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

Translating the Interplay of Cognition and Physical Performance in COPD and Interstitial Lung Disease: Meeting Report and Literature Review

TOPIC IMPORTANCE

Cognitive and physical limitations are common in individuals with chronic lung diseases, but their interactions with physical function and activities of daily living are not well characterized. Understanding these interactions and potential contributors may provide insights on disability and enable more tailored rehabilitation strategies.

REVIEW FINDINGS

This review summarizes a 2-day meeting of patient partners, clinicians, researchers, and lung associations to discuss the interplay between cognitive and physical function in people with chronic lung diseases. This report covers four areas: (1) cognitive-physical limitations in patients with chronic lung diseases; (2) cognitive assessments; (3) strategies to optimize cognition and motor control; and (4) future research directions. Cognitive and physical impairments have multiple effects on quality of life and daily function. Meeting participants acknowledged the need for a standardized cognitive assessment to complement physical assessments in patients with chronic lung diseases. Dyspnea, fatigue, and age were recognized as important contributors to cognition that can affect motor control and daily physical function. Pulmonary rehabilitation was highlighted as a multidisciplinary strategy that may improve respiratory and limb motor control through neuroplasticity and has the potential to improve physical function and quality of life.

SUMMARY

There was consensus that cognitive function and the cognitive interference of dyspnea in people with chronic lung diseases contribute to motor control impairments that can negatively affect daily function, which may be improved with pulmonary rehabilitation. The meeting generated several key research questions related to cognitive-physical interactions in individuals with chronic lung diseases.

Balance measures for fall risk screening in community-dwelling older adults with COPD: A longitudinal analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) increases fall risk, but consensus is lacking on suitable balance measures for fall risk screening in this group. We aimed to evaluate the reliability and validity of balance measures for fall risk screening in community-dwelling older adults with COPD.

METHODS

In a secondary analysis of two studies, participants, aged ≥60 years with COPD and 12-month fall history or balance issues were tracked for 12-month prospective falls. Baseline balance measures - Brief Balance Evaluation Systems Test (Brief BESTest), single leg stance (SLS), Timed Up and Go (TUG), and TUG Dual-Task (TUG-DT) test - were assessed using intra-class correlation (ICC2,1) for reliability, Pearson/Spearman correlation with balance-related factors for convergent validity, t-tests/Wilcoxon rank-sum tests with fall-related and disease-related factors for known-groups validity, and area under the receiver operator characteristic curve (AUC) for predictive validity.

RESULTS

Among 174 participants (73 ± 8 years; 86 females) with COPD, all balance measures showed excellent inter-rater and test-retest reliability (ICC2,1 = 0.88-0.97) and moderate convergent validity (r = 0.34-0.77) with related measures. Brief BESTest and SLS test had acceptable known-groups validity (p < 0.05) for 12-month fall history, self-reported balance problems, and gait aid use. TUG test and TUG-DT test discriminated between groups based on COPD severity, supplemental oxygen use, and gait aid use. All measures displayed insufficient predictive validity (AUC<0.70) for 12-month prospective falls.

CONCLUSION

Though all four balance measures demonstrated excellent reliability, they lack accuracy in prospectively predicting falls in community-dwelling older adults with COPD. These measures are best utilized within multi-factorial fall risk assessments for this population.

Questionnaires that assess disability in children and adolescents with low back pain adhere to the concepts of the International classification of functioning, disability and health (ICF), but lack validity for this population: a systematic review

PURPOSE

We aimed to identify Patient-Reported Outcome Measures (PROMs) that assess disability in children and adolescents with low back pain (LBP), analyzing their adherence to the International Classification of Functioning, Disability and Health (ICF) biopsychosocial model; and to describe the measurement properties of these PROMs.

METHODS

We searched Pubmed, Embase and CINAHL databases. The review included searches up to March 2022. Meaningful concepts of the PROMs were linked to ICF domains, and we manually searched for the measurement properties of each included PROM.

RESULTS

We included 23 studies, of which eight PROMs were analyzed. We retrieved 182 concepts in total. Activities was the domain with the highest number of linked concepts, whereas personal factors had no linked concepts. The modified Hannover Functional Ability Questionnaire (mHFAQ) and the Micheli Functional Scale (MFS) had measurement properties tested in children and adolescents, but had no information about construct validity.

CONCLUSION

Although most of the identified PROMs had broad coverage of their concepts in the ICF, only two PROMs had measurement properties tested in the population of interest in this review, in which the mHFAQ presented wide coverage in relation to the ICF. Further studies are needed to investigate content validity of these PROMs.

Postural balance in COPD with obstructive sleep apnoea: a cross-sectional study

Objective

The aim of this study was to assess the postural balance in COPD patients with obstructive sleep apnoea (OSA). Physical activity, anxiety and depression symptoms, mood, and falls were also assessed in this population.

Methods

Moderate to severe COPD patients were assessed for laboratory and clinical postural balance (force platform and mini-balance evaluation systems test (Mini-BESTest)), physical activity (accelerometry), OSA (polysomnography), sleep quality (Pittsburgh Sleep Quality Index), sleepiness (Epworth Sleepiness Scale), anxiety and depression symptoms (Hospital Anxiety and Depression Scale), dyspnoea (modified Medical Research Council), clinical status (COPD Assessment Test) and mood (Brunel Mood Scale). Self-reported falls were recorded for 6 months via phone calls.

