthmatics. Patients with asthma who had been diagnosed by a physician were included after excluding those who did not respond to the self-reported questionnaire.

RESULTS

In all, 1,733/6,372 (27.1%) asthma patients and 258/788 (32.7%) patients with uncontrolled asthma (who had visited the emergency room because of asthma exacerbation in the prior 12 months) reported histories of falls. In asthmatics, the crude odds ratio (OR) for falls was 1.57 (95% confidence interval [CI]: 1.48-1.67); the OR for falls in the group with uncontrolled asthma was 2.13 (95% CI: 1.83-2.47). The multivariate OR for falls in the asthma group (compared to the non-asthma group) was 1.27 (95% CI, 1.18-1.35) and the OR for falls in the uncontrolled asthma group (again compared to the non-asthma group) was 1.55 (95% CI, 1.32-1.82). Subgroup analysis of the adjusted ORs for falls in asthmatics by age group revealed a significant difference between the presence of asthma and uncontrolled asthma, and falls, in each age group, similar to the relationship evident in the total adult population.

CONCLUSION

Asthma is associated with falls, even after adjusting for sociodemographic and comorbid variables.

Gait abnormalities of COPD are not directly related to respiratory function

STUDY OBJECTIVE

To assess whether gait abnormalities in COPD depend on mere impairment of respiratory function.

METHODS

In 40 patients with COPD at different GOLD stages and 28 controls, we evaluated: forced expiratory volume in 1s (FEV1); partial pressure of oxygen; Mini-Mental State Examination (MMSE); dynamic balance through the Mini-BESTest (MBT); Timed Up and Go (TUG) test without and with dual task counting aloud back by three; 6-min walk test (6MWT); body sway during quiet stance (stabilometry); spatial-temporal variables of gait by a 4-m long sensorized walkway (baropodometry). Lower-limb muscle strength, tendon reflexes, and sensation were also clinically evaluated.

RESULTS

Muscle strength of proximal but not distal muscles was slightly reduced in patients, whereas reflexes and sensation were unaffected. FEV1, partial pressure of oxygen, MMSE, MBT, stabilometry, as well as baropodometry, were abnormal and unrelated to muscle weakness. The time taken to perform the TUG test was increased, and to a larger extent with than without dual task. At baropodometry, variability of step length was increased; abnormalities of gait variables were associated with larger body sway but not with FEV1 or hypoxemia. Gait speed at 6MWT was correlated with MBT score and with FEV1 as well as hypoxemia.

CONCLUSIONS

6MWT findings give a measure of gait disability linked to endurance-related respiratory failure. Gait at baropodometry is associated with impairment of balance, cognitive status and abnormal dual task performance. We suggest that central nervous lesions, presumably of vascular origin, are detrimental to balance and gait in COPD.

Gout Can Increase the Risk of Receiving Rotator Cuff Tear Repair Surgery

BACKGROUND

Gout commonly involves joint inflammation, and clinical epidemiological studies on involved tendons are scant. Rotator cuff tears are the most common cause of shoulder disability, and surgery is one of the choices often adopted to regain previous function.

PURPOSE

To investigate the risk of receiving rotator cuff repair surgery among patients with gout and to analyze possible risk factors to design an effective prevention strategy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors studied a 7-year longitudinal follow-up of patients from the Taiwan Longitudinal Health Insurance Database 2005 (LHID2005). This included a cohort of patients who received a diagnosis of gout during 2004-2008 (gout cohort) and a cohort matched by propensity scores (control cohort). A 2-stage approach that used the National Health Interview Survey 2005 was used to obtain missing confounding variables from the LHID2005. The crude hazard ratio (HR) and adjusted HR were estimated between the gout and control cohorts.

RESULTS

The gout and control cohorts comprised 32,723 patients with gout and 65,446 people matched at a ratio of 1:2. The incidence of rotator cuff repair was 31 and 18 per 100,000 person-years in the gout and control cohorts, respectively. The crude HR for rotator cuff repair in the gout cohort was 1.73 (95% confidence interval [CI], 1.23-2.44; P < .01) during the 7-year follow-up period. After adjustment for covariates by use of the 2-stage approach, the propensity score calibration-adjusted HR was 1.60 (95% CI, 1.12-2.29; P < .01) in the gout cohort. Further analysis revealed that the adjusted HR was 1.73 (95% CI, 1.20-2.50; P < .001) among patients with gout who did not take hypouricemic medication and 2.70 (95% CI, 1.31-5.59; P < .01) for patients with gout aged 50 years or younger.

