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

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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.
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Age and Sex Differences in Balance Outcomes
among Individuals with Chronic Obstructive
Pulmonary Disease (COPD) at Risk of Falls
Sanaa A. Alsubheen, Marla Beauchamp, Cindy Ellerton, Roger Goldstein,
Jennifer Alison, Gail Dechman, Kimberley J. Haines, Samantha Harrison,
Anne Holland, Annemarie Lee, Alda Marques, Lissa Spencer, Michael
Stickland, Elizabeth H. Skinner & Dina Brooks
To cite this article: Sanaa A. Alsubheen, Marla Beauchamp, Cindy Ellerton, Roger Goldstein,
Jennifer Alison, Gail Dechman, Kimberley J. Haines, Samantha Harrison, Anne Holland, Annemarie
Lee, Alda Marques, Lissa Spencer, Michael Stickland, Elizabeth H. Skinner & Dina Brooks (2022)
Age and Sex Differences in Balance Outcomes among Individuals with Chronic Obstructive
Pulmonary Disease (COPD) at Risk of Falls, COPD: Journal of Chronic Obstructive Pulmonary
Disease, 19:1, 166-173, DOI: 10.1080/15412555.2022.2038120
To link to this article: https://doi.org/10.1080/15412555.2022.2038120
© 2022 The Author(s). Published by Taylor &
Francis Group, LLC.
Published online: 07 Apr 2022.
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COPD: JOURNAL OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
2022, VOL. 19, NO. 1, 166–173
Age and Sex Differences in Balance Outcomes among Individuals with
Chronic Obstructive Pulmonary Disease (COPD) at Risk of Falls
Sanaa A. Alsubheena,b , Marla Beauchampa,b, Cindy Ellertonb,c, Roger Goldsteinb,c,d,e, Jennifer Alisonf,1,
Gail Dechmang,h, Kimberley J. Hainesi, Samantha Harrisonj, Anne Hollandk,l,m,n , Annemarie Leen,o,p,
Alda Marquesq, Lissa Spencerr, Michael Sticklands,t, Elizabeth H. Skinneri,o and Dina Brooksc,d,e
aSchool of Rehabilitation Science, Faculty of Health Science, McMaster University, Hamilton, ON, Canada; bDepartment of Respiratory
Medicine, West Park Healthcare Centre, Toronto, ON, Canada; cDepartment of Physical Therapy, Faculty of Medicine, University of Toronto,
Toronto, ON, Canada; dRehabilitation Sciences Institute, School of Graduate Studies, University of Toronto, Toronto, ON, Canada; eDepartment
of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; fSchool of Health Sciences, Faculty of Medicine and Health,
University of Sydney, Sydney, NSW, Australia; gSchool of Physiotherapy, Faculty of Health, Dalhousie University, Halifax, NS, Canada;
hDepartment of Medicine, Respirology, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada; iPhysiotherapy
Department, Western Health, Melbourne, VIC, Australia; jSchool of Health and Social Care, Teesside University, Middlesbrough, UK;
kDepartment of Physiotherapy, Alfred Health, Melbourne, VIC, Australia; lDepartment of Allergy, Immunology and Respiratory Medicine,
Monash University, Melbourne, VIC, Australia; mRespiratory Research, Monash University, Melbourne, VIC, Australia; nInstitute for Breathing
and Sleep, Melbourne, VIC, Australia; oDepartment of Physiotherapy, School of Primary and Allied Health Care, Monash University,
Melbourne, VIC, Australia; pCentre for Allied Health Research and Education, Cabrini Health, Malvern, VIC, Australia; qLab3R-Respiratory
Research and Rehabilitation Laboratory, School of Health Sciences (ESSUA) and Institute of Biomedicine (iBiMED), University of Aveiro,
Aveiro, Portugal; rDepartment of Physiotherapy, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; sDivision of Pulmonary Medicine,
Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; tG.F. MacDonald Centre for Lung Health, Covenant Health,
Edmonton, AB, Canada
ABSTRACT
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.
ABBREVIATIONS:
ABC: activity specific balance confidence scale; BBS: Berg balance scale; BEST test: balance evaluation
system test; BMI: body mass index; COPD: chronic obstructive pulmonary disease; FVC: forced vital
capacity; 6-MWT: 6-min walk test; PR: pulmonary rehabilitation
Introduction
The prevalence of Chronic obstructive pulmonary disease
(COPD) is increasing rapidly in females than males [1, 2],
with the highest female prevalence found in North America
and in urban settings [2]. Furthermore, COPD is more prev-
alent in individuals who are ≥ 60 years [1]. Several studies
have suggested that symptoms, pulmonary function, exacer-
bation frequency and comorbidities vary with age and sex in
individuals with COPD [3–9]. Females < 65 years have more
severe dyspnea [3–6], airflow limitation [7], and exhibit a
higher risk of exacerbations [7–9] but have better forced
expiratory volume in 1 s (FEV1) [8] than males with COPD.
© 2022 The Author(s). Published by Taylor & Francis Group, LLC.
CONTACT Sanaa A. Alsubheen alsubhes@mcmaster.ca School of Rehabilitation Science, McMaster University, IAHS Building Room 430, 1400 Main Street
West, Hamilton, L8S 1C7 ON, Canada.
1Present address: Allied Health, Sydney Local Health District, Sydney, Australia.
https://doi.org/10.1080/15412555.2022.2038120
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work is properly cited
ARTICLE HISTORY
Received 23 July 2021
Accepted 31 January 2022
KEYWORDS
Age;
balance;
COPD;
falls;
sex
COPD: JOURNAL OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE 167
With respect to comorbidities, males with COPD have a
higher risk of developing ischemic heart disease [6, 10, 11],
while osteoporosis [6, 10, 11], anxiety and depression [3, 5,
6] are more frequent in females. Older adults with COPD
have increased risk of cardiovascular diseases, osteoporosis,
fractures, as well as depression and anxiety [12]. In partic-
ular, females > 65 years with COPD have lower exercise
tolerance [9, 13] and multiple comorbidities [14].
Interestingly, females have a greater 5-year survival than
males (87% vs. 76%) with COPD [8].
Advanced age, female sex, and deficits in balance control
are all associated with an increased risk of falls [15–18],
attributed to decreased levels of physical activity [16], muscle
weakness [16], altered trunk muscle mechanics [15] and
somatosensory deficits [19]. Such functional limitations can
lead to activity avoidance, reduced activities of daily living,
social isolation, depression, and decreased health-related quality
of life, all of which impact the management of COPD [20].
Balance training combined with pulmonary rehabilitation
(PR) and fall prevention programs improves balance impair-
ments [21, 22], health-related quality of life, fatigue, and
mental health [23] and reduces the risk of falls in COPD
[18]. However, despite these balance training benefits, bal-
ance impairments persisted in patients with acute exacer-
bation of COPD (AECOPD) after one-month of training
compared to patients without AECOPD [24]. The declined
balance in AECOPD may need adjusting balance training
programs to maximize training benefits in patients with
AECOPD. Similarly, potential age and sex differences in
balance impairments in individuals with COPD may require
clinicians to modify balance training parameters (duration,
intensity, & frequency) for optimizing treatment effects and
obtaining better outcomes.