Results

COPD patients (n=70) were divided according to the polysomnography findings into the no OSA (n=30), mild OSA (n=25), and moderate to severe OSA (n=15) groups. Compared to patients with no OSA, those with moderate to severe OSA (msOSA group) presented median (interquartile range) increased path length (30.5 (23.9-34.5) cm versus 39.0 (30.6-52.6) cm, anteroposterior displacement (1.89 (1.39-2.31) cm versus 2.54 (2.06-2.83) cm and postural adjustment velocity (1.02 (0.80-1.15) cm·s-1 versus 1.30 (1.02-1.76) cm·s-1) (p<0.05). No differences were observed in the Mini-BESTest scores among the groups. The msOSA group presented a greater number of recurrent fallers in the first follow-up trimester. No association was observed between postural balance and age and pulmonary function.

Conclusion

Individuals with COPD and moderate to severe OSA present changes in postural balance, including broader oscillation, faster postural adjustments and a greater risk of falls than those with no OSA. Physical activity, anxiety and depression symptoms, and mood are similar between COPD patients with and without OSA.

Which Components of The International Classification of Functioning, Disability and Health (ICF) are Covered by Cardiac Rehabilitation Assessment Tools among Individuals with Heart Failure?

BACKGROUND

The therapeutic assessment of functioning in cardiac rehabilitation from the perspective of the International Classification of Functioning, Disability and Health (ICF) can provide a biopsychosocial approach to health care. However, it is unclear which components are reflected in the instruments used for cardiac rehabilitation in individuals with heart failure (HF).

OBJECTIVES

To investigate which ICF components (body function, structures, activities, participation, environmental factors, and personal factors) are represented in the assessment instruments used in individuals with HF and to identify the most appropriate instrument to use based on the inclusion of these factors.

METHODS

Forty-four clinical trials included in an updated Cochrane systematic review that investigated the effects of exercise-based cardiac rehabilitation in patients with HF were reviewed. The instruments were analyzed to extract significant concepts linked to the ICF codes.

RESULTS

A total of 12 outcomes and 40 instruments were identified. The concepts were linked to 2466 codes in the following ICF components: body functions (41.8%), activities (29.7%), participation (8.4%), environmental factors (3.8%), personal factors (1.3%), and body structures (1.0%); other concepts (13.9%) were classified as not covered by ICF. None of the instruments presented concepts linked to all ICF components. The Minnesota Living with Heart Failure Questionnaire (MLHFQ), however, demonstrated comprehensive coverage of the ICF components, with the exception of body structure.

CONCLUSIONS

Body function was the most frequently detected ICF component. Individual instruments did not provide a comprehensive perspective on the functioning level of individuals with HF. The MLHFQ provided the greatest coverage of ICF components.

Performance-based outcome measures to assess functionality in hospitalised patients with COPD exacerbations: a systematic review of the measurement properties

INTRODUCTION

Hospitalised patients with exacerbations of COPD (ECOPD) may have physical and functional impairments that impact morbidity and readmission. Therefore, it is crucial to properly identify reduced functionality in these patients to support a personalised rehabilitation. The objective of this study is to summarise and compare the measurement properties of functionality performance-based outcome measures for hospitalised patients with ECOPD.

METHODS

A systematic review based on the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) was performed. The PubMed, Embase, PEDro and Cochrane databases were searched using terms related to functionality, hospitalised patients with ECOPD and measurement properties. Studies were selected and extracted by two researchers. The COSMIN Risk of Bias checklist was applied to assess the methodological quality of the studies and measurement property results were compared with the criteria for good measurement properties. Quality of evidence was graded using a modified Grades of Recommendation, Assessment, Development and Evaluation approach.

RESULTS

13 studies were included with nine outcome measures, namely the 6-min pegboard ring test, the de Morton mobility index, the incremental shuttle walk test (ISWT), the 6-min walk test (6MWT), maximum inspiratory pressure (MIP), the Berg balance scale, 4-m gait speed, handgrip strength and the 6-min stepper test. Construct validity was rated as sufficient, except for the ISWT. Responsiveness, assessed only for MIP, was considered insufficient and measurement errors for the ISWT and 6MWT were insufficient, with a very low quality of evidence for all measurement properties.

CONCLUSION

Measurement properties of performance-based outcome measures to assess functionality in patients hospitalised with ECOPD are still scarce, with very low evidence supporting validity and a lack of evidence of responsiveness and reliability. Further studies are needed to address this topic and guide assertive and personalised management.

mHealth Impact on Gait and Dynamic Balance Outcomes in Neurorehabilitation: Systematic Review and Meta-analysis

Gait and dynamic balance are two main goals in neurorehabilitation that mHealth systems could address. To analyze the impact of using mHealth systems on gait and dynamic balance outcomes in subjects with neurological disorders. Randomized controlled trials (RCT) published in PubMed, Web of Science, Scopus, and PEDro databases were searched up to April 2023. Studies including adults with neurological disorders, analyzing the effectiveness of mHealth systems on gait and dynamic balance compared with conventional therapy and/or not intervention, were included. The PEDro scale and the Cochrane Collaboration's 2.0 tool were used for the methodological quality and risk of bias assessment. The Review Manager 5.4 software was used to obtain meta-analyses. 13 RCT were included in the systematic review and 11 in the meta-analyses, involving 528 subjects. A total of 21 mobile applications were identified for gait and balance training, and to enhance physical activity behaviors. There were significant differences in gait parameters, speed by 0.10 s/m (95% confidence interval (CI)=0.07,0.13;p<0.001), cadence by 8.01 steps/min (95%CI=3.30,12.72;p<0.001), affected step length by 8.89 cm (95%CI=4.88,12.90;p<0.001), non-affected step length by 8.08 cm (5%CI=2.64,13.51;p=0.004), and in dynamic balance, Timed Up and Go by -7.15 s (95%CI=-9.30,-4.99;p<0.001), and mobility subscale of Posture Assessment Scale for Stroke by 1.71 points (95%CI=1.38,2.04;p<0.001). Our findings suggested the use of mHealth systems for improving gait in subjects with neurological disorders, but controversial results on dynamics balance recovery were obtained. However, the quality of evidence is insufficient to strongly recommend them, so further research is needed.

