Balance training: its influence on pulmonary rehabilitation

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.

Pulmonary rehabilitation and risk of fall in elderly with chronic obstructive pulmonary disease

BACKGROUND

Few data are available on the effects of pulmonary rehabilitation (PR) on risk of fall in over 80 individuals with chronic obstructive pulmonary disease (COPD). We investigated the effectiveness of PR on the risk of fall in older as compared to younger than 80 individuals.

METHODS

Parallel-group retrospective exploratory study of individuals undergone in-hospital PR. The risk of fall was defined as a gait speed ≤0.8 m/s (primary outcome). Outcome measures (exercise capacity, physical performance, symptoms, and health status) were also assessed.

RESULTS

As compared to younger, individuals over 80 suffered from more severe symptoms, a reduction in physical performance and in exercise capacity and greater risk of fall (P=0.0001). The proportion of participants at risk of fall increased with age, and after PR decreased significantly without any significant difference between age groups. However, 53.4% of older individuals were still at risk of fall, as compared to 17.5% of those under 80 (P=0.0001). After PR, both populations had improved outcomes measures, without any significant between group differences.

CONCLUSIONS

In individuals with COPD pulmonary rehabilitation reduced the risk of fall, while improving outcome measures independent of age, however, more than 50% of those over 80 were still at risk of fall. The pulmonary rehabilitation programs for individuals over 80 should include strategies effective in reducing the risk of fall.

Using the RE-AIM framework to evaluate physical activity-based fall prevention interventions in older adults with chronic conditions: A systematic review

Falls are a serious public health problem, especially for older adults with chronic conditions. The purpose of this systematic review was to evaluate the translational potential of physical activity-based balance interventions for older adults with common chronic conditions guided by the Reach, Effectiveness/Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. Databases were searched (2011-2021) to identify studies with physical activity-based fall prevention interventions for older adults with chronic conditions. Data were collected using the RE-AIM coding guide and Mixed Methods Appraisal Tool for evidence quality. The search yielded 122 articles, of which 14 distinct studies were included. The most reported RE-AIM dimensions across the studies were Reach (46.2%) and Implementation (40.5%), with Effectiveness/Efficacy (29.4%), Adoption (2.0%), and Maintenance (5.4%) being the least reported. Studies were largely conducted in controlled research environments with minimal staff involvement and without long-term follow-up periods. While studies found that physical activity-based programs were effective in improving balance, information on representativeness and adoption/maintenance of programs was lacking. Studies included sufficient details about the intervention (content, dosage, progression). External validity RE-AIM indicators were reported less frequently than internal validity indicators. The studies were of moderate quality overall. Studies often lacked information on indicators critical for understanding how to implement these programs. This review signals the need to investigate the translation of these interventions from controlled research settings to clinical settings to improve the public impact of fall prevention for this population.

The effectiveness of home-based balance and pulmonary rehabilitation program in individuals with chronic obstructive pulmonary disease: a randomized controlled trial

BACKGROUND

Balance impairment and increased fall risk have been demonstrated in individuals with chronic obstructive pulmonary disease (COPD). However, studies investigating the effects of balance training especially when combined with pulmonary rehabilitation (PR) program in home-based setting are scarce.

AIM

To examine whether adding balance training to home-based pulmonary rehabilitation improves balance, fall risk, and disease-related symptoms in individuals with COPD.

DESIGN

Randomized, controlled, assessor-blinded trial with parallel two-group design.

SETTING

Home-based setting.

POPULATION

Forty-eight individuals diagnosed with COPD.

METHODS

Participants with COPD were randomly allocated to either a home-based PR or home-based balance training combined with PR (PR-BT) group (24 per group). Both groups exercised three days per week for eight-week. Primary outcomes were fall risk index and functional balance as measured by the Physiological Profile Assessment (PPA) and Timed Up and Go (TUG), respectively. Secondary outcomes were the Activities-specific Balance Confidence (ABC), Modified Medical Research Council dyspnea (mMRC), Six-Minute Walk Test (6MWT), and COPD assessment test (CAT). All outcome measures were assessed at baseline, post-intervention, and three-month follow-up.

RESULTS

All participants completed the trial, with no reported adverse events. At post-intervention, the PR-BT group demonstrated significantly greater improvements in PPA fall risk score (PR-BT: 1.1±0.8, PR: 2.4±1.5), TUG (PR-BT: 10.7±1.3, PR: 14.4±4.4 s) and these improvements remained at three-month follow-up (all P<0.01). The ABC, mMRC, and CAT scores were also significant better for the PR-BT than the PR group both after intervention and at three-month follow-up (all P<0.05).

CONCLUSIONS

Eight-week home-based balance and PR program is effective in improving balance as well as dyspnea, and well-being in individuals with COPD.

CLINICAL REHABILITATION IMPACT

Home-based balance and PR program is a promising approach for COPD rehabilitation especially in patients who are at risk of falls.

Clinical Effects of Rehabilitation on Balance in People With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Background

Patients with chronic obstructive pulmonary disease (COPD) have systemic damage secondary to the primary pulmonary impairment, expressed in impaired peripheral musculature and a deficit in postural control compared to healthy subjects. This study aimed to determine the effects of rehabilitation on balance in patients with COPD.