As noted earlier, age and sex differences were detected
in several demographical, physiological, and functional out-
comes in individuals with COPD, which are reported to
affect therapeutic approaches to individuals with COPD [6,
25]. To our knowledge, no previous study assessed age and
sex differences in balance outcomes in individuals with
COPD. Therefore, this study explores the association of age
and sex differences on balance outcomes among individuals
with COPD who are at risk of falling. We hypothesized that
females and older adults have higher balance deficits than
males and younger individuals with COPD.
Methods
Study design and participants
This study was reported in accordance with the STrengthening
the Reporting of OBservational studies in Epidemiology
(STROBE) [26]. A secondary analysis of baseline data from
an ongoing randomized controlled trial (RCT) that is inves-
tigating the effect of pulmonary rehabilitation combined
with balance training on fall reduction in individuals with
COPD was conducted (https://clinicaltrials.gov/ct2/show/
NCT02995681) [27]. Ethics approval was received for the
RCT protocol at all participating sites, and informed consent
was obtained from all participants. A full description of the
recruitment process and data collection is described in the
published protocol [27].
Participants were included in this study if they meet the
following inclusion criteria: (1) aged 50 years or more; (2)
had a confirmed clinical diagnosis of COPD using a spi-
rometry test based on the Global Initiative for Chronic
Obstructive Lung Disease (GOLD) criteria—postbronchodi-
lator FEV1/forced vital capacity (FVC) ratio < 70%; (3)
reported a history of falls or balance problems; and (4)
completed baseline balance measures including the Berg
Balance Scale (BBS) [28], the Balance Evaluation System
Test (BEST test) [29], and Activity specific Balance
Confidence scale (ABC) [30].
Clinical and physiological characteristics of 223 individ-
uals with COPD [age, sex, body mass index (BMI), smoking
history, oxygen use, spirometry, presence of comorbid con-
ditions, six-min walk test (6-MWT), Baseline Dyspnea Index
(BDI), and number of falls at one and two years] were
retrieved from baseline study data. Balance outcomes were
compared in male and female, adults (50-65 years) and older
adults (> 65 years) [31]. The severity of dyspnea was deter-
mined by the number of oxygen users and the BDI score
(total score =12, 12 meaning no dyspnea) [32].
Balance outcome measures
Balance was assessed using the BBS, BEST test, and ABC
scale [28–30]. The BBS assesses 14 tasks such as transfers,
reaching, turning around and single-legged standing and
has a total score of 56 points, with higher scores indicating
better balance [28]. The BBS is a valid [r = 0.53–0.75] and
reliable [Interrater correlation coefficient (ICC) = 0.94] mea-
sure of balance control [33]. The minimal clinically import-
ant difference (MCID) value for the BBS is a change of 5-7
points [34] and the Minimal Detectable change (MDC) value
is found to be 5.9 points in one study [33] and 3.5 in
another study [35].
The BEST test assesses six subsystems of balance control:
biomechanics, stability limits/verticality, anticipatory pos-
tural adjustments, postural responses, sensory orientation,
and stability during gait [29]. It consists of 27 tasks with
some items consisting of two sets of four subitems (for left
and right sides), equaling a total of 36-items. Each item is
scored on a 4-level, ordinal scale from zero (worst perfor-
mance) to three (best performance). Scores for the test and
each section are provided as a percentage of total points
ranging from 0 100%. The BEST test is a valid [r = 0.64]
and reliable [ICC = 0.85] measure of balance control [33].
The MCID value for the BEST test is a change of 13-17
points [34] and the MDC value is 6.3 points [33].
The ABC scale requires participants to indicate their
confidence performing 16 functional activities without losing
their balance. The total score ranges from 0% to 100%, with
higher scores indicating greater balance confidence [30].
The ABS scale, is a valid [r = 0.75] measure of balance con-
fidence [33]. The MCID value for the ABC scale is a change
of 19 points [34] and the MDC is 8.3% [35].
168 S. A. ALSUBHEEN ETAL.
Assessment of exercise tolerance
Exercise tolerance was assessed using the 6-MWT. Patients
walk for six minutes, attempting to cover as much distance
as possible within the time allotted. The distance covered
is measured in meters [36]. A detailed description of the
test is published [37]. The test has been shown to be valid
and reproducible [38] and has been previously used to
assess exercise tolerance in COPD [39]. In average, healthy
adults aged 40–80 years can walk 571 m (range, 380–
782 m) [13].
The expected value of the 6-MWT was calculated using
the equation proposed by Troosters [40] as follows: Predicted
6MWT = 218 + 5.14 * height (cm) – 5.32 * age (years) – 1.8
* weight (kg) + 51.31 * sex. Then, the percentage of the
predicted value of the 6-MWT was calculated by dividing
the absolute value of the 6-MWT by the predicted value of
6-MWT and then multiplying by 100 as follows: Absolute
6-MWT/predicted 6-MWT * 100.
Statistical analysis
Statistical analyses were performed using SPSS® (version
27, Chicago, IL, USA). A P value of < 0.05 was considered
statistically significant. Descriptive statistics were used to
report the clinical and physiological variables (age, BMI,
smoking history, and comorbidities). An independent t-test
was used to detect differences in age and sex groups for
the number of falls in the last one and two years, spi-
rometry data, the 6-MWT (absolute and % of predicted
values), and BDI. A chi-square test was used to detect
differences between groups for oxygen use. One-way
ANOVA was used to detect differences in balance out-
comes (BEST test, BBS, and ABC) based on age groups
(adults: 50–65, older adults > 65 years) and sex (male,
female). Pearsons correlation coefficients (r) were calcu-
lated between balance measures and risk factors. The rela-
tionship strength of the correlations were classified as
follows: 0.1 ≤ r < 0.3 = weak associ ation, 0.3 ≤ r < 0.5 = mod-
erate association, r ≥ 0.5 = strong association [41]. A mul-
tivariable regression analysis was run to examine the effect
of age (continuous variable) and sex (male, female) on
balance measures (BBS, BEST test, ABC scale) at baseline.
A second multivariable regression analysis was run to
examine how other risk factors modulate the effect of age
and sex on balance outcomes. Risk factors that had sig-
nificant correlations with balance measures (Table 3) were
included in the regression analyses.
Table 1. Clinical and physiological characteristics of individuals with COPD.