CONCLUSION

Patients with gout, particularly those aged 50 years or younger and without hypouricemic medication control, are at a relatively higher risk of receiving rotator cuff repair surgery. Strict control of uric acid levels with hypouricemic medication may effectively reduce the risk of rotator cuff repair.

Validity, Reliability, and Ability to Identify Fall Status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in Patients With COPD

BACKGROUND

The Berg Balance Scale (BBS), Balance Evaluation Systems Test (BESTest), Mini-BESTest, and Brief-BESTest are useful in the assessment of balance. Their psychometric properties, however, have not been tested in patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVE

This study aimed to compare the validity, reliability, and ability to identify fall status of the BBS, BESTest, Mini-BESTest, and the Brief-BESTest in patients with COPD.

DESIGN

A cross-sectional study was conducted.

METHODS

Forty-six patients (24 men, 22 women; mean age=75.9 years, SD=7.1) were included. Participants were asked to report their falls during the previous 12 months and to fill in the Activity-specific Balance Confidence (ABC) Scale. The BBS and the BESTest were administered. Mini-BESTest and Brief-BESTest scores were computed based on the participants' BESTest performance. Validity was assessed by correlating balance tests with each other and with the ABC Scale. Interrater reliability (2 raters), intrarater reliability (48-72 hours), and minimal detectable changes (MDCs) were established. Receiver operating characteristics assessed the ability of each balance test to differentiate between participants with and without a history of falls.

RESULTS

Balance test scores were significantly correlated with each other (Spearman correlation rho=.73-.90) and with the ABC Scale (rho=.53-.75). Balance tests presented high interrater reliability (intraclass correlation coefficient [ICC]=.85-.97) and intrarater reliability (ICC=.52-.88) and acceptable MDCs (MDC=3.3-6.3 points). Although all balance tests were able to identify fall status (area under the curve=0.74-0.84), the BBS (sensitivity=73%, specificity=77%) and the Brief-BESTest (sensitivity=81%, specificity=73%) had the higher ability to identify fall status.

LIMITATIONS

Findings are generalizable mainly to older patients with moderate COPD.

CONCLUSIONS

The 4 balance tests are valid, reliable, and valuable in identifying fall status in patients with COPD. The Brief-BESTest presented slightly higher interrater reliability and ability to differentiate participants' fall status.

Relationship between balance and physical activity measured by an activity monitor in elderly COPD patients

Background

Little is known regarding the relationship between balance impairments and physical activity in COPD. There has been no study investigating the relationship between balance and objectively measured physical activity. Here we investigated the association between balance and physical activity measured by an activity monitor in elderly COPD patients.

Materials and methods

Twenty-two outpatients with COPD (mean age, 72±7 years; forced expiratory volume in 1 second, 53%±21% predicted) and 13 age-matched healthy control subjects (mean age, 72±6 years) participated in the study. We assessed all 35 subjects’ balance (one-leg standing test [OLST] times, Short Physical Performance Battery total scores, standing balance test scores, 4 m gait speed, and five-times sit-to-stand test [5STST]) and physical activity (daily steps and time spent in moderate-to-vigorous physical activity per day [MV-PA]). Possible confounders were assessed in the COPD group. The between-group differences in balance test scores and physical activity were analyzed. A correlation analysis and multivariate regression analysis were conducted in the COPD group.

Results

The COPD patients exhibited significant reductions in OLST times (P=0.033), Short Physical Performance Battery scores (P=0.013), 4 m gait speed (P<0.001), five-times sit-to-stand times (P=0.002), daily steps (P=0.003), and MV-PA (P=0.022) compared to the controls; the exception was the standing balance test scores. The correlation and multivariate regression analyses revealed significant independent associations between OLST times and daily steps (P<0.001) and between OLST times and MV-PA (P=0.014) in the COPD group after adjusting for possible confounding factors.

Conclusion

Impairments in balance and reductions in physical activity were observed in the COPD group. Deficits in balance are independently associated with physical inactivity.

Chronic obstructive pulmonary disease phenotypes and balance impairment

BACKGROUND/OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is a respiratory disease that results in airflow limitation and respiratory distress, also having many nonrespiratory manifestations that affect both function and mobility. Preliminary evidence suggests that balance deficits constitute an important secondary impairment in individuals with COPD. Our objective was to investigate balance performance in two groups of COPD patients with different body compositions and to observe which of these groups are more likely to experience falls in the future.

METHODS

We included 27 stable COPD patients and 17 healthy individuals who performed a series of balance tests. The COPD patients were divided in two groups: emphysematous and bronchitic. Patients completed the activities balance confidence scale and the COPD assessment test questionnaire and afterward performed the Berg Balance Scale, timed up and go, single leg stance and 6-minute walking distance test. We analyzed the differences in the balance tests between the studied groups.

