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

Postural control and fear of falling assessment in people with chronic obstructive pulmonary disease: a systematic review of instruments, international classification of functioning, disability and health linkage, and measurement properties

OBJECTIVES

To systematically review the instruments used to assess postural control and fear of falling in people with chronic obstructive pulmonary disease (COPD), and to synthesize and evaluate their breadth of content and measurement properties.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, CINAHL, CENTRAL, PsycINFO, PEDro, and OTSeeker databases searched in September 2012.

STUDY SELECTION

Two independent reviewers performed the selection of articles, the ICF linking process and quality assessment. Only quantitative studies were included, irrespective of language or publication date.

DATA EXTRACTION

This systematic review comprised two phases. Phase 1 aimed to identify the commonly used instruments to assess postural control and fear of falling in the COPD literature. The breadth of content of each instrument was examined based on the International Classification of Functioning, Disability and Health (ICF). In phase 2, a measurement property search filter was adopted and used in four electronic databases to retrieve properties reported in the COPD population. The COSMIN checklist was used to assess the methodological quality of each measurement property reported.

DATA SYNTHESIS

Seventeen out of 401 publications were eligible in phase 1. Seventeen instruments were identified including 15 for postural control and 2 for fear of falling assessment. The Berg Balance Scale, the Short Physical Performance Battery, and the Activities-specific Balance Confidence (ABC) scale were the most frequently used instruments to assess postural control and fear of falling respectively. The ICF categories covered varied considerably among instruments. The Balance Evaluation Systems test and ABC presented the greatest breadth of content. Measurement properties reported included criterion predictive validity (4 instruments), construct validity (11 instruments) and responsiveness (1 instrument), with inconsistent findings based on 'fair' and 'poor' quality studies.

CONCLUSIONS

Different instruments with heterogeneous content have been used to assess postural control and fear of falling outcomes. Standardized assessment methods and best evidence on measurement properties is required in the COPD literature.

Falls in elderly people: a multifactorial analysis of risk markers using data from the Swedish general population study 'Good ageing in Skåne'

BACKGROUND AND AIMS

The aim of this study was to describe the prevalence of falls in a general older population, especially among the most elderly, and the risk markers associated with falls.

METHODS

This is a cross-sectional study in which 38 fall risk markers were analysed in non-, occasional- and frequent-fallers. The population was 2,865 individuals (aged 60-93), randomly selected from the general population register. The risk of falling was calculated as age-adjusted odds ratios. The relation between the number of risk markers for an individual and falls was also analysed.

RESULTS

About one in ten reported falling during the past 6 months, 35% of which were over 90 years old. Twenty-one risk markers were significantly related to falls confirming falling as a multifactorial problem. These included a variety of diseases, symptoms, medical and physical functions, life-style factors and the taking of certain drugs. The five risk markers with the highest odds ratio in frequent fallers were 'tendency to fall' (37.9), 'low walking speed' (12.8), consumption of 'neuroleptics' (10.9), 'impaired mobility' (10.0) and 'dementia' (5.4). Subjects with more than four and seven risk markers showed a 9- respectively 28-fold increase in the risk of falling, especially among frequent fallers and those aged over 90 years.

CONCLUSION

Falls are common in the elderly population and the risk is multifactorial. The results imply that there is an overrepresentation of fallers in a distinct subgroup of the very elderly and those with multiple risk markers. The self-perceived clinical sign 'tendency to fall' seems highly sensitive as indicator of individuals at risk. Several risk markers may be treatable. Fall risk seems to increase in a non-linear, almost exponential way with increasing number of risk markers.

Proprioceptive changes impair balance control in individuals with chronic obstructive pulmonary disease

Introduction

Balance deficits are identified as important risk factors for falling in individuals with chronic obstructive pulmonary disease (COPD). However, the specific use of proprioception, which is of primary importance during balance control, has not been studied in individuals with COPD. The objective was to determine the specific proprioceptive control strategy during postural balance in individuals with COPD and healthy controls, and to assess whether this was related to inspiratory muscle weakness.