Variable
Male
N = 123
Female
N = 100
Adults
(50–65 years)
N = 47
Older adults
(> 65 years)
N = 176
All participants
N = 223
Age, year 73 ± 8 71 ± 9 60 ± 4 75 ± 6 72 ± 9
Sex, N (%)
Males 20 (43) 103 (59) 123 (55)
Females 27 (57) 73 (41) 100 (45)
BMI, kg/m227 ± 5 28 ± 6 29 ± 6 27 ± 6 28 ± 6
Smoking, pack/year 52 ± 47 41 ± 22 45 ± 36 47 ± 39 47 ± 38
Have comorbidities, N (%)
Diabetes 26 (21) 16 (16) 5 (11) 37 (21) 42 (19)
Cardiac disease 47 (38) 31 (31) 11 (23) 67 (38) 78 (35)
Hypertension 58 (47) 35 (35) 12 (26) 81 (46) 93 (42)
Anxiety and depression 12 (10) 20 (20) 10 (21) 22 (13) 32 (14)
Dyslipidemia 38 (31) 17 (17) 7 (15) 48 (27) 55 (25)
GERD 11 (9) 16 (16) 7 (15) 20 (11) 27 (12)
MSK conditions 66 (54) 72 (72) 25 (53) 113 (64) 138 (62)
Falls History
Falls in the last year 0.60 ± 0.8 0.88 ± 0.80.74 ± 0.9 0.87 ± 0.9 0.73 ± 0.8
Falls in the last 2 years 0.78 ± 0.8 1.1 ± 0.90.72 ± 0.8 0.91 ± 0.9 0.90 ± 0.9
Spirometry N = 76 N = 49 N = 29 N = 96 N = 125
FEV1, L 1.55 ± 0.7 1.16 ± 0.61.42 ± 0.7 1.39 ± 0.7 1.40 ± 0.7
FEV1% predicted 51.4 ± 17, N = 104 53.2 ± 17, N = 75 50.9 ± 16, N = 47 52.6 ± 17, N = 132 52.1 ± 17, N = 180
FVC, L 3.15 ± 0.9 2.19 ± 0.62.74 ± 0.8 2.78 ± 0.9 2.77 ± 0.9
FVC % predicted 76.8 ± 22 79.9 ± 22 75.2 ± 17 78.9 ± 23 78 ± 22
FEV1/FVC, ratio 0.49 0.52 0.52 0.51 0.51
Oxygen use, N (%)
Yes 13 (11) 23 (23)8 (17) 26 (15) 34 (15)
No 110 (89) 77 (77) 39 (83) 150 (85) 189 (85)
BDI, points out of 12 7 ± 3 6 ± 26 ± 3 6 ± 3 6 ± 2
6-MWT, m 336 ± 163 272 ± 129363 ± 191 292 ± 135307 ± 151
%PV, 6-MWT 53.5 ± 24 42.8 ± 20 48.8 ± 23
Note: Descriptive statistics were used to describe the clinical and physiological characteristics of individuals with COPD. Continuous data are presented as mean
and standard deviation (SD). Categorical data are presented as number and percentage (%).
Independent t-test was used to detect dierences in age and sex groups for the variables: BDI, Spirometry, falls history, and 6-MWT. Chi-square test was used
to detect dierences between groups for the oxygen use.
Signicant dierence between groups, p < 0.05.
Abbreviations: COPD: chronic obstructive pulmonary disease; N: sample size; BMI: body mass index; GERD: Gastroesophageal Reux Disease; MSK: musculoskeletal,
BDI: baseline dyspnea index, FEV1: forced expiratory volume at 1 s; FVC: forced vital capacity; 6-MWT: 6-min walk test, %PV: percentage of predicted value of
the 6-MWT.
COPD: JOURNAL OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE 169
Results
Clinical and physiological characteristics
Analyses of the clinical and physiological characteristics were
completed for 223 individuals with COPD (123 male, 100
female). On average, participants were 72 ± 9 years of age, with
a mean BMI of 28 ± 6 kg/m2. Females significantly used more
oxygen [N = 23 for female vs. 13 for male, p < 0.05], had lower
FEV1 [Mean difference (MD) = 0.39 L, p < 0.05], FVC [MD
= 0.96 L, p < 0.05], BDI [MD = 1 point, p < 0.05], and exercise
tolerance [Absolute (MD = 64 m) & % of Predicted value
(MD = 11%) of the 6-MWT, p < 0.05], and higher number
of falls in the last one [MD = 0.3-point, p < 0.05] and two
[MD = 0.3-point, p < 0.05] years, than males with COPD.
Older adults (> 65 years) had significant lower exercise
tolerance [MD = 71 m, p < 0.05] than adults (50–65 years).
A summary of the clinical and physiological characteristics
between adults and older adults and between males and
females is presented in Table 1.
Balance outcomes – age and sex dierences
Significant differences in balance outcomes were detected
between the two age groups. Adults > 65 years had worse
scores in three out of the six BEST test subcategories includ-
ing: body biomechanics, anticipatory postural adjustments,
and stability in gait, and worse overall balance compared
to adults ≤65 years with COPD as detected by the BBS [MD
= 3 points, p < 0.009] and BEST test total score [MD = 7
points, p < 0.01] (Table 2).
Significant differences in balance outcomes were also
detected between males and females with COPD. Females
had poorer scores in all BEST test subcategories except
biomechanics, worse overall balance, and less confidence to
perform balance-related activities compared to males as
detected by the BBS [MD = 2 points, p < 0.02], BEST test
total score [MD = 7 points, p < 0.003] and ABC scale [MD
= 10 points, p < 0.001] (Table 2).
Associations with balance outcomes
Associations of age and balance outcomes
Pearsons correlations revealed significant negative and mod-
erate associations between age and BBS scores (r = −0.37,
p < 0.001), BEST test score (r = −0.33, p < 0.001), and negative
and weak association with the ABC scale (r = −0.13, p < 0.03),
indicating that overall balance, and confidence to perform
balance-related activities decline with aging.
Associations of sex and balance outcomes
Pearsons correlations revealed significant negative and weak
associations between sex and BBS scores (r = −0.17, p < 0.001),
BEST test score (r = −0.22, p < 0.001), and ABC scale
(r = −0.29, p < 0.001), indicating that females with COPD
have poorer overall balance and less confidence to perform
balance-related activities than males with COPD.
Associations of other risk factors and balance outcomes
Pearsons correlations revealed significant positive and strong
correlations for the BDI with the ABC scale (r = 0.50,
p < 0.001), and for the 6-MWT with the BBS (r = 0.50,
p < 0.001), BEST test (r = 0.54, p < 0.001), and ABC scale
Table 2. Age and sex dierences in balance outcomes in individuals with COPD (n = 223).
Variable
Adults
(50–65 years)
Older adults
(> 65 years) P value Males Females P value All participants
BBS, points 51 ± 4 (49–52) 48 ± 8 (46–49) 0.009 49 ± 6 (48–50) 47 ± 8 (45–49) 0.02 48 ± 7 (47–49)
BEST test
I. Biomechanics, points 10 ± 3 (9–11) 9 ± 3 (8–9) 0.002 9 ± 3 (9–10) 9 ± 3 (8–9) NS 9 ± 3 (9–10)
Biomechanics, % 68 ± 19 (62–74) 57 ± 21 (54–60) 0.002 62 ± 23 (58–66) 57 ± 18 (54–61) NS 60 ± 22 (57–63)
II. Stability limits/
verticality, points
17 ± 2 (16–18) 16 ± 3 (16- 17) NS 17 ± 3 (16–17) 16 ± 3 (15–16) 0.003 16 ± 3 (16–17)
Stability limits/verticality,
%
81 ± 10 (78–84) 78 ± 13 (76–80) NS 81 ± 12 (78–83) 76 ± 13 (73–78) 0.003 78 ± 13 (77–80)
III. Anticipatory postural
adjustment, points
13 ± 3 (13–14) 12 ± 3 (11–12) 0.003 13 ± 3 (12–13) 12 ± 3 (11–12) 0.03 12 ± 3 (12–13)
Anticipatory postural
adjustment, %
74 ± 15 (70–79) 65 ± 19 (62–68) 0.003 71 ± 17 (67–73) 64 ± 19 (61–68) 0.03 68 ± 19 (65–70)
IV. Postural responses,
points
13 ± 4 (12–15) 12 ± 5 (11–13) NS 13 ± 5 (13–14) 11 ± 5 (10–12) 0.001 12 ± 5 (12–13)
Postural responses, % 74 ± 25 (66–81) 67 ± 27 (63–71) NS 74 ± 25 (70–79) 62 ± 26 (56–67) 0.001 69 ± 27 (65–72)
V. Sensory orientation,
points
13 ± 2 (12–14) 12 ± 3 (11–12) NS 13 ± 3 (12–13) 12 ± 3 (11–12) 0.04 12 ± 3 (12–13)
Sensory orientation, % 85 ± 16 (81–89) 79 ± 21 (76–83) NS 83 ± 18 (80–87) 78 ± 22 (73–82) 0.04 81 ± 21 (78–83)
VI. Stability during gait,
points
16 ± 4 (15–17) 14 ± 5 (13–15) 0.02 15 ± 4 (14–16) 14 ± 5 (13–15) 0.02 14 ± 5 (14–15)
Stability during gait, % 75 ± 18 (70–80) 67 ± 22 (64–70) 0.02 72 ± 21 (68–76) 65 ± 22 (60–70) 0.02 69 ± 23 (66–72)
Total, points 82 ± 14 (78–86) 75 ± 19 (72–77) 0.01 80 ± 16 (77–83) 73 ± 16 (70–76) 0.003 77 ± 17 (74–79)
Total, % 76 ± 13 (72–79) 69 ± 16 (67–72) 0.01 74 ± 15 (71–76) 68 ± 15 (65–71) 0.003 71 ± 15 (69–73)
ABC, % 71 ± 21 (65–77) 72 ± 21 (69–75) NS 77 ± 19 (74–81) 66 ± 21 (61–70) 0.001 72 ± 21 (69–75)
Note: One-way ANOVA was used to detect dierences in balance outcomes based on age and sex. Data are presented as mean ± SD and 95% condence
intervals (95% CI).