RESULTS

Bronchitic COPD was associated with a decreased value when compared to emphysematous COPD for the following variables: single leg stance (8.7 vs 15.6; P<0.001) and activities balance confidence (53.2 vs 74.2; P=0.001). Bronchitic COPD patients had a significantly higher value of timed up and go test compared to patients with emphysematous COPD (14.7 vs 12.8; P=0.001).

CONCLUSION

Patients with COPD have a higher balance impairment than their healthy peers. Moreover, we observed that the bronchitic COPD phenotype is more likely to experience falls compared to the emphysematous phenotype.

Chronic Obstructive Pulmonary Disease Increases the Risk of Hip Fracture: A Nationwide Population-Based Cohort Study

Hip fractures can lead to functional disability and high mortality rates among elderly patients. The aim of this study was to investigate whether chronic obstructive pulmonary disease (COPD) is a risk factor for hip fracture. A retrospective population-based 4-year cohort study was conducted using case–control matched analysis of data from the Taiwan Longitudinal Health Insurance Database 2005 (LHID2005). Patients with a diagnosis of COPD between January 1, 2004 and December 31, 2007 were enrolled. A 2-stage approach and data from the National Health Interview Survey 2005 were applied to adjust for missing confounders in the LHID2005 cohort. Hazard ratios (HRs) and adjusted HRs were estimated hip fracture risk for the COPD. We enrolled 16,239 patients in the COPD cohort and 48,747 (1:3) patients in non-COPD cohort. The hip fracture incidences were 649 per 100,000 person-years in the study cohort and 369 per 100,000 person-years in non-COPD cohort. The hip fracture HR during the follow-up period was 1.78 (P < 0.001) and the adjusted hip fracture HR was 1.57 (P < 0.001) after adjustment for covariates by using the 2-stage approach method. Patients with COPD were at hip fracture risk and fracture-prevention strategies are essential for better quality of care.

Balance Training in Pulmonary Rehabilitation: EFFECTS ON PSYCHOSOCIAL OUTCOMES

PURPOSE

Balance impairment in chronic obstructive pulmonary disease (COPD) is associated with a worsening of quality of life (QOL) as related with fatigue perception, depression, and anxiety. The aim of this study was to examine the effect of balance training included in pulmonary rehabilitation (PR) on QOL, fatigue perception, depression, and anxiety in patients with COPD.

METHODS

Patients were assigned randomly to an intervention or PR-only group. The intervention group underwent balance training 3 times a week for 6 months concurrently with PR. The PR-only group received 6 months of the standard PR program. Quality of life was assessed at the beginning and at the end of the program using the St. George's Respiratory Questionnaire, fatigue using the Multidimensional Fatigue Inventory, and anxiety and depression using the Hospital Anxiety and Depression Scale. Exercise tolerance was determined from the 6-minute walk test.

RESULTS

After the 6 months of the intervention or PR-only, both the intervention (n = 32) and PR-only (n = 30) groups improved their QOL (activity, impact, and total) with a significant intergroup difference (P < .05) after PR. General fatigue, physical fatigue, and reduced activity decreased in both groups with an intergroup difference (P < .05). Anxiety decreased significantly in both groups with a greater change in the intervention group (P < .01). Only the intervention group had an improved depression score at the end of 6 months.

CONCLUSIONS

Balance training added to PR improved health-related QOL, fatigue, and mental health in patients with COPD.

Interpretability of Change Scores in Measures of Balance in People With COPD

BACKGROUND

Balance deficits and an increased fall risk are well documented in individuals with COPD. Despite evidence that balance training programs can improve performance on clinical balance tests, their minimal clinically important difference (MCID) is unknown. The aim of this study was to determine the MCID of the Berg Balance Scale (BBS), Balance Evaluation Systems Test (BESTest), and Activities-Specific Balance Confidence (ABC) scale in patients with COPD undergoing pulmonary rehabilitation.

METHODS

We performed a secondary analysis of data from two studies of balance training in COPD (n = 55). The MCID for each balance measure was estimated using the following anchor and distribution-based approaches: (1) mean change scores on a patient-reported global change in balance scale, (2) optimal cut-point from receiver operating characteristic curves (ROCs), and (3) the minimal detectable change with 95% confidence (MDC95).

RESULTS

Data from 55 patients with COPD (mean age, 71.2 ± 7.1 y; mean FEV1, 39.2 ± 15.8% predicted) were used in the analysis. The smallest estimate of MCID was from the ROC method. Anchor-based estimates of the MCID ranged from 3.5 to 7.1 for the BBS, 10.2 to 17.4 for the BESTest, and 14.2 to 18.5 for the ABC scale; their MDC95 values were 5.0, 13.1, and 18.9, respectively.