Methods

Center of pressure displacement was determined in 20 individuals with COPD and 20 age/gender-matched controls during upright stance on an unstable support surface without vision. Ankle and back muscle vibration were applied to evaluate the relative contribution of different proprioceptive signals used in postural control.

Results

Individuals with COPD showed an increased anterior-posterior body sway during upright stance (p = 0.037). Compared to controls, individuals with COPD showed an increased posterior body sway during ankle muscle vibration (p = 0.047), decreased anterior body sway during back muscle vibration (p = 0.025), and increased posterior body sway during simultaneous ankle-muscle vibration (p = 0.002). Individuals with COPD with the weakest inspiratory muscles showed the greatest reliance on ankle muscle input when compared to the stronger individuals with COPD (p = 0.037).

Conclusions

Individuals with COPD, especially those with inspiratory muscle weakness, increased their reliance on ankle muscle proprioceptive signals and decreased their reliance on back muscle proprioceptive signals during balance control, resulting in a decreased postural stability compared to healthy controls. These proprioceptive changes may be due to an impaired postural contribution of the inspiratory muscles to trunk stability. Further research is required to determine whether interventions such as proprioceptive training and inspiratory muscle training improve postural balance and reduce the fall risk in individuals with COPD.

Pulmonary rehabilitation: a review of the recent literature

Pulmonary rehabilitation (PR) is an evidence-based, multidisciplinary, comprehensive intervention that can be integrated into the management of individuals with chronic lung disease. It aims to reduce symptoms, optimize function, increase participation in daily life, and reduce health-care resource utilization. In this review, we summarize the new developments in PR over the past 5 years. Issues related to patient assessment include a comparison of cycle- and walking-based measures of exercise capacity, the emergence of multidimensional indices, the refinement of the minimal clinically important difference, and the importance of assessing physical activity. Issues related to exercise training focus on strategies to optimize the training load. We also comment on the acquisition of self-management skills, balance training, optimizing access, and maintaining gains following completion of PR.

Differences in walking pattern during 6-min walk test between patients with COPD and healthy subjects

Background

To date, detailed analyses of walking patterns using accelerometers during the 6-min walk test (6MWT) have not been performed in patients with chronic obstructive pulmonary disease (COPD). Therefore, it remains unclear whether and to what extent COPD patients have an altered walking pattern during the 6MWT compared to healthy elderly subjects.

Methodology/Principal Findings

79 COPD patients and 24 healthy elderly subjects performed the 6MWT wearing an accelerometer attached to the trunk. The accelerometer features (walking intensity, cadence, and walking variability) and subject characteristics were assessed and compared between groups. Moreover, associations were sought with 6-min walk distance (6MWD) using multiple ordinary least squares (OLS) regression models. COPD patients walked with a significantly lower walking intensity, lower cadence and increased walking variability compared to healthy subjects. Walking intensity and height were the only two significant determinants of 6MWD in healthy subjects, explaining 85% of the variance in 6MWD. In COPD patients also age, cadence, walking variability measures and their interactions were included were significant determinants of 6MWD (total variance in 6MWD explained: 88%).

Conclusions/Significance

COPD patients have an altered walking pattern during 6MWT compared to healthy subjects. These differences in walking pattern partially explain the lower 6MWD in patients with COPD.

Exercise prescription for hospitalized people with chronic obstructive pulmonary disease and comorbidities: a synthesis of systematic reviews

INTRODUCTION

The prescription of physical activity for hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) can be complicated by the presence of comorbidities. The current research aimed to synthesize the relevant literature on the benefits of exercise for people with multimorbidities who experience an AECOPD, and ask: What are the parameters and outcomes of exercise in AECOPD and in conditions that are common comorbidities as reported by systematic reviews (SRs)?

METHODS

An SR was performed using the Cochrane Collaboration protocol. Nine electronic databases were searched up to July 2011. Articles were included if they (1) described participants with AECOPD, chronic obstructive pulmonary disease (COPD), or one of eleven common comorbidities, (2) were an SR, (3) examined aerobic training (AT), resistance training (RT), balance training (BT), or a combination thereof, (4) included at least one outcome of fitness, and (5) compared exercise training versus control/sham.