Abbreviations: COPD: chronic obstructive pulmonary disease; N: sample size; BBS: Berg balance scale; BEST test: balance evaluation system test; ABC:
Activities-specic Balance Condence Scale; CI: condence intervals, NS: nonsignicant.
170 S. A. ALSUBHEEN ETAL.
(r = 0.54, p < 0.001). A summary of all significant Pearsons
correlations is presented in Table 3.
Predictors of balance outcomes
A summary of the regression models is presented in Tabl e
4. In the first model, age and sex were significant predictors
of the BBS, BEST test, and the ABC scale (p < 0.001). Males
had higher BBS [B (SE) = −3.2 (0.88), p < 0.001] and BEST
test [B (SE) = −12.3 (2.7), p < 0.001] scores than females,
and with nine-year increase in age, BBS scores decreased
by 3 points [B (SE) = −0.34 (0.05), p < 0.001] and BEST test
decreased by 3.5% [B (SE) = −0.39 (0.16), p = 0.014]. Males
also had higher balance confidence than females [B (SE) =
−12.3 (2.7), p < 0.001], and with nine-year increase in age,
the ABC score decreased by 3.5% [B (SE) = −0.39 (0.16),
p = 0.014]. Together, age and sex explained 19%, 17% and
10% of the variability in BBS, BEST test, and the ABC
scores, respectively (Table 4).
After controlling for the effect of other balance risk fac-
tors, age, BDI, and the 6-MWT were significant predictors
of the BBS (p < 0.001). With each nine-year increase in age,
BBS scores decreased by 2 points [B (SE) = −0.23 (0.05),
p < 0.001], with each two scores increase in the BDI, BBS
scores increased by 1.5 points [B (SE) = 0.73 (0.18),
p < 0.001], and with each 30 m increase in the 6-MWT, BBS
scores increased by 0.39 points [B (SE) = 0.013 (0.003),
p < 0.001]. Together, age, BDI, and the 6-MWT explained
38% of the variability in the BBS scores.
For the BEST test, age, sex, BDI, and the 6-MWT were
significant predictors. Males had higher BEST test scores
than females [B (SE) = −4.51 (1.9), p = 0.02], with e ach
nine-year increase in age, BEST test score decreased by
3.4% [B (SE) = −0.38 (0.10), p < 0.001], with each one
score increase in BDI, BEST test scores increased by 1.5%
[B (SE) = 1.5 (0.38), p < 0.001], and with each 30 m
increase in the 6-MWT, BEST test scores increased by
1.2% [B (SE) = 0.04 (0.01), p < 0.001]. Together, age, sex,
BDI, and the 6-MWT explained 40% of the variability in
the BEST test scores. And for the ABC sale, BDI and the
6-MWT were significant predictors. With each one score
increase in the BDI, ABC scale scores increased by 2.4%
[B (SE) = 2.4 (0.53), p < 0.001], and with each 30 m
increase in the 6-MWT, ABC scale score increased by
1.2% [B (SE) = 0.04 (0.01), p < 0.001]. Together, BDI, and
the 6-MWT explained 44% of the variability in the ABC
scale scores (Table 4).
Discussion
This study demonstrates age- and sex-related differences in
balance outcome measures among individuals with COPD
at risk of falls. Within this cohort, females had higher bal-
ance impairments and lower confidence to perform func-
tional activities than males with COPD. Advanced age was
moderately associated with poor balance control and weakly
with balance confidence. These age and sex differences in
balance outcomes justify the potential importance of balance
retraining for optimizing pulmonary rehabilitation and falls
prevention programs in individuals with COPD. However,
after controlling for the effect of balance risk factors such
as dyspnea and exercise tolerance levels, age and sex were
important factors for predicting balance impairments but
not balance confidence. These results indicate that when
designing balance training programs, dyspnea and exercise
tolerance levels should be considered to obtain better treat-
ment outcomes.
COPD does aggravate balance deficits, through a com-
bination of altered postural activity of the trunk muscles
[15], lower extremity muscle weakness, decreased levels of
physical activity [16], and somatosensory deficits [19], and
higher postural and functional balance impairments have
been observed in individuals with COPD compared to
healthy/control subjects [42–45]. Reduced exercise tolerance,
gait speed, muscle force, and lung capacity, as well as the
presence of comorbidities, history of exacerbations, and the
use of oxygen therapy, are all potential risk factors under-
lying these balance impairments [42–45]. The higher balance
deficits among females with COPD reported in the present
Table 3. A summary of signicant Pearson’s correlations of risk factors and balance measures in individuals with COPD.
Variables
BBS, points
P-value
BEST test, %
P-value
ABC scale, %
P-value
Age −0.37, < 0.001 −0.33, < 0.001 −0.13, = 0.03
Sex, male −0.17, < 0.001 −0.22, < 0.001 −0.29, < 0.001
BDI 0.43, < 0.001 0.44, < 0.001 0.50, < 0.001
6-MWT 0.50, < 0.001 0.54, < 0.001 0.54, < 0.001
Falls in the last year −0.21, < 0.001 −0.23, < 0.001 −0.29, < 0.001
Falls in the last two years −0.27, < 0.001 −0.28, < 0.001 −0.30, < 0.001
FVC, L 0.17, = 0.007 0.34, < 0.001
FVC% 0.16, = 0.009
Have Cardiac disease −0.13, = 0.03
Have Hypertension 0.13, = 0.03
Have Dyslipidemia 0.18, = 0.004
Have GERD 0.13, = 0.04
Have MSK condition −0.18, = 0.005
Abbreviations: COPD: chronic obstructive pulmonary disease BBS: Berg balance scale; BEST test: balance evaluation system test; ABC: Activities-specic Balance
Condence Scale, NS: non-signicant, FVC: forced vital capacity, GERD: Gastroesophageal Reux Disease; MSK: musculoskeletal, BDI: baseline dyspnea index,
6-MWT: 6-min walk test.