Age and Sex Differences in Balance Outcomes among Individuals with Chronic Obstructive Pulmonary Disease (COPD) at Risk of Falls

No previous research has examined age and sex differences in balance outcomes in individuals with chronic obstructive pulmonary disease (COPD) at risk of falls. A secondary analysis of baseline data from an ongoing trial of fall prevention in COPD was conducted. Age and sex differences were analyzed for the Berg Balance scale (BBS), Balance Evaluation System Test (BEST test) and Activities-specific Balance Confidence Scale (ABC). Overall, 223 individuals with COPD were included. Females had higher balance impairments than males [BBS: mean (SD) = 47 (8) vs. 49 (6) points; BEST test: 73 (16) vs. 80 (16) points], and a lower confidence to perform functional activities [ABC = 66 (21) vs. 77 (19)]. Compared to a younger age (50-65 years) group, age >65 years was moderately associated with poor balance control [BBS (r = - 0.37), BEST test (r = - 0.33)] and weakly with the ABC scale (r = - 0.13). After controlling for the effect of balance risk factors, age, baseline dyspnea index (BDI), and the 6-min walk test (6-MWT) explained 38% of the variability in the BBS; age, sex, BDI, and 6-MWT explained 40% of the variability in the BEST test; And BDI and the 6-MWT explained 44% of the variability in the ABC scale. This study highlights age and sex differences in balance outcomes among individuals with COPD at risk of falls. Recognition of these differences has implications for pulmonary rehabilitation and fall prevention in COPD, particularly among females and older adults.

Balance Function in Patients With COPD: A Systematic Review of Measurement Properties

To conduct an overview, evaluation, and synthesis of measurement properties of instruments assessing balance of COPD patients. Electronic searches were performed in Web of Science, Scopus, Embase, PubMed, CINAHL, PsycINFO, WanFang, and China National Knowledge Infrastructure databases up to the end of April 2021. Two reviewers independently evaluated the methodological quality using the Consensus-based Standards for the Selection of Health Status Measurement Instrument checklist, and rated the overall quality level of evidence was graded based upon a modified Grades of Recommendation, Assessment, Development, and Evaluation approach. Finally, 12 instruments were included. The Berg Balance Scale and the Timed Up and Go test were the most frequently used tools to evaluate balance. None of 12 instruments provide any information regarding cross-cultural validation or criterion validation. High-quality studies exploring measurement properties with a focus on the criterion validity and cross-cultural validity of balance measurements in COPD patients are warranted.

Effects of specific inspiratory muscle training combined with whole-body endurance training program on balance in COPD patients: Randomized controlled trial

PURPOSE

This study aims to assess the effect of inspiratory muscle training (IMT) combined with endurance training (ET) on balance in patients with chronic obstructive pulmonary disease (COPD).

METHODS

We studied 32 male patients (62 ± 6 years) with moderate to very severe COPD. They were randomly assigned to an experimental group (IMT+ET) n = 16 or a control group (ET) n = 16 with similar characteristics. The evaluations were carried out at inclusion and after eight weeks of the training period. Functional balance was assessed by the Berg Balance Scale (BBS), the Timed-up and Go (TUG), the Single Leg Stance test (SLS), and the Activities-specific Balance Confidence (ABC) scale. The strength of the inspiratory muscles (PImax) was assessed by maximal inspiratory mouth pressure. Functional exercise performance was assessed by the 6 minutes walking test (6MWT). IMT program consists in performing two daily sets of 30 inspirations with 50% of PImax increased by 10% every two weeks. ET program consists in performing 30 min treadmill exercise at 60% to 80% of the average speed achieved during the 6MWT three days per week.

RESULTS

After the training period, the experimental group demonstrated greater improvements in BBS (IMT+ET vs. ET; p = 0.019), and in ABC (IMT+ET vs. ET; p = 0.014). However, no significant differences between groups were observed for TUG, SLS, and 6MWT. There was a significant difference between groups in PImax (IMT+ET vs. ET; p = 0.030). Significant moderate correlations were obtained between ΔPImax and ΔBBS for both groups (IMT+ET: r = 0.624, p = 0.010; ET r = 0.550, p = 0.027) as well as for ΔABC but only in the experimental group (IMT+ET: r = 0.550, p = 0.027).

CONCLUSION

Compared to ET alone, the results suggest that IMT combined with ET enhances inspiratory muscle function and functional balance according to BBS and ABC in patients with COPD. We suggest that inspiratory muscle training might be introduced as additional training to pulmonary rehabilitation programs aimed at improving balance in COPD patients.

TRIAL REGISTRATION

The trial registry name: Clinical Trials; Registration number: NCT04084405; URL: https://clinicaltrials.gov/ct2/show/NCT04084405.