RESULTS

This synthesis examined 58 SRs of exercise training in people with AECOPD, COPD, or eleven chronic conditions commonly associated with COPD. Meta-analyses of endurance (aerobic or exercise capacity, 6-minute walk distance--6MWD) were shown to significantly improve in most conditions (except osteoarthritis, osteoporosis, and depression), whereas strength was shown to improve in five of the 13 conditions searched: COPD, older adults, heart failure, ischemic heart disease, and diabetes. Several studies of different conditions also reported improvements in quality of life, function, and control or prevention outcomes. Meta-analyses also demonstrate that exercise training decreases the risk of mortality in older adults, and those with COPD or ischemic heart disease. The most common types of training were AT and RT. BT and functional training were commonly applied in older adults. The quality of the SRs for most conditions was moderate to excellent (>65%) as evaluated by AMSTAR scores.

CONCLUSION

In summary, this synthesis showed evidence of significant benefits from exercise training in AECOPD, COPD, and conditions that are common comorbidities. A broader approach to exercise and activity prescription in pulmonary rehabilitation may induce therapeutic benefits to ameliorate clinical sequelae associated with AECOPD and comorbidities such as the inclusion of BT and functional training.

[Chronic obstructive pulmonary disease in the elderly]

Chronic obstructive pulmonary disease (COPD) is one of the most prevalent diseases. Its prevalence increases with the age, and causes a high morbidity and mortality in the elderly population. COPD is currently considered as an inflammatory disease characterised by a pulmonary obstruction that is not fully reversible, and is associated with a high comorbidity. The treatment in the elderly does not differ much from that used in young adults, although the high comorbidity, the multiple prescription drugs and the use of different inhalation devices means that treatment has to be adapted to each patient. The presence of exacerbations, inactivity, systemic inflammation and dyspnea leads to a decrease in activity and loss of physical function. In this review we will update the physiology, diagnosis and treatment of COPD in the elderly, and the prevention of geriatric syndromes in this disease.

Postural Control Is Impaired in People with COPD: An Observational Study

PURPOSE

We investigated deficits in postural control and fall risk in people with chronic obstructive pulmonary disease (COPD).

METHOD

Twenty people with moderate to severe COPD (mean age 72.3 years, standard deviation [SD] 6.7 years) with a mean forced expiratory volume in 1 second (FEV(1)) of 46.7% (SD 13%) and 20 people (mean age 68.2 years, SD 8.1) who served as a comparison group were tested for postural control using the Sensory Organization Test (SOT). A score of zero in any trial of the SOT was registered as a fall. On the basis of the SOT results, participants were categorized as frequent fallers (two or more falls) or as fallers (one fall). To explore the potential influence of muscle weakness on postural control, knee extensors concentric muscle torque was assessed with an isokinetic dynamometer. Physical activity level was assessed with the Physical Activity Scale for the Elderly.

RESULTS

People with COPD showed a 10.8% lower score on the SOT (p=0.016) and experienced more falls (40) than the comparison group (12). The proportion of frequent fallers and fallers during the SOT was greater (p=0.021) in the COPD group (four of 10) than in the comparison group (two of seven). People with COPD showed deficits in knee extensors muscle strength (p=0.01) and a modest trend toward reduced physical activity level. However, neither of these factors explained the deficits in postural control observed in the COPD group.

CONCLUSIONS

People with COPD show deficits in postural control and increased risk of falls as measured by the SOT. The deficits in postural control appear to be independent of muscle weakness and level of physical activity. Postural control interventions and fall risk strategies in the pulmonary rehabilitation of COPD are recommended.

Deficits in postural control in individuals with COPD - emerging evidence for an important secondary impairment

Emerging evidence suggests that individuals with COPD demonstrate reductions in balance control that may be associated with an increased fall risk. The purpose of this review is to: 1) provide a brief overview of balance control and its assessment; 2) review relevant literature describing balance impairment in individuals with COPD; and 3) highlight important areas for future research. The observation of balance deficits and an increased fall risk in patients with COPD suggests the need for including balance assessment and training for patients enrolled in pulmonary rehabilitation who may be vulnerable. Further studies are needed to determine which aspects of balance are affected and to examine the impact of interventions.