CONCLUSIONS

Among patients with COPD undergoing pulmonary rehabilitation, a change of 5 to 7 points for the BBS, 13 to 17 points for the BESTest, and 19 points for the ABC scale is required to be both perceptible to patients and beyond measurement error.

Predictors of All-Cause Mortality in Patients With Severe COPD and Major Depression Admitted to a Rehabilitation Hospital

BACKGROUND

COPD is a major cause of all-cause mortality. We examined predictors of 1-year mortality in patients with severe COPD and major depression after inpatient treatment in a rehabilitation hospital.

METHODS

We screened 898 consecutively admitted patients. Of these, 138 patients received the diagnoses of COPD according to American Thoracic Society Guidelines and major depression by Diagnostic and Statistical Manual of Mental Disorders, 4th edition and signed consent; 67 were randomized to a treatment adherence enhancement intervention and 71 to usual care. We assessed history of falls, dyspnea-related disability, severity of depression, medical burden, and cognitive functioning. Following discharge from inpatient rehabilitation, participants were prospectively followed, and mortality was ascertained over 52 weeks from hospital notes and reports of primary care physicians and relatives.

RESULTS

One-year, all-cause mortality was 22% (31 of 138). Multivariate Cox regression analysis showed that history of falls in the 6 months preceding hospital admission was the strongest predictor of mortality (OR, 3.05; 95% CI, 1.40-6.66; P < .005). Dyspnea during activities (Pulmonary Functional Status and Dyspnea Questionnaire-Modified domain) was also associated with mortality (OR, 1.05; 95% CI, 1.02-1.08; P < .002). Depression severity, medical burden, and cognitive impairment were not predictors of mortality.

CONCLUSIONS

Recent falls and dyspnea during activities identify subgroups of depressed patients with COPD at increased risk for all-cause mortality. These subgroups are in need of clinical attention and follow-up and can serve as targets for prevention research aiming to inform clinical strategies and public health planning.

Risk and clinical predictors of osteoporotic fracture in East Asian patients with chronic obstructive pulmonary disease: a population-based cohort study

INTRODUCTION

Osteoporosis is becoming an impending epidemic in the Asia-Pacific region. The association between risk of osteoporotic fracture (OTPF) and chronic obstructive pulmonary disease (COPD) in East Asian patients is yet to be fully examined. We conducted a nationwide population-based retrospective cohort study of 98,700 patients aged ≥50 years with or without COPD using a national administrative claims dataset.

MATERIALS AND METHODS

The patients were divided into COPD and comparison groups comprising 19,740 and 78,960 patients, respectively. The groups were 1 to 4 matched for age, gender, index date, diabetes mellitus, pre-existing osteoporosis and chronic kidney disease. Information such as the geographic area where southern part represented more sunshine exposure, smoking-related diagnoses, alcohol use disorder, whether there was regular use of inhaled corticosteroids and oral corticosteroids, vitamin D prescriptions, Charlson-Deyo comorbidity index score, and other relevant medical comorbidities were extracted for analysis. They were followed up until OTPF or the end of the year 2013. The outcome measure was an osteoporotic vertebral fracture and other long-bone fractures. A multivariate Cox model was constructed to derive adjusted hazard ratios (aHR) for OTPF with corresponding 95% confidence intervals (CI) after controlling for age, sex, insurance premium category, vitamin D prescription, osteoporosis, and coronary heart disease (CHD). Kaplan-Meier curves of the probability of OTPF-free survival for each cohort were compared using the log-rank test. Patients with OTPF during the first follow-up year were excluded from the overall risk calculation. Contributing factors to the increased risk of OTPF in COPD patients were examined in a sensitivity analysis.

RESULTS

After a total follow-up of 68,743 patient-years for the COPD group and 278,051 patient-years for the matched comparison group, the HR for OTPF was 1.24 (95% CI [1.02-1.51]; P = 0.0322) in COPD patients. The aHR was increased by 30% for vertebral OTPF (aHR = 1.297, 95% CI [1.020-1.649]; P = 0.0339). Differential lag time sensitivity analysis revealed a progressively elevated risk up to 8-fold increase in women (aHR = 8.0 (95% CI [1.81-35.4]; P < 0.01)) during the fifth follow-up year. COPD patients with pre-existing osteoporosis or given vitamin D prescription harbor a sustained increased risk up to the 5th (aHR, 4.1; 95% CI [1.61-10.35]) and third (aHR, 2.97; 95% CI [1.48-5.97]) follow-up year, respectively.

