Effects of Pulmonary Rehabilitation on Gait Characteristics in Patients with COPD

Exercise-based interventions targeting balance and falls in people with COPD: a systematic review and meta-analysis

INTRODUCTION

This review quantifies the mean treatment effect of exercise-based interventions on balance and falls risk in people with COPD.

METHODS

A structured search strategy (2000-2023) was applied to eight databases to identify studies evaluating the impact of exercise-based interventions (≥14 days in duration) on balance or falls in people with COPD. Pooled mean treatment effects (95% confidence intervals (CIs), 95% prediction intervals (PIs)) were calculated for outcomes reported in five or more studies. Inter-individual response variance and the promise of behaviour change techniques (BCTs) were explored.

RESULTS

34 studies (n=1712) were included. There were greater improvements in balance post intervention compared to controls for the Berg Balance Scale (BBS) (mean 2.51, 95% CI 0.22-4.80, 95% PI -4.60-9.63), Timed Up and Go (TUG) test (mean -1.12 s, 95% CI -1.69- -0.55 s, 95% PI -2.78-0.54 s), Single-Leg Stance (SLS) test (mean 3.25 s, 95% CI 2.72-3.77 s, 95% PI 2.64-3.86 s) and Activities-specific Balance Confidence (ABC) scale (mean 8.50%, 95% CI 2.41-14.58%, 95% PI -8.92-25.92%). Effect on falls remains unknown. Treatment effects were larger in male versus mixed-sex groups for the ABC scale and SLS test, and in balance training versus other exercise-based interventions for the BBS and TUG test. Falls history was not associated with changes in balance. Meta-analysis of individual response variance was not possible and study-level results were inconclusive. Eleven promising BCTs were identified (promise ratio ≥2).

CONCLUSION

Evidence for the effect of exercise-based interventions eliciting clinically important improvements in balance for people with COPD is weak, but targeted balance training produces the greatest benefits. Future exercise interventions may benefit from inclusion of the identified promising BCTs.

Biofeedback Respiratory Rehabilitation Training System Based on Virtual Reality Technology

Traditional respiratory rehabilitation training fails to achieve visualization and quantification of respiratory data in improving problems such as decreased lung function and dyspnea in people with respiratory disorders, and the respiratory rehabilitation training process is simple and boring. Therefore, this article designs a biofeedback respiratory rehabilitation training system based on virtual reality technology. It collects respiratory data through a respiratory sensor and preprocesses it. At the same time, it combines the biofeedback respiratory rehabilitation training virtual scene to realize the interaction between respiratory data and virtual scenes. This drives changes in the virtual scene, and finally the respiratory data are fed back to the patient in a visual form to evaluate the improvement of the patient's lung function. This paper conducted an experiment with 10 participants to evaluate the system from two aspects: training effectiveness and user experience. The results show that this system has significantly improved the patient's lung function. Compared with traditional training methods, the respiratory data are quantified and visualized, the rehabilitation training effect is better, and the training process is more active and interesting.

Validity and reliability of the DANU sports system for walking and running gait assessment

Objective. Gait assessments have traditionally been analysed in laboratory settings, but this may not reflect natural gait. Wearable technology may offer an alternative due to its versatility. The purpose of the study was to establish the validity and reliability of temporal gait outcomes calculated by the DANU sports system, against a 3D motion capture reference system.Approach. Forty-one healthy adults (26 M, 15 F, age 36.4 ± 11.8 years) completed a series of overground walking and jogging trials and 60 s treadmill walking and running trials at various speeds (8-14 km hr-1), participants returned for a second testing session to repeat the same testing.Main results. For validity, 1406 steps and 613 trials during overground and across all treadmill trials were analysed respectively. Temporal outcomes generated by the DANU sports system included ground contact time, swing time and stride time all demonstrated excellent agreement compared to the laboratory reference (intraclass correlation coefficient (ICC) > 0.900), aside from ground contact time during overground jogging which had good agreement (ICC = 0.778). For reliability, 666 overground and 511 treadmill trials across all speeds were examined. Test re-test agreement was excellent for all outcomes across treadmill trials (ICC > 0.900), except for swing time during treadmill walking which had good agreement (ICC = 0.886). Overground trials demonstrated moderate to good test re-test agreement (ICC = 0.672-0.750), which may be due to inherent variability of self-selected (rather than treadmill set) pacing between sessions.Significance. Overall, this study showed that temporal gait outcomes from the DANU Sports System had good to excellent validity and moderate to excellent reliability in healthy adults compared to an established laboratory reference.