Association Between Inspiratory Muscle Function and Balance Ability in Older People: A Pooled Data Analysis Before and After Inspiratory Muscle Training

Inspiratory muscle training (IMT) improved balance ability and respiratory muscle function in healthy older adults. The current study is a retrospective analysis to explore the relationship between inspiratory muscle function, balance ability, and adaptation to IMT. All participants (total = 129; IMT = 60; age range = 65-85 years) performed inspiratory and balance assessments, including the mini-balance evaluation system test, maximal inspiratory pressure, and peak inspiratory flow tests. Baseline inspiratory muscle function was positively related to balance ability (p < .05), and IMT-induced improvements in inspiratory function (23.3% in maximal inspiratory pressure, 8.0% in peak inspiratory flow rate, 14.9% in maximal peak inspiratory power) were related to improvements in balance (10.6% in mini-balance evaluation system test), with the greatest improvements (17.0%) observed in the oldest participants (76-85 years old, p < .05). In conclusion, with or without IMT, positive associations between inspiratory function and balance ability exist, with greater improvements in inspiratory muscle function related to greater improvements in balance ability.

Convergent validity and reproducibility of the International classification of functioning, disability and health (ICF) core set for the physical health of community-dwelling older adults

BACKGROUND

Physical health is an important factor for what is considered successful aging. Using valid and reproducible tools to classify PH of older adults may help to develop appropriate rehabilitation protocols for this population.

OBJECTIVE

To evaluate the convergent validity and reproducibility of the International Classification of Functioning, Disability and Health (ICF) core set to classify the physical health of older adults.

METHODS

A total of 101 older adults were evaluated for handgrip strength, physical performance (Short Physical Performance Battery), and physical activity level (International Physical Activity Questionnaire). Physical health was classified with the ICF core set (14 categories of body functions, 4 of body structures, 9 of activity and participation, and 3 environmental factors) and an impairment index was calculated for each component.

RESULTS

Higher levels of physical activity were associated to lower impairment index in the body function and activity and participation components, but was not associated to environmental factors. Better physical performance and handgrip strength were also related to lower impairment index in all components. The Intraclass Correlation Coefficient analysis indicated good reproducibility for body function, body structure, the capacity component of the activity and participation, and for two environmental factors (use of medications and assistive devices), but moderate reproducibility for the performance component of activity and participation, and poor reproducibility for the environmental factor related to access to health services.

CONCLUSION

The ICF core set for the physical health of older adults is a valid and reproducible tool and can be used in clinical practice and research.

Effects of Exercise-Based Interventions on Fall Risk and Balance in Patients With Chronic Obstructive Pulmonary Disease: A SYSTEMATIC REVIEW

PURPOSE

Chronic obstructive pulmonary disease (COPD) is a highly prevalent disease characterized by airflow limitation and is associated with decreased balance and increased fall risk. Since falls are related to increased mortality, interventions targeting balance and fall risk could reduce morbidity and mortality. The objective of this review was to systematically assess the effects of exercise-based interventions on fall risk and balance in patients with COPD.

METHODS

PubMed, Web of Science, EMBASE, and CINAHL were screened for randomized controlled trails and within-group studies evaluating effects of exercise-based interventions on fall risk or balance in patients with COPD. Data were presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

Fifteen studies were identified, 6 randomized controlled trails and 9 within-group studies. All interventions reported positive effects on balance outcomes. No studies reported fall risk. Taking current recommendations of balance outcome measures in patients with COPD into account, pulmonary rehabilitation combined with balance training had the highest effect size. Nine papers had concerns regarding bias, mostly due to the lack of blinding outcome assessors.

CONCLUSIONS

Exercise-based interventions have a positive effect on balance in patients with COPD. Pulmonary rehabilitation with balance training seems to have the most beneficial effect on balance. The effects on fall risk, as well as the long-term intervention effects remain unclear. A standardized balance assessment and research on long-term effects and fall risk are recommended.

Static and dynamic balance impairment and relationship with disease-related factors in patients with chronic obstructive pulmonary disease : A cross-sectional study

BACKGROUND

Disease and aging-related factors may predispose chronic obstructive pulmonary disease (COPD) patients to impaired balance, although the underlying determinants of impaired balance in COPD patients are still unknown. The purpose of this study was to identify the determinants of impaired balance in COPD patients. Also, we aimed to determine which balance measures (clinical or laboratory tests) are more indicative in determining balance impairment in these patients.

METHODS

This cross-sectional study recruited 24 patients with moderate to severe COPD and 24 age-matched healthy subjects. Participants were evaluated regarding demographic and clinical data, previous falls history, lower limb muscle strength, exercise capacity, physical activity and balance level.

RESULTS

COPD patients exhibited significantly a longer test duration on timed up and go test, a higher sway index on the postural stability and lower directional control score on the limit of stability of Biodex balance system (all, p < 0.001) compared to healthy controls, whereas there was no difference in Berg balance scale score between groups (p > 0.05). Balance impairment of the patient group was significantly associated with nonpulmonary conditions, such as physical activity level, exercise capacity, lower limb muscle strength, and with fall history. Also, COPD patients represented significantly lower physical activity level and exercise capacity, weaker lower limb muscle strength than healthy controls (all, p < 0.001).

CONCLUSIONS

Patients with moderate to severe COPD exhibit apparently important reductions in balance control that is directly associated with nonpulmonary consequences and fall history. These results may be extremely important to fall prevention and to guide the development of interventions for this population.

Feasibility, tolerance and effects of adding impact loading exercise to pulmonary rehabilitation in people with chronic obstructive pulmonary disease: study protocol for a pilot randomised controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a disorder linked with a multitude of extra pulmonary manifestations (also known as treatable traits), including low bone mineral density (BMD). To date, no specific guidelines exist for the management of BMD in this population. Impact loading exercise has been identified as an intervention that improves or maintains BMD in other populations. However, the feasibility of and tolerance to impact loading exercise has not been tested in people with COPD. The aim of the proposed study will be to investigate the feasibility and tolerance of adding impact loading exercise to a standard pulmonary rehabilitation programme (PRP) in people with COPD and report its effects on bone health, balance and falls risk.