CONCLUSIONS

Our nationwide population-based cohort study demonstrates that East Asian COPD patients aged 50 and beyond do harbor a modestly increased risk for osteoporotic vertebral fractures particularly for those who are female, have pre-existing osteoporosis or require vitamin D prescription.

Balance recovery is compromised and trunk muscle activity is increased in chronic obstructive pulmonary disease

Increased respiration in chronic obstructive pulmonary disease (COPD) requires greater abdominal muscle activation, which may impact on contribution of the trunk to postural control. This study aimed to determine whether recovery of balance from postural perturbations and trunk muscle activity differs in people with and without COPD before and/or after exercise. Electromyography (EMG) of the obliquus internus (OI) and externus (OE) abdominis, rectus abdominis (RA), erector spinae (ES) and deltoid muscles was recorded with surface electrodes during rapid shoulder flexion and extension. Time taken to regain baseline centre of pressure velocity (vCOP) and the number of postural adjustments following arm movement was calculated from force plate data. Time to recover balance in the direction of postural disturbance (anteroposterior vCOP) was longer in COPD, particularly more severe COPD, than controls. Mediolateral vCOP (perpendicular to the perturbation) and the number of postural adjustments did not differ between groups, but people with more severe COPD were less successful at returning their mediolateral vCOP to baseline. Abdominal muscle EMG was similar between groups, but controls had greater ES EMG during arm movements. Individuals with more severe COPD had greater OE and RA EMG both before and during arm movement compared to those with less severe COPD and controls. Following exercise, OE and ES EMG increased in people with less severe COPD. This study shows that severe COPD is associated with impaired ability to recover balance and greater trunk muscle activity during postural challenges. Augmented trunk muscle activity may limit the contribution of trunk movements to balance recovery and could contribute to increased falls risk.

Effects of a pulmonary rehabilitation program with balance training on patients with COPD

PURPOSE

Patients with chronic obstructive pulmonary disease (COPD) have balance impairments. However, pulmonary rehabilitation (PR) is associated with only minor improvements in functional balance. Therefore, there is a need to explore the role of balance training within PR. This study aimed at assessing the effects of a PR program, with a specific component of balance training, on functional balance of patients with COPD.

METHODS

Outpatients with COPD (N = 22, age = 68.0 ± 11.8 years; forced expiratory volume in 1 second = 72.2 ± 22.3% predicted) participated in a 12-week PR program including exercise training and psychosocial support and education. Exercise training sessions comprised endurance, strength, and a specific component of balance training. The Timed Up and Go (TUG) test was used to assess functional balance before and after the PR. Health-related quality of life (St George's Respiratory Questionnaire), quadriceps muscle strength (10 repetition maximum), and exercise tolerance (6-minute walk test) were also assessed.

RESULTS

Patients demonstrated significant improvements in TUG scores after PR (mean change -1.7 ± 1.4 seconds; P = .001; effect size = 1.249). Before PR, 9 (41%) participants and after PR only 1 (4.5%) participant had a TUG performance worse than the average performance of age-matched healthy peers (P = .008). The St George's Respiratory Questionnaire symptoms score (P = .012), quadriceps muscle strength (P = .001), and exercise tolerance (P = .001) were also improved.

CONCLUSIONS

Pulmonary rehabilitation with a specific component of balance training had a large effect on functional balance in patients with COPD. Findings highlight the value of including balance training in PR programs. Further research is needed to determine the optimal intervention to improve balance and its specific components among patients with COPD.

Medications associated with falls in older people: systematic review of publications from a recent 5-year period

PURPOSE

Falls are an important public health problem in older people. Medication use is considered a risk factor for falls. This study systematically reviewed recent studies to determine the medications that might be associated with the risk of falling in older people.

METHODS

We conducted a systematic review of prospective and retrospective studies identified through the MEDLINE and CINAHL databases that quantitatively assessed the contribution of medications to falls risk in participants ≥60 years old published in English between May 2008 and April 2013.

RESULTS

The search identified 1,895 articles; 36 articles met the inclusion criteria. Of the 19 studies that investigated the effect of polypharmacy on the risk of falling, six studies reported that the risk of falling increased with polypharmacy. Data on the use of antihypertensive medications including calcium channel blockers, beta-blockers, and angiotensin system blocking medications were collected in 14 studies, with mixed results. Twenty-nine studies reported an association between the risk of falls and psychotropic medications including sedatives and hypnotics, antidepressants, and benzodiazepines.

CONCLUSIONS

The use of sedatives and hypnotics and antidepressants including tricyclic antidepressants, selective serotonin reuptake inhibitors, and serotonin norepinephrine reuptake inhibitors appears to be related with an increased risk of falls. It is not clear if the use of antihypertensive medications is associated with the risk of falls in older people.