COPD: JOURNAL OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE 171
study can be attributed to the more frequent use of oxygen
therapy, reduced exercise tolerance, and decreased lung func-
tion. These findings are consistent with a previous report
that noted worse balance control among community-dwelling
older females. In that study, poor balance control was
attributed to less effective proprioceptive control [46].
Besides, the decreased lung capacity in females was consis-
tent with previous observations [9, 39]. In one study, lower
lung function was associated with lower exercise tolerance
[47]. Thus, we may attribute the poor exercise tolerance in
females with COPD to the decreased FEV1 and FVC.
Impaired balance has been linked to an increased risk
of falls among individuals with COPD [42], and the current
study reported more frequent falls in the last one and two
years among females with COPD. Possible factors that cause
frequent falls in COPD include reduced balance confidence,
older age, increased dyspnea, physical inactivity, reduced
exercise tolerance, and muscle weakness [16, 17, 42]. In
this study, females with COPD had reduced balance con-
fidence and exercise tolerance, and increased balance
impairments and dyspnea, all explain the increased number
of falls among females with COPD. Previous research has
linked the lower balance confidence to perform
balance-related activities in females to less effective func-
tioning in daily life and activity avoidance [48] with
increased physical and mental health co-morbidities [6, 11].
Besides, a high prevalence of falls may cause reduced qual-
ity of life and increased mortality in individuals with COPD
[42]. Thus, preserving balance function in those patients
is important to sustain their quality of life and reduce the
risk of falls, especially among females with COPD.
Several studies have documented that healthy older adults
have more balance deficits than younger adults [15, 16].
Advanced age causes deterioration in the sensory systems
and changes muscle activation leading to impaired balance
in older adults [46, 49]. In avoiding falls, older adults tend
to maintain higher stability while walking, unlike young
adults who change walking speed or stride length [49]. We
noted differences in stability limits and postural responses
on the BEST test between older and younger adults, but
these did not reach statistical significance. However, despite
the higher balance deficits in older adults with COPD, the
number of falls in the last one and two years were the same
in both groups. Although age > 65 years is a known risk
factor for falls, this might not be expressed because of the
reduced physical activities among older adults, leading to
less frequent falls [50].
Balance training combined with PR, fall prevention pro-
grams, Tai Chi, and cycling exercise have been shown to
improve balance and fall risk in individuals with COPD
[21, 22]. However, when designing balance training pro-
grams, dyspnea and exercise tolerance levels are important
factors to consider in this population [21, 22, 51]. These
considerations are consistent with the findings of our study
showing the significant effect of these factors in predicting
balance impairments and confidence to perform functional
activities in COPD.
Strengths and limitations
This study has several strengths. It provides new information
about age and sex differences in balance outcome measures
among individuals with COPD at risk of falls. The data of
this study were collected as part of a large international
RCT (Canada, United Kingdom, Australia, and Portugal),
which increases the external validity of the results.
Additionally, balance impairments were evaluated using tools
Table 4. A summary of regression models for balance measures in individuals with COPD.
Predictors
BBS, points BEST test, % ABC scale, %
Beta, P-value Beta, P-value Beta, P-value
Model 1 Model 2 Model 1 Model 2 Model 1 Model 2
Demographics:
Age −0.38, < 0.001 −0.27, < 0.001 −0.36, < .001 −0.21, < 0.001 −0.16, = 0.014 0.01, NS
Sex-male −.22, < 0.001 −0.07, NS −0.26, < .001 −0.14, < 0.02 −0.29, < 0.001 −0.05, NS
Falls history −0.09, NS −0.05, NS −0.08, NS
Spirometry:
FVC, L −0.09, NS 0.11, NS
FVC% 0.02, NS
Comorbidities:
Cardiac disease −0.08, NS
Hypertension 0.05, NS
Dyslipidemia 0.11, NS
GERD 0.08, NS
MSK conditions −0.08, NS
Physiological
measures:
BDI 0.25, < 0.001 0.24, < 0.001 0.28, < 0.001
6-MWT 0.28, < 0.001 0.35, < 0.001 0.32, < 0.001
R20.19 0.38 0.17 0.40 0.10 0.44
Adj R20.18 0.36 0.17 0.38 0.09 0.41
Overall F25.0 26.3 23.0 20.8 12.3 13.3
P-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
Dependent variables: BBS, BEST test, and ABC scale.
Abbreviations: COPD: chronic obstructive pulmonary disease BBS: Berg balance scale; BEST test: balance evaluation system test; ABC: Activities-specic Balance
Condence Scale, NS: non-signicant, FVC: forced vital capacity, GERD: Gastroesophageal Reux Disease; MSK: musculoskeletal, BDI: baseline dyspnea index,
6-MWT: 6-min walk test.
172 S. A. ALSUBHEEN ETAL.
that are valid and reliable for individuals with COPD [16,
17, 20].
This study also has limitations. Causation cannot be
implied from cross-sectional and correlational analyses.
Furthermore, the age and sex differences in the balance
outcomes were small, and their clinical importance needs
to be substantiated. Lastly, the sample size for the spirometry
data was small (n = 125), which precluded further analysis
that assesses age and sex differences in balance outcomes
across COPD with different disease severity based on GOLD
criteria. Future studies are needed to examine balance mea-
sures based on age, sex, and disease severity.
Conclusion
In individuals with COPD who are at risk of falls, females,
and older adults (>65 years) had more balance impairments
than males and younger adults. These observations have
implications for pulmonary rehabilitation and fall prevention
in this population, particularly among females and older
individuals with COPD. We recommend taking age, sex,
and dyspnea and exercise tolerance levels into account when
planning balance training for individuals with COPD.
Acknowledgments
Dr. Dina Brooks holds the National Sanitarium Association (NSA)
Chair in Respiratory Rehabilitation Research. Dr. Marla Beauchamp
holds a Canada Research Chair in Mobility, Aging, and Chronic
Disease. This study was funded by the Canadian Institute of Health
Research (CIHR funding reference # PJT 148566).
Declaration of Interest
All authors declare no conict of interest.
Funding
is study was funded by the Canadian Institute of Health Research
(CIHR funding reference # PJT 148566).
ORCID
Sanaa A. Alsubheen http://orcid.org/0000-0001-9841-7522
Anne Holland http://orcid.org/0000-0003-2061-845X
Elizabeth H. Skinner http://orcid.org/0000-0003-0268-7160
Dina Brooks http://orcid.org/0000-0001-6080-5052
References
1. Varmaghani M, Dehghani M, Heidari E, etal. Global prevalence
of chronic obstructive pulmonary disease: systematic review and
Meta-analysis. East Mediterr Health J. 2019;25(1):47–57.
DOI:10.26719/emhj.18.014
2. Ntritsos G, Franek J, Belbasis L, etal. Gender-specic estimates
of COPD prevalence: a systematic review and Meta-analysis. Int
J Chron Obstruct Pulmon Dis. 2018;13:1507–1514. DOI:10.2147/
COPD.S146390
3. Roche N, Deslée G, Caillaud D, Initiatives BPCO Scientic
Committee, et al. Impact of gender on COPD expression in a
real-life cohort. Respir Res. 2014;15:20–23.