Methods

An exhaustive search was conducted in four databases (Pubmed, Cochrane Library, EMBASE, Web of Science). Articles with a population of COPD receiving rehabilitation (therapeutic exercise, pulmonary rehabilitation, or physical therapy modalities) in an outpatient setting were included. Two independent reviewers selected and assessed the study quality. The risk of bias was assessed with the Cochrane Risk of Bias Tool for Randomized Controlled Trials.

Results

A total of eight studies involving 284 patients were included in the qualitative synthesis. The meta-analysis showed an overall result in favor of balance training for the Berg Balance Scale (mean difference 3.91 points; 95% CI: 1.51 to 6.31; P = 0.001), Timed Up and Go test (mean difference -1.58 s; 95% CI: -2.63 to -0.53; P = 0.003) and Unipedal stance test (mean difference 3.56 s, 95% CI: 2.58 to 4.54; P).

Conclusion

This meta-analysis revealed that rehabilitation improve static and dynamic balance in patients with COPD.

Systematic Review Registration

PROSPERO ID: CRD42020218367.

[Pulmonary rehabilitation in the in-hospital and outpatient phases]

Pulmonary rehabilitation programmes aim to improve aerobic capacity and enhance quality of life in patients with chronic pulmonary disease, facilitating their participation and integration in different areas and activities of daily living, through the prescription and performance of physical exercise, as well as education on risk factors and healthy living. In multidisciplinary processes, various health professionals work together to support patients through the rehabilitation process, guiding lifestyle changes to improve their level of physical activity, nutritional factors, smoking cessation, diabetes management, medication adherence and weight loss, based on theories of behavioural change. The main objective of pulmonary rehabilitation programmes is to empower users in self-care and facilitate long-term management of chronic lung disease.

Balance impairment in individuals with COPD: a systematic review with meta-analysis

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) are four times more likely to fall than healthy peers, leading to increased morbidity and mortality. Poor balance is a major risk factor for falls. This review aims to quantify the extent of balance impairment in COPD, and establish contributing clinical factors, which at present are sparse.

METHODS

Five electronic databases were searched, in July 2017 and updated searches were performed in March 2019, for studies comparing balance in COPD with healthy controls. Meta-analyses were conducted on sample mean differences (MD) and reported correlations between balance and clinical factors. Meta-regression was used to quantify the association between mean difference in percentage predicted forced expiratory volume in 1 s (FEV₁) and mean balance impairment. Narrative summaries were provided where data were insufficient for meta-analysis.

RESULTS

Twenty-three studies were included (n=2751). Meta-analysis indicated COPD patients performed worse than healthy controls on timed up and go (MD=2.77 s, 95% CI 1.46 s to 4.089 s, p=<0.005), single leg stance (MD=-11.75 s, 95% CI -15.12 s to -8.38 s, p=<0.005) and berg balance scale (MD=-6.66, 95% CI -8.95 to -4.37, p=<0.005). The pooled correlation coefficient between balance and reduced quadriceps strength was weak-moderate (r=0.37, 95% CI 0.23 to 0.45, p=<0.005). The relationship between differences in percentage predicted FEV₁ and balance were negligible (r² =<0.04).

CONCLUSIONS

Compared with healthy controls, people with COPD have a clinically meaningful balance reduction, which may be related to reduced muscle strength, physical activity and exercise capacity. Our findings support a need to expand the focus of pulmonary rehabilitation to include balance assessment and training, and further exploration of balance impairment in COPD. PROSPERO registration number CRD4201769041.

Balance Impairment and Effectiveness of Exercise Intervention in Chronic Obstructive Pulmonary Disease-A Systematic Review

OBJECTIVE

To systematically review the evidence for balance impairment and effectiveness of interventions on balance in people with chronic obstructive pulmonary disease (COPD).

DATA SOURCES

Four electronic databases (Scopus, CINAHL, PubMed, Cochrane Library databases) were searched from inception until June 30, 2019.

STUDY SELECTION

Two reviewers independently searched with keywords focusing on COPD, postural control, and exercise. Cross-sectional studies related to balance and randomized controlled trials (RCTs) related to the effectiveness of exercise intervention on balance outcomes were included.

DATA EXTRACTION

Two reviewers independently extracted data of balance impairment on participants, exercise training on balance outcome measures. Methodological quality of cross-sectional studies was assessed using the National Institutes of Health (NIH) Quality Assessment Tool. Methodological quality of RCTs was assessed using the Physiotherapy Evidence Database (PEDro) scale and bias was analyzed using the Cochrane risk of bias.

DATA SYNTHESIS

A narrative review with descriptive synthesis was used. Fifteen cross-sectional studies and 4 RCTs met the final inclusion criteria. The quality of 10 cross-sectional studies were rated as moderate to high (NIH score≥7). Most studies demonstrated impaired balance in people with COPD than in people without COPD. The quality of all included RCTs was good to excellent (PEDro score=6-9). One RCT had a low risk of bias. Generally, pulmonary rehabilitation program combined with balance training, Tai Chi, and cycling exercise showed significant improvement in balance in people with COPD.

CONCLUSIONS

Impaired balance is evident in people with COPD. Available RCTs suggest that exercise interventions may improve balance performance in COPD patients. However, more research on the effect of exercise interventions on balance in COPD patients is still required.