The minimal clinically important difference in the treadmill six-minute walk test in active women with breast cancer during and after oncological treatments

PURPOSE

To examine the minimal clinically important difference (MCID) in the treadmill 6-minute walk test (6MWT) in women with breast cancer.

MATERIALS AND METHODS

A secondary analysis of cross-sectional data from 112 women who were undergoing chemotherapy or had undergone anticancer treatment was conducted. Participants completed the 6MWT on a treadmill and the European Organization for Research and Treatment of Cancer Questionnaire (EORTC-QLQ-C30) twice, eight weeks apart. Change in the physical function domain of the EORTC-QLQ-C30 was used to classify the "positive change" subgroup (≥5 points difference) and the "unchanged" subgroup (<5 points difference). This was combined with the distance difference from the 6MWTs, determining the MCID as the cut-off from the area under the receiver operating characteristic (AUROC) curve (anchor-based determination). The MCID was also determined from (1) the effect size and (2) the difference in standard error (SEM) of the results of the first and second 6MWT (distribution-based determination).

RESULTS

The MCIDs in the during-chemotherapy group was 66.5 and 41.5 m and those in the after-treatment group to be 41.4 and 40.5 m (SEM and effect size based respectively).

CONCLUSIONS

The MCID in the treadmill 6MWT distance could be used to interpret changes in the physical health status of women with breast cancer.IMPLICATIONS FOR REHABILITATIONThe MCID for the 6MWT on treadmill in active women with breast cancer is of approximately 54 m during chemotherapy, and 41.6 m after treatment.The MCID on treadmill 6MWT distance could be used to interpret a decline in the physical health status of women with breast cancer.The 6MWT on treadmill could be an easy, feasible, performed under controlled conditions, alternative to the 6MWT to obtain valuable information in this population.

Greater exercise tolerance in COPD during acute intermittent compared to continuous shuttle walking protocols: A proof-of-concept study

Objectives: Ground-based walking is a simple training modality which would suit pulmonary rehabilitation (PR) settings with limited access to specialist equipment. Patients with COPD are, however, unable to walk uninterruptedly at a relatively fast walking pace to optimise training benefits. We compared an intermittent (IntSW) to a continuous (CSW) shuttle walking protocol.Methods: In 14 COPD patients (mean ± SD. FEV₁: 45 ± 21% predicted) we measured walking distance, cardiac output (CO), arterial oxygen saturation (SpO₂), and symptoms during (a) an IntSW protocol, consisting of 1-min walking alternating with 1-min rest, and (b) a CSW protocol, both sustained at 85% of predicted VO₂ peak to the limit of tolerance (Tlim).Results: Median (IQR) distance was greater (p = 0.001) during the IntSW protocol (735 (375-1107) m) than the CSW protocol (190 (117-360) m). At iso-distance (distance at Tlim during CSW) the IntSW compared to the CSW protocol was associated with lower CO (8.6 ± 2.6 vs 10.3 ± 3.7 L/min; p = 0.013), greater SpO₂ (92 ± 6% versus 90 ± 7%; p = 0.002), and lower symptoms of dyspnoea (2.8 ± 1.3 vs 4.9 ± 1.4; p = 0.001) and leg discomfort (2.3 ± 1.7 vs 4.2 ± 2.2; p = 0.001). At Tlim symptoms of dyspnoea and leg discomfort did not differ between the IntSW (4.4 ± 1.9 and 3.6 ± 2.1, respectively) and the CSW protocol.Conclusions: The IntSW protocol may provide important clinical benefits during exercise training in the PR settings because it allows greater work outputs compared to the CSW.