DOI:10.1186/1465-9921-15-20
4. Skoczyński S, Zejda J, Brożek G, et al. Clinical importance of
sex dierences in dyspnea and its sex related determinants in
asthma and COPD patients. Adv Med Sci. 2019;64(2):303–308.
DOI:10.1016/j.advms.2019.03.003
5. Zysman M, Burgel P-R, Brinchault-Rabin G, on behalf of the
Initiatives BPCO scientic committee and investigators, et al.
Relationship between gender and survival in a real-life cohort
of patients with COPD. Respir Res. 2019;20(1):5. DOI:10.1186/
s12931-019-1154-3
6. Gut-Gobert C, Cavaillès A, Dixmier A, etal. Women and COPD:
do we need more evidence? Eur Respir Rev. 2019;28(151):180055.
DOI:10.1183/16000617.0055-2018
7. DeMeo DL, Ramagopalan S, Kavati A, COPDGene Investigators,
et al. Women manifest more severe COPD symptoms across the
life course. Int J Chron Obstruct Pulmon Dis. 2018;13:3021–3029.
DOI:10.2147/COPD.S160270
8. Perez TA, Castillo EG, Ancochea J, etal. Sex dierences between
women and men with COPD: a new analysis of the 3CIA study.
Respir Med. 2020;171:106105. DOI:10.1016/j.rmed.2020.106105
9. de Torres JP, Casanova C, Hernandez C, etal. Gender and COPD
in patients attending a pulmonary clinic. Chest. 2005;128(4):2012–
2016. DOI:10.1016/j.rmedu.2006.01.003
10. Trigueros JA, Riesco JA, Alcázar-Navarrete B, et al. Clinical
features of women with COPD: Sex dierences in a cross-sectional
study in Spain (“the ESPIRAL-ES study”). COPD. 2019;Volume
14:2469–2478. DOI:10.2147/COPD.S217921
11. Almagro P, García FL, Cabrera FJ, et al. Comorbidity and
gender-related dierences in patients hospitalized for COPD. e
ECCO study. Respir Med. 2010;104(2):253–259. DOI:10.1016/j.
rmed.2009.09.019
12. Gelberg J, McIvor RA. Overcoming gaps in the management of
chronic obstructive pulmonary disease in older patients. Drugs
Aging. 2010;27(5):367–375. DOI:10.2165/11535220-000000000-
00000
13. Casanova C, Celli BR, Barria P, on behalf of the Six Minute
Walk Distance Project (ALAT), et al. e 6-min walk distance
in healthy subjects: reference standards from seven countries.
Eur Respir J. 2011;37(1):150–156. DOI:10.1183/09031936.00194909
14. Miller J, Edwards LD, Agustí A, Evaluation of COPD
Longitudinally to Identify Predictive Surrogate Endpoints
(ECLIPSE) Investigators, et al. Comorbidity, systemic inamma-
tion and outcomes in the ECLIPSE cohort. Respir Med.
2013;107(9):1376–1384. DOI:10.1016/j.rmed.2013.05.001
15. Smith MD, Chang AT, Seale HE, et al. Balance is impaired in
people with chronic obstructive pulmonary disease. Gait Posture.
2010;31(4):456–460. DOI:10.1016/j.gaitpost.2010.01.022
16. Beauchamp MK, Sibley KM, Lakhani B, et al. Impairments in
systems underlying control of balance in COPD. Chest.
2012;141(6):1496–1503. DOI:10.1378/chest.11-1708
17. Beauchamp MK, Hill K, Goldstein RS, et al. Impairments in
balance discriminate fallers from non-fallers in COPD. Respir
Med. 2009;103(12):1885–1891. DOI:10.1016/j.rmed.2009.06.008
18. Pereira ACAC, Xavier RF, Lopes AC, et al. e mini-balance
evaluation system test can predict falls in clinically stable out-
patients with COPD: a 12-Mo prospective cohort study. J
Cardiopulm Rehabil Prev. 2019;39(6):391–396. DOI:10.1097/
HCR.0000000000000427
19. Roig M, Eng JJ, Road JD, et al. Falls in patients with chronic
obstructive pulmonary disease: a call for further research. Respir
Med. 2009;103(9):1257–1269. DOI:10.1016/j.rmed.2009.03.022
20. Oliveira CC, Lee A, Granger CL, et al. Postural control and fear
of falling assessment in people with chronic obstructive pulmo-
nary disease: a systematic review of instruments, international
classication of functioning, disability and health linkage, and
measurement properties. Arch Phys Med Rehabil. 2013;94(9):1784–
1799.e7. DOI:10.1016/j.apmr.2013.04.012
COPD: JOURNAL OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE 173
21. Chuatrakoon B, Ngai SPC, Sungkarat S, et al. Balance impairment
and eectiveness of exercise intervention in chronic obstructive pul-
monary disease—a systematic review. Arch Phys Med Rehabil.
2020;101(9):1590–1602.
22. Delbressine JM, Vaes AW, Goërtz YM, et al. Effects of
exercise-based interventions on fall risk and balance in patients
with chronic obstructive pulmonary disease: a systematic review.
J Cardiopulm Rehabil Prev. 2020;40(3):152–163. DOI:10.1097/
HCR.0000000000000513
23. Mkacher W, Mekki M, Chaieb F, et al. Balance training in pul-
monary rehabilitation. J Cardiopulm Rehabil Prev. 2015;35(4):278–
285. DOI:10.1097/HCR.0000000000000122
24. Harrison SL, Araujo T, Goldstein R, etal. Balance measures over
12 months in individuals with chronic obstructive pulmonary
disease. J Cardiopulm Rehabil Prev. 2019;39(3):E21–4.
DOI:10.1097/HCR.0000000000000435
25. Butler SJ, Li LSK, Ellerton L, et al. Prevalence of comorbidities
and impact on pulmonary rehabilitation outcomes. ERJ Open
Res. 2019;5(4):00264-2019. DOI:10.1183/23120541.00264-2019
26. Vandenbroucke JP, von Elm E, Altman DG, STROBE Initiative,
et al. Strengthening the reporting of observational studies in
epidemiology (STROBE): explanation and elaboration. Int J Surg.
2014;12(12):1500–1524. DOI:10.1016/j.ijsu.2014.07.014
27. Beauchamp MK, Brooks D, Ellerton C, etal. Pulmonary rehabil-
itation with balance training for fall reduction in chronic ob-
structive pulmonary disease: protocol for a randomized controlled
trial. JMIR Res Protoc. 2017;6(11):e228. DOI:10.2196/resprot.8178
28. Berg K, Wood-Dauphine S, Williams JI, etal. Measuring balance
in the elderly: preliminary development of an instrument.
Physiother Canada. 1989;41(6):304–311. DOI:10.3138/ptc.41.6.304
29. Horak FB, Wrisley DM, Frank J. e balance evaluation systems
test (BESTest) to differentiate balance deficits. Phys Ther.
2009;89(5):484–498. DOI:10.2522/ptj.20080071
30. Powell LE, Myers AM. e activities-specic balance condence
(ABC) scale. Journals Gerontol Ser A Biol Sci Med Sci.
1995;50A(1):M28–34. DOI:10.1093/gerona/50A.1.M28
31. StatisticsCanada. Age Categories, Life Cycle Groupings. 2007.
[cited 19 Jan 2021]. Available from: https://www.statcan.gc.ca/
eng/concepts/denitions/age2. .