Minimizing the evidence-practice gap - a prospective cohort study incorporating balance training into pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease

BACKGROUND

We have recently demonstrated the efficacy of balance training in addition to Pulmonary Rehabilitation (PR) at improving measures of balance associated with an increased risk of falls in individuals with Chronic Obstructive Pulmonary Disease (COPD). Few knowledge translation (KT) projects have been conducted in rehabilitation settings. The goal of this study was to translate lessons learnt from efficacy studies of balance training into a sustainable clinical service.

METHODS

Health care professionals (HCPs) responsible for delivering PR were given an hour of instruction on the principles and practical application of balance training and the researchers offered advice regarding; prescription, progression and practical demonstrations during the first week. Balance training was incorporated three times a week into conventional PR programs. Following the program, HCPs participated in a focus group exploring their experiences of delivering balance training alongside PR. Service users completed satisfaction surveys as well as standardized measures of balance control. At six month follow-up, the sustainability of balance training was explored.

RESULTS

HCPs considered the training to be effective at improving balance and the support provided by the researchers was viewed as helpful. HCPs identified a number of strategies to facilitate balance training within PR, including; training twice a week, incorporating an interval training program for everyone enrolled in PR, providing visual aids to training and promoting independence by; providing a set program, considering the environment and initiating a home-based exercise program early. Nineteen service users completed the balance training [ten male mean (SD) age 73 (6) y]. Sixteen patients (84%) enjoyed balance training and reported that it helped them with everyday activities and 18 (95%) indicated their wish to continue with it. Scores on balance measures improved following PR that included balance training (all p < 0.05). At six month follow-up balance training is being routinely assessed and delivered as part of standardised PR.

CONCLUSIONS

Implementing balance training into PR programs, with support and training for HCPs, is feasible, effective and sustainable.

TRAIL REGISTRATION

Clinical Trials ID: NCT02080442 (05/03/2014).

Gait Characteristics in Patients With Chronic Obstructive Pulmonary Disease

Background: Patients with chronic obstructive pulmonary disease (COPD) have reduced gait speeds and more frequent falls. We analyzed gait characteristics and fall risk in these patients using video recordings and questionnaires to determine if these patients had any quantitative changes in gait characteristics and to determine if screening for fall risk provided useful information. Methods: Patients with COPD who had participated in pulmonary rehabilitation completed a short history falls and the Activities-Specific Balance Confidence Scale questionnaire. They performed the Get Up and Go Test. Their typical gait was video recorded and analyzed with Dartfish software. Results: Fourteen patients completed this study. The mean age was 69.7 ± 6.0 years, and the mean forced expiratory volume in 1 second was 1.01 ± 0.38 L (36.9% ± 15.6% predicted). Three patients had a history of falls without significant injury. The mean Activities-Specific Balance Confidence Scale score was 91.8 ± 14.9, but the scores ranged from 10 to 100. Patients reported decreased balance confidence when “stepping onto or off an escalator while holding onto parcels.” The mean time in the Get Up and Go Test was 11.9 ± 2.0 seconds. Spatiotemporal parameters of gait included mean step length 0.65 ± 0.6 m, mean double support time 0.36 ± 0.05 seconds, mean double support time ratio 30.4% ± 3.1%, average free walking speed 65.3 ± 6.9 m/min, and number of steps per minute 100.4 ± 8.8. The speed was significantly slower and the double support time was significantly longer when compared with normal values. Conclusions: Most patients had good balance confidence scores. Their gait and balance were qualitatively normal using the Tinetti tools for assessment. Therefore, their risk for falls seems low. They had a reduced step length and increased time spent in double support, changes which might represent subtle adaptations to reduced balance.

Balance impairment in patients with COPD

BACKGROUND/PURPOSE

Chronic obstructive pulmonary disease (COPD) is a respiratory disease that results in progressive airflow limitation and respiratory distress. Physiopathological features of COPD suggest that people who suffer from this disease have many risk factors for falls that have been identified in older individuals. The aim of the study was to compare and quantify functional balance between COPD patients and healthy subjects; to investigate the risk of falls in acute stages of the disease and to identify risk factors that could lead to falls.

METHODS

We studied 46 patients with moderate-severe COPD (29 stable and 17 in acute exacerbation--AECOPD) and 17 healthy subjects (control group) having similar demographic data. We analyzed the difference in Berg Balance Scale (BBS), Single Leg Stance (SLS) and Timed Up and Go test (TUG) between these three groups and the correlation of these scores with a number of incriminatory factors.