Updated Perspectives on the Role of Biomechanics in COPD: Considerations for the Clinician

Patients with chronic obstructive pulmonary disease (COPD) demonstrate extra-pulmonary functional decline such as an increased prevalence of falls. Biomechanics offers insight into functional decline by examining mechanics of abnormal movement patterns. This review discusses biomechanics of functional outcomes, muscle mechanics, and breathing mechanics in patients with COPD as well as future directions and clinical perspectives. Patients with COPD demonstrate changes in their postural sway during quiet standing compared to controls, and these deficits are exacerbated when sensory information (eg, eyes closed) is manipulated. If standing balance is disrupted with a perturbation, patients with COPD are slower to return to baseline and their muscle activity is differential from controls. When walking, patients with COPD appear to adopt a gait pattern that may increase stability (eg, shorter and wider steps, decreased gait speed) in addition to altered gait variability. Biomechanical muscle mechanics (ie, tension, extensibility, elasticity, and irritability) alterations with COPD are not well documented, with relatively few articles investigating these properties. On the other hand, dyssynchronous motion of the abdomen and rib cage while breathing is well documented in patients with COPD. Newer biomechanical technologies have allowed for estimation of regional, compartmental, lung volumes during activity such as exercise, as well as respiratory muscle activation during breathing. Future directions of biomechanical analyses in COPD are trending toward wearable sensors, big data, and cloud computing. Each of these offers unique opportunities as well as challenges. Advanced analytics of sensor data can offer insight into the health of a system by quantifying complexity or fluctuations in patterns of movement, as healthy systems demonstrate flexibility and are thus adaptable to changing conditions. Biomechanics may offer clinical utility in prediction of 30-day readmissions, identifying disease severity, and patient monitoring. Biomechanics is complementary to other assessments, capturing what patients do, as well as their capability.

Technologies for the Instrumental Evaluation of Physical Function in Persons Affected by Chronic Obstructive Pulmonary Disease: A Systematic Review

Several systems, sensors, and devices are now available for the instrumental evaluation of physical function in persons with Chronic Obstructive Pulmonary Disease (COPD). We aimed to systematically review the literature about such technologies. The literature search was conducted in all major scientific databases, including articles published between January 2001 and April 2022. Studies reporting measures derived from the instrumental assessment of physical function in individuals with COPD were included and were divided into application and validation studies. The quality of validation studies was assessed with the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) risk of bias tool. From 8752 articles retrieved, 21 application and 4 validation studies were included in the systematic review. Most application studies employed accelerometers, gait analysis systems, instrumented mattresses, or force plates to evaluate walking. Surface electro-myography or near-infrared spectroscopy were employed in four studies. Validation studies were heterogeneous and presented a risk of bias ranging from inadequate to doubtful. A variety of data regarding physical function can be retrieved from technologies used in COPD studies. However, a general lack of standardization and limitations in study design and sample size hinder the implementation of the instrumental evaluation of function in clinical practice.

Self-paced and fixed speed treadmill walking yield similar energetics and biomechanics across different speeds

BACKGROUND

Treadmill assessments are often performed at a fixed speed. Feedback-controlled algorithms allow users to adjust the treadmill speed, hereby potentially better resembling natural self-paced locomotion. However, it is currently unknown whether the energetics and biomechanics of self-paced differ from fixed-paced treadmill walking. Such information is important for clinicians and researchers using self-paced locomotion for assessing gait.

RESEARCH QUESTION

To investigate whether energy cost and biomechanics are different between self-paced and matched-speed fixed-paced locomotion.

METHODS

18 healthy participants (9 males/9 females, mean ± standard deviation age 24.8 ± 3.3 years, height 1.71 ± 0.81 m, weight 65.9 ± 8.1 kg) walked at four different self-paced speeds (comfortable, slow, very slow, fast) in randomized order on an instrumented treadmill while three-dimensional motion capture and gas exchange were measured continuously. The average walking speed during the last 2 min of the self-paced trials was used to match the speed in fixed-paced conditions. Linear mixed models were used to assess differences in mean values and within-subject variations between conditions (self-paced and fixed-paced) and speeds. Statistical Parametric Mapping was used to assess differences in kinematics of the lower limb between conditions.

RESULTS

Although self-paced walking consistently resulted in a 4-6% higher net cost of walking, there were no significant differences in the net cost of walking between conditions. Further, there were also no differences of clinical relevance in spatiotemporal outcomes and sagittal-plane lower-limb kinematics between the self-paced and fixed-paced conditions. Within-trial variability was also not significantly different between conditions.

SIGNIFICANCE

Self-paced and fixed-paced treadmill walking yield similar energetics and kinematics in healthy young individuals when mean values or linear measures of variation are of interest.

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.

Short Physical Performance Battery: Response to pulmonary rehabilitation and minimal important difference estimates in patients with chronic obstructive pulmonary disease

OBJECTIVE

To determine the response to a pulmonary rehabilitation (PR) program and minimal important differences (MIDs) for the Short Physical Performance Battery (SPPB) subtests and SPPB summary score in patients with Chronic Obstructive Pulmonary Disease (COPD).