32. Mahler DA, Weinberg DH, Wells CK, et al . e measurement
of dyspnea. Contents, interobserver agreement, and physiologic
correlates of two new clinical indexes. Chest. 1984;85(6):751–758.
DOI:10.1378/chest.85.6.751
33. Jácome C, Cruz J, Oliveira A, et al. Validity, reliability, and
ability to identify fall status of the berg balance scale, BESTest,
mini-BESTest, and brief-BESTest in patients with COPD. Phys
er. 2016;96(11):1807–1815. DOI:10.2522/ptj.20150391
34. Beauchamp MK, Harrison SL, Goldstein RS, etal. Interpretability
of change scores in measures of balance in people with COPD.
Chest. 2016;149(3):696–703. DOI:10.1378/chest.15-0717
35. Mkacher W, Tabka Z, Trabelsi Y. Minimal detectable change for
balance measurements in patients with COPD. J Cardiopulm
Rehabil Prev. 2017;37(3):223–228. DOI:10.1097/
HCR.0000000000000240
36. Enright PL, Sherrill DL. Reference equations for the six-minute
walk in healthy adults. Am J Respir Crit Care Med. 1998;158(5 Pt
1):1384–1387. DOI:10.1164/ajrccm.158.5.9710086
37. Enright PL. e six-minute walk test. Respir Care. 2003;48:783–
785.
38. Grosbois JM, Riquier C, Chehere B, et al. Six-minute stepper
test: a valid clinical exercise tolerance test for COPD patients.
Int J Chron Obstruct Pulmon Dis. 2016;11:657.
39. Ferrari R, Tanni SE, Lucheta PA, etal. Gender dierences in predic-
tors of health status in patients with COPD. J Bras Pneumol.
2010;36(1):37–43. DOI:10.1590/S1806-37132010000100008
40. Troosters T, Gosselink R, Decramer M. Six minute walking dis-
tance in healthy elderly subjects. Eur Respir J. 1999;14(2):270–
274. DOI:10.1034/j.1399-3003.1999.14b06.x
41. Field A. Discovering statistics using IBM SPSS statistics. 4th ed.
London, UK: Sage; 2013.
42. Birinci T, Kısa EP, Akıncı B, etal. e investigation of falls and
balance from the perspective of activities of daily living in pa-
tients with COPD. COPD J Chronic Obstr Pulm Dis.
2021;18(2):147–156. DOI:10.1080/15412555.2021.1904867
43. de Castro LA, Morita AA, Sepúlveda-Loyola W, et al. Are there
dierences in muscular activation to maintain balance between
individuals with chronic obstructive pulmonary disease and con-
trols? Respir Med. 2020;173:106016. DOI:10.1016/j.
rmed.2020.106016
44. Crişan AF, Oancea C, Timar B, et al. Balance impairment in
patients with COPD. PLoS One. 2015;10(3):e0120573.
DOI:10.1371/journal.pone.0120573
45. Park JK, Deutz NEP, Cruthirds CL, et al. Risk factors for pos-
tural and functional balance impairment in patients with chron-
ic obstructive pulmonary disease. JCM. 2020;9(2):609.
DOI:10.3390/jcm9020609
46. Riva D, Mamo C, Fanì M, et al. Single stance stability and
proprioceptive control in older adults living at home: gender
and age differences. J Aging Res. 2013;2013:561695. pages.
DOI:10.1155/2013/561695
47. Farkhooy A, Bodegård J, Erikssen JE, et al. Cross-sectional and
longitudinal analyses of the association between lung function
and exercise capacity in healthy Norwegian men. BMC Pulm
Med. 2018;18(1):118. DOI:10.1186/s12890-018-0655-z
48. Nemmers TM, Miller JW. Factors inuencing balance in healthy
community-dwelling women age 60 and older. J Geriatr Phys
er. 2008;31:93–100.
49. Shkuratova N, Morris ME, Huxham F. Eects of age on balance
control during walking. Arch Phys Med Rehabil. 2004;85(4):582–
588. DOI:10.1016/j.apmr.2003.06.021
50. Franco MR, Tong A, Howard K, et al . Older people’s perspec-
tives on participation in physical activity: a systematic review
and thematic synthesis of qualitative literature. Br J Sports Med.
2015;49(19):1268–1276. DOI:10.1136/bjsports-2014-094015
51. Mkacher W, Mekki M, Tabka Z, et al. Eect of 6 months of
balance training during pulmonary rehabilitation in patients with
COPD. J Cardiopulm Rehabil Prev. 2015;35(3):207–213.
DOI:10.1097/HCR.0000000000000109
... Poor balance control is a risk factor for falls [7], and repeated falls can lead to activity restriction and reduced independence or loss of confidence [10]. Additionally, advanced age (>65 years) and female sex have been associated with reduced balance confidence, balance instability, impairment of proprioceptive control and activity avoidance in older adults and patients with chronic diseases [11][12][13][14]. The use of gait aids may also further reduce balance confidence, as can the decline in exercise capacity and diminished lower extremity function [11,[15][16][17]. ...
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Background: Limited research assessed the validity of the Activities-specific Balance Confidence, ABC) Scale in individuals with chronic obstructive pulmonary disease, COPD) at risk of falls. We report on the scale's construct and criterion validity. Methods: Construct validity was established by assessing known groups, convergent and divergent validity. A receiver operating characteristic, ROC) curve and logistic regression examined the criterion validity of the scale. Results: In 223 individuals with COPD, the ABC Scale significantly, p < 0.001) discriminated between groups, with lower scores for females [Mean difference, MD) = 10%], rollator use [MD = 13%], and fallers [MD = 12%], and had a strong association [r = 0.58, p < 0.001] with Berg Balance Scale. The scale distinguished fallers from non-fallers with a cutoff value of 58% [Area Under the Curve = 0.64, 95% CI = 0.57 - 0.72, p < 0.001] and significantly identified fall status [B, SE) = -0.03, 0.01), p < 0.001] with an odds ratio of 0.97, 95%CI = 0.96 - 0.99). The sensitivity, specificity, and test accuracy were: 61, 58, and 60%, respectively. Conclusion: The ABC Scale showed evidence for known groups, convergent and divergent validity and can assist in identifying fall status in individuals with COPD.
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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.
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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, and 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 analysed using the Cochrane risk of bias. Data Synthesis A narrative review with descriptive synthesis was used. Fifteen cross-sectional studies and four RCTs met the final inclusion criteria. The quality of ten cross-sectional studies were rated as moderate to high (NIH score≥7). Most studies demonstrated impaired balance in people with COPD compared with controls. 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 (PR) 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.
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Reduced balance function has been observed during balance challenging conditions in the chronic obstructive pulmonary disease (COPD) population and is associated with an increased risk of falls. This study aimed to examine postural balance during quiet standing with eyes open and functional balance in a heterogeneous group of COPD and non-COPD (control) subjects, and to identify risk factors underlying balance impairment using a large panel of methods. In COPD and control subjects, who were mostly overweight and sedentary, postural and functional balance were assessed using center-of-pressure displacement in anterior-posterior (AP) and medio-lateral (ML) directions, and the Berg Balance Scale (BBS), respectively. COPD showed 23% greater AP sway velocity (p = 0.049). The presence of oxygen therapy, fat mass, reduced neurocognitive function, and the presence of (pre)diabetes explained 71% of the variation in postural balance in COPD. Transcutaneous oxygen saturation, a history of exacerbation, and gait speed explained 83% of the variation in functional balance in COPD. Neurocognitive dysfunction was the main risk factor for postural balance impairment in the control group. This suggests that specific phenotypes of COPD patients can be identified based on their type of balance impairment.