METHODS

This is a protocol for a pilot feasibility and tolerance randomised controlled trial (RCT). Fifty-eight people with COPD will be randomly allocated, on a 1:1 ratio, to either the experimental or control group. Initially, participants in both groups will complete a standard 8-week (twice-weekly) PRP followed by a 32-week period of maintenance exercises. Over the initial 8-week period, participants allocated to the experimental group will also undertake targeted lower limb resistance exercises and commence a programme of impact loading exercises (e.g. bounding and drop jumps). On completion of the initial 8-week PRP, in addition to the standard maintenance exercises, participants in the experimental group will continue with home-based impact loading exercises, four times a week, for the extra 32 weeks. The primary outcome of this study is feasibility of and tolerance to impact loading exercises. Feasibility will be measured using data collected pertaining to recruitment, withdrawal and completion. Adherence to the exercises will be collected using exercise logs. Tolerance to the exercises will be determined using outcomes to assess pain, recording any adverse effects such as a fall and feedback from the participants in semi-structured interviews on completing of the trial. The effects of the 40-week experimental intervention on bone health, balance and falls risk will be reported.

DISCUSSION

This pilot RCT will test the feasibility and tolerance of an intervention that has never been trialed in people with COPD. It will also provide initial information regarding the size of the effect this intervention has on outcomes such as BMD, balance and falls risk. These data will be critical when designing a definitive RCT to advance this area of research.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ANZCTR): 12620001085965 (20/10/2020).

Feasibility of a 6-Month Home-Based Fall Prevention Exercise Program in Older Adults with COPD

Purpose

Older adults with chronic obstructive pulmonary disease (COPD) have a high risk and rate of falls. Home-based fall prevention exercise programs reduce falls in older adults and may be an alternative approach for people with COPD without access to hospital-based rehabilitation. Therefore, we aimed to determine the feasibility of a home-based fall prevention exercise program in older adults with COPD and to examine the effect of the program on fall-related outcomes at baseline, 3 and 6 months.

Patients and Methods

Adults ≥60 years with COPD at risk for falls participated in a single group study. The intervention was a 6-month home-based fall prevention program which included 40 minutes of independent exercise three times per week, four physiotherapist home visits, bimonthly phone calls, and an optional booster session post-exacerbation. An independent assessor collected outcome measures at home at baseline, 3- and 6-months. Primary feasibility criteria were recruitment and retention rates (≥70%) and exercise adherence (≥60%). Functional outcomes included the Berg Balance Scale (BBS), the Balance Evaluation Systems Test (BESTest), the Activities-Specific Balance Confidence (ABC) scale, the repeated chair-stand test, self-reported function, and fall history.

Results

Thirty-six patients (female 63.8%, mean age 74.4 ± 6.1 years; mean FEV₁ 45.0 ± 13.8% predicted) were enrolled. The recruitment rate was 46.8%, participant retention rate was 69.4%, and exercise adherence rate was 73.6%. Repeated measures ANOVA showed improvements at 3- and 6-months compared to baseline in the BBS (p=0.001) and the BESTest total scores and sub-scores (p=0.001).

Conclusion

The home-based fall prevention exercise program met one of the three pre-specified feasibility criteria (exercise adherence), and improved balance-related measures of fall risk in older adults with COPD. Our findings highlight important opportunities for refinement of the study design prior to undertaking a full-scale trial.

The Investigation of Falls and Balance from the Perspective of Activities of Daily Living in Patients with COPD

The aim of this study was (1) to compare the activities of daily living (ADLs), perceived falling risk and balance in chronic obstructive pulmonary disease (COPD) patients with or without falling history and (2) to investigate the relationship between ADLs and balance. Fourteen patients with COPD with a history of falling whose mean falling frequency was 2.64 ± 0.74 times in the last 12-months (fallers) and 14 age and sex-matched patients with COPD with no history of falling (non-fallers) were included. The outcome measures were the London Chest Activity of Daily Living (LCADL) scale, Activities-Specific Balance Confidence (ABC) scale, Berg Balance Scale (BBS), 6-minute walking test, and quadriceps-femoris strength. Fallers reported increased dyspnoea perception in ADLs, decreased balance confidence, and disturbed balance compared with non-fallers (p < 0.05). A strong correlation was found between the LCADL scale item score (dressing the upper body) and the BBS total score (rho = -0.81, p = 0.001) in fallers. The LCADL scale item score (going out socially) was significantly correlated with the total score of the ABC scale (rho = -0.61, p = 0.001). Moderate correlations were found between the LCADL scale item scores (dressing the upper body, washing hair, and walking up stairs) and the BBS total score (p < 0.003). This study demonstrated that increased severity of dyspnoea perception during ADLs is associated with impaired balance and poor balance confidence, regardless of functional capacity and peripheral muscle strength in patients with COPD. The balance confidence was low in functional mobility-based activities in patients with COPD with a history of falling.

Evaluation of balance in patients with chronic obstructive pulmonary disease with practical tests

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) have impaired balance and hence fall more frequently. Easy application of balance evaluation tests can prevent the loss of time in the outpatient clinic for patients with COPD. In this study, we aimed to compare the efficacy of Berg Balance Scale (BBS), a time-consuming but a widely used test, with other easy-to-perform tests such as the Single Leg Stance (SLS), Five Repetition Sit to Stand (5STS), Four Step Square (FSST), and Timed Up and Go (TUG) tests.