RESULTS

The presence of COPD was associated with significant worsening of balance tests: BBS (55 control, vs. 53 COPD, vs. 44 AECOPD points p<0.001), TUG (8.6 control vs. 12.3 COPD vs. 15.9 AECOPD seconds. p<0.001), SLS (31.1 control vs. 17.7 COPD vs. 7.2 AECOPD seconds p<0.001) which may be associated with an increased risk of falls. Anxiety and depression were significantly associated with decreased balance test scores; anxiety (2 control vs. 6 COPD vs. 9 AECOPD points p<0.001) depression (2 control vs. 7 COPD vs. 12 AECOPD points p<0.001).

CONCLUSIONS

According to our results COPD patients in moderate-severe stages and especially those in exacerbation have a high risk of falls.

Optimizing nonpharmacological management following an acute exacerbation of chronic obstructive pulmonary disease

Though the guidelines for the optimal management of chronic obstructive pulmonary disease (COPD) following an acute exacerbation (AE) are well established, issues associated with poor adherence to nonpharmacological interventions such as self-management advice and pulmonary rehabilitation will impact on hospital readmission rates and health care costs. Systems developed for clinically stable patients with COPD may not be sufficient for those who are post-exacerbation. A redesign of the manner in which such interventions are delivered to patients following an AECOPD is necessary. Addressing two or more components of the chronic care model is effective in reducing health care utilization in patients with COPD, with self-management support contributing a key role. By refining self-management support to incorporate the identification and treatment of psychological symptoms and by providing health care professionals adequate time and training to deliver respiratory-specific advice and self-management strategies, adherence to nonpharmacological therapies following an AE may be enhanced. Furthermore, following up patients in their own homes allows for the tailoring of advice and for the delivery of consistent health care messages which may enable knowledge to be retained. By refining the delivery of nonpharmacological therapies following an AECOPD according to components of the chronic care model, adherence may be improved, resulting in better disease management and possibly reducing health care utilization.

Depressive symptoms are independently associated with recurrent falls in community-dwelling older adults

BACKGROUND

Falls and depression are two major public health problems that affect millions of older people each year. Several factors associated with falls are also related to depressive symptoms such as medical conditions, sleep quality, use of medications, cognitive functioning, and physical capacities. To date, studies that investigated the association between falls and depressive symptoms did not control for all these shared factors. The current study addresses this issue by examining the relationship between falls and depression symptoms after controlling for several confounders.

METHODS

Eighty-two community-dwelling older adults were enrolled in this study. The Geriatric Depression Scale (GDS-30) was used to evaluate the presence of depressive symptoms, and the following question was used to assess falls: "Did you fall in the last 12 months, and if so, how many times?"

RESULTS

Univariate analyses indicated that the number of falls was significantly correlated with gender (women), fractures, asthma, physical inactivity, presence of depressive symptoms, complaints about quality of sleep, use of antidepressant drugs, and low functional capacities. Multivariate analyses revealed that depressive symptoms were significantly and independently linked to recurrent falls after controlling for confounders.

CONCLUSIONS

Results of the present study highlight the importance of assessing depressive symptoms during a fall risk assessment.

The Effect of a Short Duration, High Intensity Exercise Intervention on Gait Biomechanics in Patients With COPD: Findings From a Pilot Study

Previous work has shown that patients with chronic obstructive pulmonary disease (COPD) demonstrate changes in their gait biomechanics as compared to controls. This pilot study was designed to explore the possibility that biomechanical alterations present in COPD patients might be amenable to treatment by exercise training of skeletal muscle. This study investigated the effect of a 6-week exercise intervention on gait biomechanics in patients with COPD under both a rest and a non-rested condition. Seven patients with COPD underwent a supervised cardio-respiratory and strength training protocol 2-3 times per week for 6-weeks for a total of 16-sessions. Spatiotemporal, kinematic and kinetic gait variables were collected prior to and post intervention. All patients demonstrated significant improvements in strength following the intervention. The knee joint biomechanics demonstrated a significant main effect for intervention and for condition. Step width demonstrated a significant interaction as it decreased from pre- to post-intervention under the rest condition and increased under the non-rested condition. It does appear that being pushed (non-rested) has a strong influence at the knee joint. The quadriceps muscles, the primary knee extensors, have been shown to demonstrate muscular abnormalities in patients with COPD and the intervention may have influenced gait patterns through an effect on this skeletal muscle structure and function. Additionally, the intervention influenced step width closer to a more healthy value. Patients with COPD are more likely to fall and step width is a risk factor for falling suggesting the intervention may address fall risk. Whether a longer duration intervention would have more profound effects remains to be tested.