DESIGN

Retrospective analysis using distribution- and anchor-based methods.

SETTING

PR center in the Netherlands including a comprehensive 8-week inpatient and 14-week outpatient program of 40 sessions.

PARTICIPANTS

632 patients with COPD (age: 65±8 years, 50% male, FEV₁: 43 (27-47) % predicted) INTERVENTION: Not applicable.

MAIN OUTCOME MEASURE

Baseline and post PR results of the SPPB, consisting of three balance standing tests, 4-meter gait speed (4MGS) test and 5-repetition sit-to-stand (5STS) test. The chosen anchors were 6-minute walk test and COPD Assessment Test. Patients were stratified according to their SPPB summary scores into a low-performance, moderate-performance or high-performance group.

RESULTS

5STS (∆= -1.14 (-4.20- -0.93) seconds) and SPPB summary score (∆= 1 (0-2) points) improved after PR in patients with COPD. In patients with low-performance at baseline, balance tandem and 4MGS significantly increased as well. Based on distribution-based calculations, the MID estimates range between 2.19-6.33 seconds for 5STS and 0.83-0.96 points for SPPB summary score.

CONCLUSIONS

The 5STS and SPPB summary score are both responsive to PR in patients with COPD. The balance tandem test and 4MGS are only responsive to PR in patients with COPD with a low-performance at baseline. Based on distribution-based calculations, a MID estimate of 1 point for the SPPB summary score is recommended in patients with COPD. Future research is needed to confirm MID estimates for SPPB in different centres.

Contribution of lower limb muscle strength to walking, postural sway and functional performance in elderly women

BACKGROUND: Aging-related deterioration of the lower limb muscle strength could highly influence the functional performance of elderly individuals. OBJECTIVE: To investigate how advancing age impacts the lower limb muscle strength and consequently affects the balance and walking performance. METHODS: Twenty-seven community-dwelling elderly females underwent isokinetic ankle dorsi/plantar flexion (ADF/APF), inversion/eversion (AIN/AEV), knee flexion/extension (KFL/KEX), hip flexion/extension (HFL/HEX), and abduction/adduction (HAB/HAD) tests, the six-minute walk test, open-eyed biped balance test on foam rubber and the performance-oriented mobility assessment (POMA). RESULTS: The Pearson’s product-moment correlation coefficients demonstrated that advancing age negatively influenced the relative work and moment produced in all the muscle groups, the POMA score (r=-0.51), walking speed (r=-0.62), and the vertical (r= 0.55) and anteroposterior (r= 0.54) postural sway velocities. The peak moment and work values of AINs and APFs; KFLs and KEXs; and HABs, HFLs, and HEXs showed a significantly positive correlation with the walking speed (α⩽ 0.05). CONCLUSION: The strength of HFLs, HEXs and HABs, as the important contributors to the walking performance, underwent attenuation as the age increased, consequently resulting in impairments of stepping profiles of elderly females. Elderly females are needed to be trained to reach the optimum levels of lower limb muscular strength to overcome premature incapacitation and have control over their independence in daily activities.

An update on pulmonary rehabilitation techniques for patients with chronic obstructive pulmonary disease

Introduction: Pulmonary rehabilitation (PR) is one of the core components in the management of patients with chronic obstructive pulmonary disease (COPD). In order to achieve the maximal level of independence, autonomy, and functioning of the patient, targeted therapies and interventions based on the identification of physical, emotional and social traits need to be provided by a dedicated, interdisciplinary PR team.Areas covered: The review discusses cardiopulmonary exercise testing in the selection of different modes of training modalities. Neuromuscular electrical stimulation as well as gait assessment and training are discussed as well as add-on therapies as oxygen, noninvasive ventilator support or endoscopic lung volume reduction in selected patients. The potentials of pulsed inhaled nitric oxide in patients with underlying pulmonary hypertension is explored as well as nutritional support. The impact of sleep quality on outcomes of PR is reviewed.Expert opinion: Individualized, comprehensive intervention based on thorough assessment of physical, emotional, and social traits in COPD patients forms a continuous challenge for health-care professionals and PR organizations in order to dynamically implement and adapt these strategies based on dynamic, more optimal understanding of underlying pathophysiological mechanisms.