METHODS

A total of 71 patients with COPD and 70 control subjects with matching demographic characteristics were included in the study. All patients undertook pulmonary function tests and their scores of 6-min walk-test (6MWT), modified Medical Research Council (mMRC) dyspnoea scale, COPD assessment questionnaire (CAT) and body mass index (B) were recorded. In addition, the severity of airway obstruction (O), the dyspnoea severity (D) and exercise capacity (E) (BODE) index scores were measured. All patients with COPD were classified into four groups, A to D, based on the GOLD 2017 criteria. All subjects undertook the BBS, SLS, 5STS, FSST and TUG tests.

RESULTS

Balance tests revealed increased balance impairment in patients with COPD in comparison with the control subjects (P < .05). The BBS, SLS, FSST and TUG examinations suggested that balance impairment was frequent in Groups C and D patients with COPD (P < .05). FSST and TUG had the highest correlation with BBS (r = -.812 and -.842 and P < .001 and <.001, respectively). The results of FSST and TUG were the closest to those of BBS test.

CONCLUSIONS

FSST and TUG tests can be applied for the assessment of bodily balance status among patients with COPD in outpatient clinics.

Balance assessment in people with COPD: An evidence-based guide

Balance problems and an increased rate and risk of falls are common in people with chronic obstructive pulmonary disease (COPD). Although a balance assessment is now recommended by clinical practice guidelines for pulmonary rehabilitation, specific tests have yet to be suggested. The purpose of this review is to provide an evidence-based synthesis of balance measurement in older adults and in people with COPD, to guide practice in this area. An overview of best practices for assessing balance and fall risk in older adults is provided along with a practical synthesis of evidence to date on common balance measures used in people with COPD such as the Timed Up and Go, Single Leg Stance, Berg Balance, and Mini and Full Balance Evaluation Systems Tests. Finally, two clinical scenarios are described to illustrate the process of evidence-based clinical decision-making with respect to balance assessment in people with COPD. Ultimately, the selection of balance test and its interpretation will depend on the purpose of the assessment, available data on psychometric properties, the patient’s individual characteristics, and the resources available to the clinician.

Which Balance Subcomponents Distinguish Between Fallers and Non-Fallers in People with COPD?

Rationale

Chronic obstructive pulmonary disease (COPD) is an increasingly prevalent lung disease linked to dysfunctional balance and an increased risk of falls. The Balance Evaluation Systems Test (BESTest) evaluates the six underlying subcomponents of functional balance. The aim of this study was to determine the specific balance subcomponents and cut-off scores that discriminate between fallers and non-fallers with COPD to guide fall risk assessment and prevention.

Methods

A secondary analysis of cross-sectional data from two prior studies in COPD was performed. Independent samples t-tests were used to explore the differences in the BESTest sub-system scores between fallers and non-fallers. Receiver operating characteristic curves were used to determine the optimal subcomponent cut-off scores that identified fallers, and the area under the curve (AUC) was used to assess test accuracy.

Results

Data from 72 subjects with COPD (mean age, 70.3 ± 7.4y; mean forced expiratory volume in 1 second, 38.9 ± 15.8% predicted) were analyzed. Two BESTest subcomponents, stability limits/verticality (fallers: 75.4%, non-fallers: 83.8%; p=0.002) and postural responses (fallers: 67.5%, non-fallers: 79.7%; p=0.008) distinguished between fallers and non-fallers. Stability limits/verticality had an AUC of 0.70 and optimal cut-off score of 73.8% for identifying fallers; postural responses had an AUC of 0.67 and optimal cut-off score of 69.4%.

Conclusion

The stability limits/verticality and postural responses subcomponents of the BESTest distinguished between fallers and non-fallers with COPD. The stability limits/verticality subcomponent can also be used to identify whether an individual with COPD is at risk of falling using a cut-off score of 73.8%. These findings suggest that specific subcomponents of balance could be targeted to optimize fall risk assessment and prevention in COPD.

The effects of decreased inspiratory capacity on postural stability during backward reach

[Purpose] The purpose of this study is to investigate the effect of decreased inspiratory capacity on the backward reach distance in healthy young individuals, as patients with chronic obstructive pulmonary disease have a high risk of falling. [Participants and Methods] Thirteen healthy volunteers (age, 19.2 ± 0.4 years: mean ± SD) participated in this study. We recorded the backward reach distance at the resting expiration level and at two different inspiratory capacity levels: −1/3 and −2/3 of inspiratory capacity, when the air is inhaled at resting expiration level. We assessed the backward reach distance for each inspiratory capacity, using one-way repeated measures analysis of variance and post-hoc analysis. [Results] We found that inspiratory capacity has a significant effect on backward reach distance. The backward reach distance was significantly decreased in participants with a −2/3 inspiratory capacity, compared with the backward reach distance in participants with a resting expiration level. [Conclusion] Patients with lung volume fractionation and decreased inspiratory capacity lack postural stability during backward reach. Therefore, the link between decreased inspiratory capacity and loss of balance in patients with chronic obstructive pulmonary disease may, in part, be due to decreased postural stability, and the resulting tendency to plan movements, which create a loss of balance.

Exercise Training in Patients With Non-Small Cell Lung Cancer During In-Hospital Chemotherapy Treatment: A RANDOMIZED CONTROLLED TRIAL

This study aimed to assess the impact of exercise training in patients with lung cancer on several outcomes compared to a control group. Results suggest that exercise programs in patients with lung cancer are a practical and beneficial intervention for enhancing mobility and physical fitness.