Rehabilitation and supportive therapy in elderly patients with Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD) very often coexists with cardiovascular, musculoskeletal and metabolic comorbidities. This condition significantly impact on the general health, function, frailty and disability of such patients, and consequently on their prognosis. Indeed, complex and recurrent symptoms of general dysfunction are commonly present and burden on the health status. Symptomatic COPD patients, even with chronic and complex comorbidities or with different degree of severity, may benefit from rehabilitation including exercise and maintenance of physical activity, in order to reducing symptoms and restoring the highest possible level of independent function. This review will focus on the associated and relevant clinical problems of these patients at the onset of disability, methods of assessment and useful non-pharmacological treatments for caring and supporting them.

Musculoskeletal disorders in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by airway obstruction and inflammation but also accompanied by several extrapulmonary consequences, such as skeletal muscle weakness and osteoporosis. Skeletal muscle weakness is of major concern, since it leads to poor functional capacity, impaired health status, increased healthcare utilization, and even mortality, independently of lung function. Osteoporosis leads to fractures and is associated with increased mortality, functional decline, loss of quality of life, and need for institutionalization. Therefore, the presence of the combination of these comorbidities will have a negative impact on daily life in patients with COPD. In this review, we will focus on these two comorbidities, their prevalence in COPD, combined risk factors, and pathogenesis. We will try to prove the clustering of these comorbidities and discuss possible preventive or therapeutic strategies.

Chronic obstructive pulmonary disease (COPD): evaluation from clinical, immunological and bacterial pathogenesis perspectives

Chronic obstructive pulmonary disease (COPD), a disease manifested by significantly impaired airflow, afflicts ∼14.2 million cases in the United States alone with an estimated 63 million people world-wide. Although there are a number of causes, the predominant cause is excessive tobacco smoke. In fact, in China, there have been estimates of 315,000,000 people that smoke. Other less frequent causes are associated with indirect cigarette smoke, air pollutants, biomass fuels, and genetic mutations. COPD is often associated with heart disease, lung cancer, osteoporosis and conditions can worsen in patients with sudden falls. COPD also affects both innate and adaptive immune processes. Cigarette smoke increases the expression of matrix metalloproteases and proinflammatory chemokines and increases lung titers of natural killer cells and neutrophils. Yet, neutrophil reactive oxygen species (ROS) mediated by the phagocytic respiratory burst and phagocytosis is impaired by nicotine. In contrast to innate immunity in COPD, dendritic cells represent leukocytes recruited to the lung that link the innate immune responses to adaptive immune responses by activating naïve T cells through antigen presentation. The autoimmune process that is also a significant part of inflammation associated with COPD. Moreover, coupled with restricted FEV1 values, are the prevalence of patients with single or multiple infections by bacteria, viruses and fungi. Finally, we focus on one of the more problematic infectious agents, the Gram-negative opportunistic pathogenic bacterium, Pseudomonas aeruginosa. Specifically, we delve into the development of highly problematic biofilm infections that are highly refractory to conventional antibiotic therapies in COPD. We offer a non-conventional, biocidal treatment that may be effective for COPD airway infections as well as with combinations of current antibiotic regimens for more effective treatment outcomes and relief for patients with COPD.

Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions

Background

Falls and chronic disease are both important health issues in older adults. The objectives of this study were to quantify the prevalence of falls and multi-morbidity (≥2 chronic conditions) in Canadian older adults; examine associations between falls and number of chronic conditions; and explore whether certain patterns of chronic disease were associated with a greater risk of falling.

Methods

Data were derived from the Canadian Community Health Survey- Healthy Aging. Primary outcomes from 16,357 community-dwelling adults aged 65 years and over were self-reported falls in the previous 12 months and presence of 13 chronic conditions. Prevalence estimates were calculated with normalized sampling weights, and hierarchical cluster analysis was used to identify clusters based on chronic condition patterns, and tested for association to falls with logistic regression.

Results

Overall prevalence of falling and multi-morbidity were 19.8% and 62.0% respectively. Fall risk was significantly greater in individuals with one, two, four, five and six or more chronic conditions relative to those with none (all p < 0.05). A seven-cluster model was selected, including groups with low prevalence of chronic disease, or high prevalence of hypertension and arthritis, visual impairment, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, or heart disease and hypertension. Only the hypertension cluster (Odds Ratio [OR] = 1.2) and COPD cluster (OR = 1.6) were significantly associated with increased falls relative to the low prevalence group.

Conclusions

Both the number and pattern of chronic conditions were related to falls. COPD emerged as a significant predictor of falls despite affecting a smaller proportion of respondents. Continued study is warranted to verify this association and determine how to incorporate consideration of chronic disease and multi-morbidity into fall risk assessments.