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Background The presence of comorbid conditions could impact performance in pulmonary rehabilitation (PR) programmes. We aimed to compare the comorbidity prevalence among those with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) and evaluate the impact on PR response. Methods We performed a retrospective cohort study, recording comorbidities for all patients with COPD or ILD referred to PR. Participants were classified as responders to PR if they met the minimal important difference for exercise capacity and health-related quality of life (HRQoL). The prevalence of comorbidities and impact on PR outcomes were compared by lung disease and by sex using a univariate analysis and multivariate logistic regression. Results The mean number of comorbidities was similar among those with COPD (3.3±2.1, n=242) and ILD (3.2±1.9, n=66) (p>0.05). Females had a higher number of comorbidities than males in both COPD (p=0.001) and ILD (p=0.017) populations. Circulatory (64%) and endocrine/metabolic (45%) conditions were most common in COPD. In ILD, digestive (55%) and circulatory (53%) comorbidities were most prevalent. In people with ILD, those over 65 years, with musculoskeletal/connective tissue disease or circulatory disease were less likely to obtain meaningful improvements in exercise capacity. There was no impact of comorbidities on exercise capacity in COPD or on HRQoL in ILD. Conclusions The majority of patients with COPD or ILD enrolled in PR programmes have multiple comorbidities that may affect improvements in exercise capacity. PR programmes may be less effective for older adults with ILD and comorbid circulatory or musculoskeletal disease.
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Abstract Background Although COPD affects both men and women, its prevalence is increasing more rapidly in women. Disease outcomes appear different among women with more frequent dyspnea and anxiety or depression but whether this translates into a different prognosis remains to be determined. Our aim was to assess whether the greater clinical impact of COPD in women was associated with differences in 3-year mortality rates. Methods In the French Initiatives BPCO real-world cohort, 177 women were matched up to 458 menon age (within 5-year intervals) and FEV1 (within 5% predicted intervals). 3-year mortality rate and survival were analyzed. Univariate and multivariate logistic regression analyses were performed. Results For a given age and level of airflow obstruction, women with COPD had more severe dyspnea, lower BMI, and were more likely to exhibit anxiety. Nevertheless, three-year mortality rate was comparable among men and women, respectively 11.2 and 10.8%. In a multivariate model, the only factors significantly associated with mortality were dyspnea and malnutrition but not gender. Conclusion Although women with COPD experience higher levels of dyspnea and anxiety than men at comparable levels of age and FEV1, these differences do not translate into variations in 3-year mortality rates. Trial registration 04–479.
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Background There is partial evidence that COPD is expressed differently in women than in men, namely on symptoms, pulmonary function, exacerbations, comorbidities or prognosis. There is a need to improve the characterization of COPD in females. Methods We obtained and pooled data of 17 139 patients from 22 COPD cohorts and analysed the clinical differences by sex, establishing the relationship between these characteristics in women and the prognosis and severity of the disease. Comparisons were established with standard statistics and survival analysis, including crude and multivariate Cox-regression analysis. Results Overall, 5355 (31.2%) women were compared with men with COPD. Women were younger, had lower pack-years, greater FEV1%, lower BMI and a greater number of exacerbations (all p < 0.05). On symptoms, women reported more dyspnea, equal cough but less expectoration (p < 0.001). There were no differences in the BODE index score in women (2.4) versus men (2.4) (p = 0.5), but the distribution of all BODE components was highly variable by sex within different thresholds of BODE. On prognosis, 5-year survival was higher in COPD females (86.9%) than in males (76.3%), p < 0.001, in all patients and within each of the specific comorbidities that we assessed. The crude and adjusted RR and 95% C.I. for death in males was 1.82 (1.69–1.96) and 1.73 (1.50–2.00), respectively. Conclusions COPD in women has some characteristic traits expressed differently than compared to men, mainly with more dyspnea and COPD exacerbations and less phlegm, among others, although long-term survival appears better in female COPD patients.
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Background The mechanisms underlying impaired balance in chronic obstructive pulmonary disease (COPD) are poorly understood, which makes it difficult to choose the best therapeutic approaches. Therefore, this study aimed to investigate patters of muscular activation to maintain balance and its determinants in this population. Methods Thirty-three subjects with COPD and 33 controls were assessed by a force platform in four tasks: standing with eyes opened (FHEO) and closed (FHEC); standing on unstable surface (SUS) and one-legged stance (OLS). Electromyographic activity of lower limb, trunk and neck muscles was concomitantly recorded. To asses functional balance, Brief-balance evaluation systems and timed up & go (TUG) tests were applied. Lung function, exercise capacity and muscle force were also assessed. Results Subjects with COPD presented worse balance and higher scalene activation than controls in OLS (mean difference 23.0 [95%CI 1.7–44.3] %Δ μVRMS; P = 0.034), besides presenting also higher activation of gluteus medius during FHEC task (mean difference 1.5 [95%CI 0.2–2.8] %Δ μVRMS; P = 0.023) and taking longer to complete the TUG (mean difference 0.6 [95%CI 0.1–1.2] seconds; P = 0.042). Exercise capacity and peripheral muscle force were determinants of functional balance (r (Eisner et al., 2011) [2]bib2 = 0.505), whereas age (OR = 1.24; 95%CI 1.02–1.52) and total lung capacity (OR = 2.42; 95%CI 1.05–5.56) were determinants of static balance. Conclusion Individuals with COPD have worse static and functional balance in comparison with controls, besides presenting higher activation of scalene and gluteus medius during static balance tasks. Exercise capacity and peripheral muscle force emerged as determinants of functional balance, whereas age and lung hyperinflation contributed to poor static balance.
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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.
Article
Purpose: This study evaluated the accuracy of the Mini-Balance Evaluation System Test (Mini-BESTest) for predicting falls in patients with chronic obstructive pulmonary disease (COPD) and investigated whether postural balance is a risk factor for falls. Methods: Postural balance was evaluated by the Mini-BESTest at baseline, and the incidence of falls over a 12-mo period was prospectively measured by a self-reported falls diary and confirmed by telephone calls. A discriminative power analysis was performed using receiver operating characteristic (ROC) curve and logistic regression analysis. Results: Sixty-seven outpatients with COPD (mean age ± SD = 67 ± 9.3 yr) were included. Twenty-five patients (37.3%) experienced ≥1 fall, and 28.2% of the falls resulted in injuries. The Mini-BESTest predicted falls in patients with COPD at the 6- and 12-mo follow-ups with a cut-off score of 22.5 (area under the curve = 0.85 and 0.87) with good sensitivity and specificity (85.7% and 66.7%; 84% and 73.8%, respectively). Higher scores on the Mini-BESTest were associated with a lower risk of falls at 12 mo (OR = 0.50; 95% CI, 0.36-0.70; P < .001). Conclusions: Postural balance assessed by the Mini-BESTest is a good predictor of falls in patients with COPD. Our results imply that impaired balance contributes to the risk of falling and that balance training and fall prevention programs may be required for this population.