Purpose:

The aim of this study was to perform a randomized trial to assess the impact of exercise training in patients with non–small cell lung cancer during chemotherapy on several outcomes in comparison to a control group (CG).

Methods:

The exercise training group (ETG) consisted of 20 patients and the CG consisted of 10 patients. In the ETG, a 4-wk in-hospital exercise training program was performed in 2-wk cycles interspersed with consecutive rounds of chemotherapy with cytostatic drugs. The exercise training program was individualized and included warm-up, respiratory muscle exercise, training on a cycle ergometer or treadmill, and Nordic walking. CG participants were assessed before and after 6 wk of chemotherapy alone.

Results:

Comparing pre- and post-intervention values, the ETG demonstrated an increase in 6-min walk distance (486 ± 92 vs 531 ± 103 m, P = .01). In a battery of physical performance tests: Up and Go Test (6.3 ± 1.0 vs 6.0 ± 1.1 sec, P = .01); chair stand (13.3 ± 2.8 vs 14.3 ± 3.4 repetitions, P = .001); and arm curl (18.4 ± 3.1 vs 20.4 ± 3.5 repetitions, P = .001) all improved significantly. Spirometry values also improved: FEV₁ % predicted (76 ± 16 vs 84 ± 15, P = .01), FVC % predicted (87 ± 14 vs 95 ± 13, P = .01), and FEV₁/FVC (73 ± 13% vs 76 ± 12%, P = .04). The exercise training was well tolerated, without any adverse events due to exercise. There were no significant improvements in the CG.

Conclusions:

This study suggests that planned, individualized, and supervised exercise programs in patients with advanced lung cancer during chemotherapy are a practical and beneficial intervention for enhancing mobility and physical fitness.

Construct validity and reliability of the Brazilian version of the Falls Efficacy Scale in patients with COPD

INTRODUCTION AND OBJECTIVE

The Brazilian version of Falls Efficacy Scale (FES-BR) used to assess the fear of falling, has not yet been validated in patients with Chronic Obstructive Pulmonary Disease (COPD). The aim of the present study was to investigate the construct validity and reliability of the (FES-BR) in patients with COPD.

METHODS

A cross-sectional study involving subjects with COPD, aged between 48 and 83 years. Data were collected by two independent and blind assessors. Construct validity was assessed using the Spearman's rank correlation coefficient between FES-BR and Berg Balance Scale, Downton fall risk index, Timed Up and Go Test (TUG), hand-grip strength (HGS), Five Times Sit to Stand Test (FTSST) and 6-Minute Walk Test (6MWT). Reliability was measured by the Cronbach's alpha coefficient, Intraclass Correlation Coefficient (ICC), and Bland-Altman plot.

RESULTS

The study included 60 subjects aged 68.3 ± 9.9 years and FEV1 56.0 ± 19.3. The correlations were significantly strong between FES-BR and the Berg Balance Scale (r = -0.66), TUG (r = 0.64), HGS (r = 0.61) and FTSST (r = 0.62); and moderate between FES-BR and the Downton fall risk index (r = 0.38) and the 6MWT (r = -0.48). All correlations had p < 0.001. Intra-rater [ICC = 0.94, (95% CI = 0.91-0.96)] and inter-rater [0.97, (95% CI = 0.97-0.98)] reliability were considered excellent.

CONCLUSIONS

The Brazilian version of FES was valid and reliable in assess fear of falling in subjects with COPD.

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.

Reliability of quadriceps muscle power and explosive force, and relationship to physical function in people with chronic obstructive pulmonary disease: an observational prospective multicenter study

Background: Muscle power declines with age and is a stronger determinant of physical function than strength. Muscle power using computerized dynamometry has not been investigated in COPD.Objectives: To determine: 1) test-retest reliability of quadriceps power using a standardized protocol with computerized dynamometry; and 2) associations between quadriceps strength and power, and functional capacity.Design/Setting: Prospective observational study in four Canadian research labs.Participants: People with mild to very severe COPD.Methods: Tests were conducted on two days. Quadriceps muscle maximal strength was evaluated during a static maneuver using maximal voluntary isometric contractions (MVIC). Rate of torque development (RTD) during MVIC was used to assess explosive force. Muscle power was measured using a dynamic, isotonic protocol from which peak and average power and peak velocity were derived. Functional capacity was assessed with the Short Physical Performance Battery (SPPB). Reliability was assessed using intraclass correlation coefficients (ICC), standard error of measurements (SEM), and Bland Altman plots. Spearman and Pearson correlation coefficients were used for associations.Results: 65 patients (age 69 ± 8 years; FEV₁ 48 ± 21% of predicted) were included. ICC was 0.77 for RTD and 0.87-0.98 for isotonic power measures (95%CI 0.63-0.99, p < .001); SEM < 10% for average/peak power and peak velocity, and > 30% for RTD. SPPB had moderate correlation with average power, but not with MVIC or RTD.Conclusion: The standardized isotonic protocol with computerized dynamometry was reliable in assessing quadriceps power in COPD. Our data highlights that average power correlates best with functional capacity, indicating higher relevance than static measures when investigating determinants of function.

Investigation of physical and functional impairments experienced by people with active tuberculosis infection: A feasibility pilot study

Background

Tuberculosis (TB) remains a significant healthcare problem. Understanding physical and functional impairments that patients with active TB present with at the time of diagnosis and how these impairments change over time while they receive anti-TB therapy is important in developing appropriate rehabilitation programmes to optimise patients’ recovery.

Objectives

The aim of this study was to assess the acceptability, implementation and practicality of conducting a prospective, observational and longitudinal trial to describe physical and functional impairments of patients with active TB.

Method

A feasibility pilot study was performed. Patients with acute pulmonary TB admitted to an urban quaternary-level hospital were recruited. Physical (muscle architecture, mass and power, balance, and breathlessness) and functional (exercise capacity) outcomes were assessed in hospital, and at 6 weeks and 6 months post-discharge. Descriptive statistics were used to analyse the data.

Results

High dropout (n = 5; 41.7%) and mortality (n = 4; 33.3%) rates were observed. Limitations identified regarding study feasibility included participant recruitment rate, equipment availability and suitability of outcome measures. Participants’ mean age was 31.5 (9.1) years and the majority were human immunodeficiency virus (HIV) positive (n = 9; 75%). Non-significant changes in muscle architecture and power were observed over 6 months. Balance impairment was highlighted when vision was removed during testing. Some improvements in 6-minute walk test distance were observed between hospitalisation and 6 months.

Conclusion

Success of a longitudinal observational trial is dependent on securing adequate funding to address limitations observed related to equipment availability, staffing levels, participant recruitment from additional study sites and participant follow-up at community level. Participants’ physical and functional recovery during anti-TB therapy seems to be limited by neuromusculoskeletal factors.

Age and Disease have a Distinct Influence on Postural Balance of Patients with COPD

The postural imbalance is an extra-pulmonary condition, associated with chronic obstructive pulmonary disease (COPD). COPD affects older individuals and it is unclear whether balance abnormalities can be described as pathophysiological mechanism or aging. The present study aimed to evaluate the influence of age or disease on postural balance of patients with COPD. Patients with COPD over 50 years old were compared with age- and sex-matched healthy adults, and with sex-matched younger healthy adults (n = 30 in each group). The Modified Sensory Organization Test (mSOT) was performed in four different conditions fixed or sway-referenced surface both either with full or no vision. It was analyzed the center of pressure (CoP) variables: amplitude, velocity, root-mean-square and load asymmetry. Three-way ANOVA and post hoc analysis were performed been represented of age (older or COPD compared with younger healthy adults) or disease influences (COPD compared with older healthy groups). Main results were as follows: The CoP excursion was faster, with higher amplitude and variability progressively from COPD vs. older healthy vs. younger healthy adults (p < 0.05) showing age and disease influences (p < 0.05). Age and disease influences were also observed in the sway-referenced surface in both vision conditions. Impairment in postural balance was found related to aging and disease in patients with COPD older than 50 years.

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.

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).

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.

The quality of systematic reviews of health-related outcome measurement instruments

BACKGROUND

Systematic reviews of outcome measurement instruments are important tools for the selection of instruments for research and clinical practice. Our aim was to assess the quality of systematic reviews of health-related outcome measurement instruments and to determine whether the quality has improved since our previous study in 2007.

METHODS

A systematic literature search was performed in MEDLINE and EMBASE between July 1, 2013, and June 19, 2014. The quality of the reviews was rated using a study-specific checklist.

RESULTS

A total of 102 reviews were included. In many reviews the search strategy was considered not comprehensive; in only 59 % of the reviews a search was performed in EMBASE and in about half of the reviews there was doubt about the comprehensiveness of the search terms used for type of measurement instruments and measurement properties. In 41 % of the reviews, compared to 30 % in our previous study, the methodological quality of the included studies was assessed. In 58 %, compared to 55 %, the quality of the included instruments was assessed. In 42 %, compared to 7 %, a data synthesis was performed in which the results from multiple studies on the same instrument were somehow combined.

CONCLUSION

Despite a clear improvement in the quality of systematic reviews of outcome measurement instruments in comparison with our previous study in 2007, there is still room for improvement with regard to the search strategy, and especially the quality assessment of the included studies and the included instruments, and the data synthesis.

Fear of falling in people with chronic obstructive pulmonary disease

BACKGROUND

Increased fear of falling (FOF) has been associated with impaired physical function, reduced physical activity and increased fall risk in older adults. Preliminary evidence suggests that individuals with chronic obstructive pulmonary disease (COPD) may have an increased FOF. This study aims to compare the level of FOF in people with COPD with healthy controls, and to determine the associations between FOF and measures of physical function, physical activity and fall risk in COPD.

METHODS

FOF was assessed in 40 participants with COPD and 25 age- and gender-matched controls using the Falls Efficacy Scale-International (FES-I). Physical function was evaluated using quadriceps hand-held dynamometry, the Berg Balance Scale and the Six-minute Walk Test. Associations between FOF, physical activity and fall risk were evaluated using the Physical Activity Scale for the Elderly and the Falls Risk in Older People - Community Setting. Pearson's correlation coefficient and stepwise multivariate linear regression were used.

RESULTS

Individuals with COPD (mean ± SD; age: 71 ± 8 years, FEV1: 45 ± 16 %pred) had higher FOF compared to controls (FES-I: 25.0 ± 7.9 vs 20.2 ± 5.2, p=0.01). Higher FOF was associated with lower quadriceps strength (p=0.02) and an impaired balance (p < 0.01); these explained 26% of the FOF variance. Reduced levels of physical activity (p=0.01) and a higher fall risk (p < 0.01) were associated with an increased FOF in COPD.

CONCLUSION

People with COPD have a higher FOF compared to the healthy peers, which is related to lower quadriceps muscle strength, impaired balance, lower levels of physical activity and an increased fall risk.